Skin Integrity Admission Assessment

Head-to-toe skin assessment completed within 24 hours of admission to document baseline skin integrity, existing wounds, scars, bruising, device-related pressure areas, and Braden score for care planning.

Admission Timing and Assessment Completion

• Skin integrity assessment completed within 24 hours of admission
• Assessment date and time documented
• Assessor name and role documented
• Admission baseline skin status recorded

Braden Score and Risk Stratification

• Braden score documented
• Braden risk level identified
• Pressure injury prevention plan initiated or updated based on risk
• Escalation to provider or wound care documented when indicated

Head-to-Toe Skin Inspection

• Head-to-toe skin inspection completed
• Skin assessed over bony prominences and pressure-prone areas
• Feet and heels inspected and documented
• Existing wounds documented with location, size, and appearance
• Scars, bruising, redness, or other skin changes documented
• Skin tears, abrasions, or open areas documented if present
• Pain, drainage, odor, warmth, or swelling noted when present

Device-Related and Preventive Skin Checks

• Skin checked under and around medical devices
• Device-related pressure areas documented if present
• Offloading, repositioning, or protective measures initiated when indicated
• Support surface or heel protection addressed when indicated

Documentation, Communication, and Follow-Up

• Findings communicated to care team when abnormal skin findings were present
• Care plan updated to reflect skin integrity risks or wounds
• Follow-up wound care or reassessment interval documented
• Photo documentation attached when required by policy