What are 4 things to look for during a skin assessment?

The skin has many important functions; including protection from harmful substances and microbes, prevention of loss of body water, and temperature control. It is therefore essential to maintain the health and integrity of the skin. Healthy adults are usually able to assess and care for their own skin, however, at extremes of age and during periods of illness skin assessment and care may need to be carried out by carers or healthcare professionals. If skin assessment is to be undertaken, the individual should be informed of the reasons and procedures so that they can consent and participate where able. Skin assessment requires moving the individual in order to examine the skin and therefore healthcare providers should use appropriate moving and handling techniques and equipment to prevent harm to themselves or the individual. It is also important that skin assessment is carried out in the right environment where there is good (preferably natural) lighting to observe the colour and texture of the skin and where a person's privacy, dignity and warmth can be respected (see NICE clinical guideline 138 ‘Patient experience’).

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8.4.5.1. Clinical (adults)
8.4.5.2. Economic (adults)
8.4.5.3. Clinical (neonates, infants, children and young people)
8.4.5.4. Economic (neonates, infants, children and young people)

The assessment for potential tissue damage includes an observation of the skin for changes in colour compared with the surrounding skin or in comparison to the skin on the contralateral side of the body. It should be noted that in some cases deep tissue injury can occur before any changes on the surface of the skin are discernible; grade 3 and 4 pressure ulcers may therefore develop without prior superficial skin damage.

For full details see review protocol in Appendix C.

This review focuses on the clinical effectiveness of skin assessment as part of a larger number of interventions for pressure ulcer prevention. The prognostic ability of skin assessment tools is reported separately.

One randomised trial by Vanderwee (2007) was included in this review.215 Evidence from this study is summarised in the clinical GRADE evidence profile below (Table 15). See also the study selection flow chart in Appendix D, forest plots in Appendix I, study evidence tables in Appendix G and exclusion list in Appendix J.

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Study	Intervention/comparison	Population	Outcomes	Comments
Vanderwee 2007215	Daily skin assessment with transparent disk. Preventative measures were started only when non-blanchable erythema (NBE) appeared and were discontinued when NBE disappeared. Braden score and daily skin assessment with transparent disk. Preventative measures were started if the Braden score was less than 17 at initial assessment or after 3 days or if NBE appeared. People assessed to be at high risk received preventative measures according to the same pressure redistribution protocol. Participants were randomised to either the Polyethylene–urethane Mattress (PUM) or to the Alternating pressure air mattress (APAM). On the former mattress, participants were turned every 4 hours, following Defloor et al. 2005. On the latter mattress, no standardised position changes were carried out. People not assessed to be at high risk received standard measures as normally used in the ward they were on.	People with an expected hospitalisation of at least 3 days admitted between May 2000 and March 2002 in 14 surgery, internal medicine and geriatric wards of 6 Belgian hospitals.	Incidence of pressure ulcers (grade 2-4) per 1000 days (95% CI) Time (days) to development of pressure ulcers (grade 2-4) Resource use: number of participants receiving preventative measures.	The study was carried out between May 2000 and March 2002. Each nursing unit took part in the study for the duration of 5 months.

The study also allowed calculation of the sensitivity and specificity: the details informing the 2 × 2 table are given in the evidence table and the forest plot is given in Appendix O. Sensitivity and specificity results are as follows:

Group 1 (NBE plus targeted preventative treatment): sensitivity 46% (95%CI 33 to 60); specificity 87% (95%CI 84 to 89)
Group 2 (Braden then NBE plus targeted preventative treatment): sensitivity 81% (95%CI 68 to 91); specificity 72% (95%CI 68 to 75).

In this context, sensitivity and specificity are likely to be confounded by preventative treatment – it is unclear if a high value of sensitivity can be attributed to the relative lack of success of the preventative treatment or the success of the risk assessment method. Therefore the false negative rate for the 2 test-and-treat interventions was considered and this is reported in the GRADE table above.

The evidence showed that, of the 251 assessed to be at-risk in the control group (Braden then NBE), 219 people were identified on the basis of having a Braden score less than 17and 32 of 572 (6%) people with a Braden score above 17 were identified using skin assessment. The study does not compare using the Braden score head-to-head with skin assessment.

No relevant economic evaluations of skin assessment techniques were identified.

