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Skin Color Awareness in Identifying Pressure Injuries

I have worked all over the country as an educator. The same gaps in education arise everywhere. A few years ago, I began teaching skin color awareness as part of my course curriculum. I feel strongly about it being a part of my inservices and course education. Understanding skin color as it relates to assessment is critical in the prevention of pressure injuries. An area of pressure injury prevention that has been weighing on my mind more often lately has to do with the mistakes made by clinicians in regard to skin assessment discrepancies with dark skin tones. I am not referring to skin tones requiring different skin products. Skin color is not a skin type.

A quick snapshot of skin color: if we are looking at the differences in skin color, patients with dark skin tones are more prone to keloidal scarring, ingrown hairs, and hyperpigmentation. Light skin has less size and distribution of melanin. Pressure injuries, signs and symptoms of infection, rashes, wounds, and scars present differently on the various skin colors. We cannot be color blind with pressure injuries and or signs and symptoms of infection. I observe providers and nurses staging and measuring scars on a dark skin tone patient. This type of discrepancy can also raise a red flag in the long-term care setting from a state surveyor perspective.

Skin Assessment and Closing the Gap

When I teach clinicians about skin color awareness and pressure injuries, I include the following tips and resources in my curriculum:

Education: Use wound images to identify descriptors of stage 1 and deep tissue pressure injuries. The National Pressure Ulcer Advisory Panel has recently published updated guidelines and photos that are available to download.

Lighting: Clinicians should always use good lighting when assessing patients. Pen lights, or handheld mirrors with lights are a plus.

Look: Take your time during assessments, conducting a full body skin sweep. Look in folds and creases.

Listen: Listen to your patients. Many times they can teach us. Pain and discomfort may warrant pressure injury development.

Feel: Feel for bogginess, induration and warmth on the skin. Remember: dark skin tones rarely blanch.

Image Source: The National Pressure Advisory Panel (


Health Information Technology: Best Practices Transforming Quality, Safety, and Efficiency: The National Pressure Ulcer Advisory Panel:

Cooper KL. Evidence-based prevention of pressure ulcers in the intensive care unit. Crit Care Nurse. 2013 Dec;33(6):57-66. doi: 10.4037/ccn2013985.

Lyder CH, Ayello EA.Pressure Ulcers: A Patient Safety Issue. In: Hughes RG, ed. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville, MD: Agency for Healthcare Research and Quality (US); 2008.

About the Author

Cheryl Carver is an independent wound educator and consultant. Carver's experience includes over a decade of hospital wound care and hyperbaric medicine. Carver single-handedly developed a comprehensive educational training manual for onboarding physicians and is the star of disease-specific educational video sessions accessible to employee providers and colleagues. Carver educates onboarding providers, in addition to bedside nurses in the numerous nursing homes across the country. Carver serves as a wound care certification committee member for the National Alliance of Wound Care and Ostomy, and is a board member of the Undersea Hyperbaric Medical Society Mid-West Chapter. 

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, HMP Global, its affiliates, or subsidiary companies.