How do you assess skin integrity in high-risk patients?

• A. Inspect for redness or breakdown, pressure injuries; use Braden scale to guide prevention.
• B. Rely on patient self-report only.
• C. Check skin only after pain is reported.
• D. No skin assessment is necessary.

Answer: (A)

Regular, comprehensive skin assessment in high-risk patients is essential because skin can deteriorate quickly under pressure, moisture, and shear. Inspect all skin surfaces, especially over bony prominences like the sacrum, heels, and hips. Look for nonblanchable redness, breakdown, or early signs of a pressure injury, and assess for moisture, maceration, edema, temperature changes, and any existing wounds. The Braden Scale provides a structured way to estimate risk and guide prevention by evaluating six areas: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Using this tool helps determine appropriate interventions such as turning and repositioning on a schedule, using pressure-relieving surfaces, managing moisture and incontinence, maintaining skin hygiene and barrier care, and addressing nutrition. Document findings and reassess regularly, and communicate changes to the care team. Relying on patient self-report alone can miss nonpainful injuries; pain may not reflect skin integrity, and delaying assessment can allow injuries to worsen. Skipping assessment altogether is unsafe. Combining careful inspection with the Braden scale is the best approach.