One economic evaluation13 was identified which included use of skin assessment as part of a more complex skin care protocol, but this was not considered useful in informing the cost effectiveness of skin assessment.

No RCTs or cohort studies were identified. Recommendations were developed using a modified Delphi consensus technique. Further details can be found in Appendix N.

No relevant economic evidence was identified.

8.2.5.1. Clinical (adults)

One study (n=1,617) showed that there is no clinically important difference in the incidence of pressure ulcers (grade 2-4) between skin assessment of non-blanchable erythema with transparent disk (NBE) plus targeted preventative measures versus the Braden scale then skin assessment with transparent disk plus targeted preventative measures (low quality).
One study (n=1,617) showed that time to development of pressure ulcers (grade 2-4) was significantly shorter for skin assessment with transparent disk (NBE) than for skin assessment with transparent disk combined with the Braden scale (control) (low quality).
One study (n=1,617) showed that there were many fewer preventative treatments initiated in the participants assessed with skin assessment compared with the Braden scale then skin assessment. However, there were slightly more participants missed using the NBE approach compared with the combined approach who later had pressure ulcers; overall the proportion of missed participants was low (4% and 1%) (moderate quality)

8.2.5.2. Economic (adults)

No relevant economic evaluations were identified.

8.2.5.3. Clinical (neonates, infants, children and young people)

No evidence was identified.

8.2.5.4. Economic (neonates, infants, children and young people)

No relevant economic evaluations were identified.

For full details see review protocol in Appendix C.

The second approach is applied in this review, but there are confounding factors in the prognostic review due to preventative treatment.

Five studies were included in the review.36,107,144,146,213 Odds ratios for the predictive effect of different skin assessment factors on pressure ulcer incidence are reported, with emphasis on those calculated from multivariable regression analyses. Sensitivity and specificity were calculated using the raw data as presented in the individual studies. The evidence is summarised in the clinical GRADE evidence profile below (Table 3). See also the study selection flow chart in Appendix D, forest plots in Appendix O, study evidence tables and the quality assessment table in Appendix G and O, and the exclusion list in Appendix J. Evidence was also considered from a further study (Compton 2008),36 that also conducted multivariable analysis of different skin assessment features, but by nurse assessment rather than using skin assessment tools.

If preventative measures are used as a consequence of skin assessment findings, the probability that an individual will develop a pressure ulcer at the start of the study will not remain constant through the study. The use of effective targeted prevention will alter the assessment of predictive ability. The results should therefore be considered with caution where preventative treatment was given, but not taken into account in the analysis. The studies varied according to their use of preventative measures:

Two did not report any preventative treatment (Compton 2008, Newman 1981).36,144
One gave preventative treatment to all participants (Nixon 2007).146
One gave preventative treatment to people at high risk following skin assessment (Vanderwee 2007).213
One was unclear about the numbers receiving preventative treatment and whether this was dependent on skin assessment (Konishi 2008).107

None of the studies took preventative treatment into account in the results.

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Study	Population	Skin assessment tool	Outcomes
Konishi 2008	People in hospital	Presence of blanchable erythema assessed by finger test.	Occurrence of pressure ulcer development according to the National Pressure Ulcer Advisory Panel classification. Length of follow up not reported. Incidence 8 (3%) pressure ulcers (all grades) and grade 4 (2%) grade 2-4.
Newman 1981	People in hospital	Thermography: presence of thermal anomaly (an area of the skin at least 1°C warmer than the surrounding skin).	Development of skin breakdown in the buttock region within 10 days of admission was reported by the nursing staff and photographed. Redness alone, however marked or persistent, was not categorized as a pressure sore. Follow up not reported. Incidence of pressure ulcers: 6 (7%).
Nixon 2006	People who have had surgery	Presence of blanchable or non-blanchable erythema, method not stated, assumed finger.	Occurrence pressure ulcer development (grade 2-4) according the classification scale adapted from international classification scales (AHCPR (Agency for Health Care Policy and Research) 1992; EPUAP, 1999). Follow up not reported. Incidence of pressure ulcers: 15 (15%)
Vanderwee 2007	People in surgical, internal medicine and geriatric wards of 6 Belgian hospitals	Daily skin assessment with transparent disk, with and without Braden scale risk assessment.	Incidence of pressure ulcers: 56 (7%). Follow up 5 months.
Compton 2008	People in ICU	Subjective nursing skin assessment on admission.	Occurrence of pressure ulcers development (grade 2-4) according to the European Pressure Ulcer Advisory Panel classification system in the course of ICU treatment. Length of follow up not reported. Incidence of pressure ulcers: 121 (17%).

