Pressure Injury Survey Guide

Conduct the Study - Skin Inspection

Inspect the skin of each patient from head-to-toe to assess skin integrity and detect existing pressure injuries.

Look closely at all bony prominences and body surfaces subject to pressure or pressure in combination with shear.

  • A handheld mirror may be used to visualize the posterior surface of each heel
  • For neonates and pediatric patients, pay particular attention to the skin over the occiput

Examine the skin/soft tissue under and around tubing and other medical devices. For example:

  • Inspect the skin under stockings, sequential compression devices, splints, braces, cervical collars, casts, and traction boots
  • Inspect the skin under oxygen and urinary catheter tubing
  • Inspect the skin under oxygen and urinary catheter tubing
  • Inspect the skin around nasogastric and orogastic tubing
  • Examine the bridge of the nose, nares, and nasal septum of patients receiving continuous positive airway pressure (BIPAP, CPAP)
  • Inspect the skin under tracheostomy flanges, ties, and inflation tubing
  • Carefully examine the oral cavity of any patient with an endotracheal tube in place. Be careful not to displace the tube.
  • Examine common sites for oximetry probes (ears, fingers, toes)
  • Do not remove or displace any device that is not ordinarily removed in course of patient care.
  • Do not remove any dressing or device for which there is a physician order to NOT remove or reposition said device.

Refer to the NDNQI® Guidelines for Data Collection and Submission on Pressure Injuries for NEW instructions on reporting medical device related pressure injuries.

Assess the skin under skin folds in the bariatric patient. Seek assistance as needed to lift folds without damaging tissue.

Palpate suspect skin to assess temperature, moisture, consistency and pain.

  1. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, & Pan Pacific Pressure Injury Alliance. (2014). Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline (E. Haesler Ed.). Osborne Park, Western Australia: Cambridge Media.