How to assess the skin and spot pressure injuries
Other platforms explain it with text and video. In VMS you practice it on the patient.
Pressure injuries can form in hours and are mostly preventable. Checking the skin over the bones at every assessment is the first step.
Step by step
Prepare
Clean your hands, introduce yourself, get consent, good light, privacy. [1]
Color
Pallor, blue, yellow or redness. In darker skin, check the lips, gums, palms, nail beds and the white of the eyes. [1]
Temperature and moisture
Back of the hand, compare both sides; dry, sweaty or wet from incontinence. [1]
Turgor
Pinch skin under the collarbone or on the forearm: slow return suggests dehydration. [1]
Pressure points
Sacrum, heels, hips, elbows, back of the head, and under tubes and devices. Press red areas: redness that does not fade is a stage 1 injury. [1]
Lesions
Describe size, color, shape and borders. For moles, use ABCDE: asymmetry, border, color, diameter, evolving. [1]
Risk score
Braden scale (sensory, moisture, activity, mobility, nutrition, friction). A score of 18 or lower means risk. [2]
Prevent and record
Reposition on schedule, keep skin clean and dry, use support surfaces, and document stage and size. [1]
Common errors
- Missing the heels.
- Not checking under devices.
- Relying on redness alone in darker skin.
Pressure injury stages [1]
| Stage | What you see | |
|---|---|---|
| Stage 1 | Intact skin, redness that does not fade when pressed | |
| Stage 2 | Shallow open area, partial skin loss | |
| Stage 3 | Full skin loss, fat may show | |
| Stage 4 | Bone, tendon or muscle exposed | |
| Unstageable | Base covered by slough or eschar | |
| Deep tissue | Purple or maroon area of intact skin |
Practice it in VMS
In VMS you do this on the patient, not on paper: every step goes on the checklist with a score, and in Teach mode Blocky tells you what comes next.
VMS cases that train this skill
Sources
- Open RN, Nursing Skills 2e (Chippewa Valley Technical College) (CC BY 4.0)
- NCSBN 2026 NCLEX-RN Test Plan
Steps adapted from Open RN, Nursing Skills 2e (Chippewa Valley Technical College), licensed under CC BY 4.0. Facts and steps also follow NCSBN 2026 NCLEX-RN Test Plan. VMS is not affiliated with these organizations. Updated: 2026-10-11.