No relevant economic evaluations were identified.

No RCTs or cohort studies were identified. Recommendations were developed using a modified Delphi consensus technique. Further details can be found in Appendix N.

No relevant economic evaluations were identified.

8.4.5.1. Clinical (adults)

One study in 249 people in hospital with 8 pressure ulcers, gave an (unadjusted) odds ratio of 9.9 (95%CI 1.9 to 50.5) for the predictor blanchable erythema assessed by the finger test for all grades of pressure ulcer according to the European Pressure Ulcer Advisory Panel classification system. The sensitivity and specificity were 75% (95%CI 35 to 97) and 77% (95%CI 71 to 82) (very low quality).
Two studies in 314 people with 8 pressure ulcers (grade 2-4) showed gross heterogeneity in the unadjusted odds ratios and in the specificity for the predictor blanchable erythema by the finger test; the sensitivity was 75% (19 to 99) for each study. (very low quality).
One study in 97 surgical inpatients with 15 pressure ulcers, showed, in multivariable analysis, that the subjective nursing assessment of non-blanchable erythema was a significant predictor of pressure ulcers (grade 2-4) according to the European Pressure Ulcer Advisory Panel classification system (OR 7.02 (95%CI 1.67 to 29.5)). The sensitivity was 73% (95%CI 45 to 92) and the specificity was 74% (95%CI 64 to 83) (very low quality). A second large study in 826 people in hospital with 56 pressure ulcers, gave an unadjusted odds ratio of 5.68 (95%CI 3.23 to 9.99) and a sensitivity of 46% (95%CI 33 to 60) and a specificity of 87% (95%CI 84 to 89); the results of both studies were possibly confounded by preventative treatment. (very low quality).
One study in 91 people in hospital with 6 pressure ulcers, who were not given preventative treatment, gave an unadjusted odds ratio of 36.7 (95%CI 1.41 to 952.2), a sensitivity of 100% (95%CI 54 to 100), and a specificity of 74% (95%CI 63 to 83) for thermography (presence of thermal anomaly – an area of the skin at least 1°C warmer than the surrounding skin) as a predictor for the development of pressure ulcers grade 2-4. (very low quality).

8.4.5.2. Economic (adults)

No relevant economic evaluations were identified.

8.4.5.3. Clinical (neonates, infants, children and young people)

No evidence was identified.

8.4.5.4. Economic (neonates, infants, children and young people)

No relevant economic evaluations were identified.

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Healthcare professionals should be aware that non-blanchable erythema may present as colour changes or discolouration, particularly in darker skin tones or types.

