One of the most challenging areas in pressure injury (PI) prevention and treatment is the detection of PIs among patients with non-Caucasian skin. Certified wound nurses often have extra training and experience in this area, but most staff nurses do not. Stage 1, Stage 2, and Deep Tissue PIs present differently in darker skin—and are often missed until they turn into more obvious Stage 3 or Stage 4 wounds.
The issue becomes an even greater challenge among obese patients of color. Obese patients are not turned or visually inspected as often, and by the time a PI is found, it may have advanced beyond a Stage 1 or 2. So how can we better detect these PIs sooner?
A little detective work
When you’re assessing skin in general, you’re focusing on several visual and tactile indicators: is it red, is it warm, is it hot, is it boggy, is it firm? In the non-Caucasian population, those indicators may require a little more investigating. A PI may look more like a bruise. And even though there’s an inflammatory response going on, you don’t necessarily see the redness. Remember a three-pronged approach for these cases:
Look: visually inspect your patient’s skin from head to toe. Most PIs happen over bony prominences—the buttocks, sacrum, and heels. Are these areas at all discolored? Compare one side to the other. Non-Caucasian skin may not be red—a PI may be darker brown or even white. Look for dryness, redness, blistering, and bruising.
Listen: ask your patient whether they have any pain or whether they’ve had a history of PIs. Explain that sometimes PIs are harder to detect in darker skin, but early detection can help prevent long-term pain or skin damage.
Feel: compare the skin’s temperature from one side to the other (i.e.: compare heels, buttocks, scapulas). If one area is cooler, it might indicate poor circulation; warmer areas may indicate inflammatory response. Also feel for texture differences. How hard is the skin? How soft? Does it feel different than surrounding skin? Is it boggy or squishy where it shouldn’t be? How indurated is the skin?
Prevention is key
Keep patient history in mind. Obese patients with diabetes are at elevated risk of PI. Use tools like the Braden Scale for Predicting Pressure Sore Risk. Treating PIs in their earliest stages—or preventing them altogether—is the key to avoiding painful complications.
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-Bergstrom N, Braden BJ, Laguzza A, Holman V. The Braden Scale for Predicting Pressure Sore Risk. Nursing Research. 1987;36(4):205-210.
-National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Emily Haesler (Ed.). Cambridge Media: Osborne Park, Western Australia; 2014.
-Pressure Injury Staging Illustrations. (2016). Retrieved from www.npuap.org/resources/educational-and-clinical-resources/pressure-injury-staging-illustrations/