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Recommendations	9. Use finger palpation or diascopy to determine whether erythema or discolouration (identified by skin assessment) is blanchable. 10. Start appropriate preventative action (see recommendations 1.1.1 – 1.1.17) in adults who have non-blanching erythema and consider repeating the skin assessment at least every 2 hours until resolved.
Relative values of different outcomes	The GDG placed the most importance on the randomised evidence for skin assessment in conjunction with targeted preventative treatment and its impact on patient outcomes. They also considered the predictive ability of skin assessment in discriminating patients at risk, particularly taking into account absolute risk differences from multivariable analyses.
Trade off between clinical benefits and harms	Evidence from 1 RCT compared the combination of risk assessment using the Braden scale (with a cut-off of 17) plus NBE versus NBE testing alone. People at high risk according to each of these 2 methods were given preventative treatment. There was no clinically important difference between interventions in terms of the incidence of pressure ulcers. However, there was a large difference in the number of preventative treatments given, with more treatments being given to the combined assessment approach than to NBE alone. The sensitivity was larger for the NBE plus Braden scale intervention than the NBE alone. The absolute risk of pressure ulcer development in people defined by each strategy to be at low risk was larger for NBE alone, but the GDG did not consider this to be an important difference. The study reported that 6% of people with normal scores on the Braden scale were identified as at risk using NBE.The evidence from Part 1 of the review suggested that NBE was an independent predictor of pressure ulcers; there was also some limited evidence on the use of thermography to predict pressure ulcer development, although the evidence included few events. Although no evidence was identified comparing risk assessment versus skin assessment and therefore, it was not possible to ascertain the value of skin assessment in addition to risk assessment, the GDG felt that the assessment of skin was important for reasons of patient care.The GDG felt that, where erythema or discoloration of the skin was identified, evidence supported the use of diascopy to determine whether the erythema was blanchable or non-blanchable, in addition to a formal risk assessment (see recommendation 1). However, the GDG noted that there were some situations in which transparent plastic discs were not available or where the use of these tools posed a specific infection risk. As such, the GDG highlighted that the use of finger palpation to identify whether erythema was blanching or non-blanching would be appropriate and preferable to any delay in obtaining specific tools. The GDG used informal consensus to agree that this reassessment should take place at least every 2 hours, until this has been resolved.
Economic considerations	No economic evidence was identified.Once erythema or discoloration has developed, it is vital to determine whether it is blanchable or non- blanchable, as non- blanchable erythema is indicative of pressure damage. The primary concern here is to prevent any pressure damage from worsening, and therefore the use of finger palpation or diascopy is considered essential. The GDG did not anticipate that using finger palpation or diascopy would substantially increase resource use over that required for the clinical skin assessment. The GDG agreed that where non-blanchable erythema is identified, regular skin assessments are required in order to prevent pressure ulcers developing through application of appropriate preventative strategies. The prevention of pressure ulcers at this stage would lead to improvements in quality of life and substantial cost savings.
Quality of evidence	The evidence in the RCT was rated as low quality. The evidence in the prognostic studies was of very low quality: there were very few pressure ulcers, multivariable analysis was not always conducted and the results were confounded, in some studies, by the use of preventative treatments, which were not taken into account in the analysis.
Other considerations	The GDG felt that it was important to highlight that people who had non-blanchable erythema would also be more likely to develop a pressure ulcer on that site, as well as other sites. Therefore, the GDG felt that people who have been identified as having non-blanchable erythema should be offered preventative treatment and reassessed on a regular basis to identify any changes in skin condition. The GDG noted that following reassessment, the individualised care plan (including the use of preventative measures) should be adapted to account for any change in risk status.

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Recommendations	11. Offer neonates, infants, children and young people who are assessed as being at high risk of developing a pressure ulcer a skin assessment by a trained healthcare professional. Take into account: skin changes in the occipital area skin temperature the presence of blanching erythema or discoloured areas of skin.
Relative values of different outcomes	The GDG was interested in any predictors for pressure ulcer development and their identification through clinical assessment by a healthcare professional. Evidence from multivariable analysis of risk was considered the most important.
Trade-off between clinical benefits and harms	The GDG used 3 statements from the Delphi consensus survey to inform the recommendation. The statements were ‘Healthcare professionals should measure skin temperature for the assessment of skin in neonates, infants, children and young people considered to be at risk of developing pressure ulcers’, ‘Healthcare professionals should use diascopy for the assessment of skin in neonates, infants, children and young people considered to be at risk of developing pressure ulcers’ and ‘Health professionals should inspect the occipital area skin when carrying out skin inspection in neonates, infants, children and young people at risk of developing pressure ulcers’. Further detail on the Delphi consensus survey can be found in Appendix N.Two statements (on skin temperature and diascopy) were included in Round 1 of the survey but were not accepted by the Delphi consensus panel at the necessary level of agreement.For the statement on diascopy, comments from the panel during Round 1 suggested some lack of understanding relating to the term ‘diascopy’. Other comments highlighted a possible infection risk of using plastic discs to carry out diascopy. The GDG discussed the statement for inclusion in Round 2 and agreed that the term diascopy should be removed to ensure that people are clear that the purpose of the assessment is to identify the presence of non-blanchable erythema and that the method of identifying this may vary between individuals. The GDG also agreed with comments from the Delphi consensus panel that any assessment of blanching should be carried out as part of a wider comprehensive skin assessment and the statement was amended further to recognise this.For the statement on skin temperature, comments from the Delphi consensus panel suggested that an assessment of skin temperature as part of a general assessment may be helpful but formal measurement was not necessary.A statement on comprehensive skin assessment was therefore developed for inclusion in Round 2, highlighting the need to account for both blanching and skin temperature as part of the assessment.During Round 2 of the Delphi consensus survey, the GDG identified from qualitative comments gathered in response to some statements, that there were specific sites in which neonates, infants, children and young people were at significant risk of developing a pressure ulcer, most importantly, the occipital region. The group felt that it was important to include statements relating to this in Round 2 of the survey and importantly, to develop a statement highlighting the need to inspect this area in the at risk population. The statement ‘Health professionals should inspect the occipital area skin when carrying out skin inspection in neonates, infants, children and young people at risk of developing pressure ulcers’ was therefore developed by the GDG and included in Round 2, where it reached an agreement of 96%. The GDG discussed the accepted statements on skin temperature, assessment of blanching, and the statement developed to address the increased incidence of occipital pressure ulcers. They identified that assessment of these factors was likely to be beneficial as part of a wider skin assessment to predict pressure ulcer development and was likely to result in a decrease in the incidence of pressure ulcers. The group therefore agreed to develop a recommendation on skin assessment, as it was likely that any benefits of conducting a skin assessment in those at risk of developing a pressure ulcer outweighed any potential harms in terms of falsely predicting pressure ulcer development, and therefore providing unnecessary preventative treatment.
Economic considerations	The GDG discussed the resource implications of carrying out skin assessments; this would likely take approximately 5 minutes of nurse time (at a cost of approximately £347). Skin assessment is used to predict the development of pressure ulcers, and therefore is an extremely useful preventative tool. The small resource use associated with skin assessment is highly likely to be offset by costs savings as more pressure ulcers are prevented. The GDG agreed that the use of skin assessment is highly likely to be cost-neutral, or even cost-saving, and will improve health related quality of life.
Quality of evidence	No RCTs or cohort studies were identified for neonates, infants, children or young people. Formal consensus using a modified Delphi was therefore used to develop the recommendation.To inform the recommendation, the GDG used 3 statements. Two statements were amended after failing to reach the pre-agreed consensus level in Round 1 and were amended and included in Round 2 of the Delphi consensus survey as a single statement which reached a 95% agreement level. One statement was included in Round 2 as a response to the qualitative responses gathered in Round 1 of the survey and reached a 96% agreement. Further details can be found in Appendix N.
Other considerations	There were no further considerations.

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Recommendations	12. Be aware of specific sites (for example, the occipital area) where neonates, infants, children and young people are at risk of developing a pressure ulcer.
Relative values of different outcomes	The GDG was interested in any predictors for pressure ulcer development and their identification through clinical assessment by a healthcare professional. Evidence from multivariable analysis of risk was considered to be the most important.
Trade-off between clinical benefits and harms	The GDG used 1 statement from the Delphi consensus survey to inform the recommendation. The statement was ‘Healthcare professionals should take into account the specific sites at risk of developing pressure ulcers in neonates, infants, children and young people, when undertaking and documenting a skin assessment’. The statement was accepted by the Delphi consensus panel. Further detail on the Delphi consensus survey can be found in Appendix N. The GDG discussed the statement and agreed that a recommendation should be developed to ensure that healthcare professionals are aware of specific sites that may be at risk of developing a pressure ulcers in neonates, infants, children and young people, as they differed from other populations (for example, adults). Specific sites highlighted by the panel as being at risk sites in the younger populations included the occiput, sacrum, back, hands and elbows. Other panel members highlighted that the use of body maps and medical photography could help to document the results of skin assessment. The GDG felt that there were likely to be benefits in ensuring that healthcare professionals were aware of areas that may be at risk in neonates, infants, children and young people in that a raised awareness may lead to a reduction in the incidence of pressure ulcers. The GDG could not identify any possible harms in raising awareness of these sites.
Economic considerations	No economic considerations.
Quality of evidence	No RCTs or cohort studies were identified for neonates, infants, children or young people. Formal consensus using a modified Delphi was therefore used to develop the recommendation.To inform the recommendation, the GDG used 1 statement which was included in Round 1 of the Delphi consensus survey and reached 96% consensus agreement. Further details can be found in Appendix N.
Other considerations	There were no further considerations.