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Control Moisture and Incontinence


Skin Inspection and Documentation

For all patients, complete a skin inspection on every patient within six hours of admission, and daily thereafter for those identified at risk for skin breakdown. Particular attention should be paid to vulnerable areas, especially over bony prominences1.

For all patients inspect and palpate for:
  • Alteration in skin moisture
  • Change in texture, turgor
  • Change in temperature compared to surrounding skin (warmer or cooler)
  • Color changes
    • Non-blanchable erythema in patients with lightly pigmented skin
    • Purplish/bluish discoloration in patients with darkly pigmented skin
  • Consistency of the tissue, such as bogginess (soft) or induration (hard)
  • Edema
  • Open areas, blisters, rash, drainage
  • Pain or itching2
  • Clients who are restricted to bed and/or chair, or those experiencing surgical intervention, should be assessed for pressure, friction and shear in all positions and during lifting, turning and repositioning3
  • Document any areas of concern as per agency/organizational policy. Using a diagram of the location on the body is useful, especially if working with unregulated health providers who may not be knowledgeable about medical terminology describing locations

Skin Care Interventions



Maximize Activity and Mobility by Reducing or Eliminating Friction and Shear
  1. Registered Nurses’ Association of Ontario (2005). Risk assessment and prevention of pressure ulcers. (Revised). Toronto, Canada: Registered Nurses’ Association of Ontario. Updated 2011.
  2. Institute for Clinical Systems Improvement (ICSI). Pressure ulcer prevention and treatment protocol. Health care protocol. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2012 Jan. 88 p. [112 references] Guideline NGC-8962. National Guideline Clearinghouse. Agency for Healthcare Research and Policy. Accessed from: http://www.guideline.gov/content.aspx?id=36059
  3. Registered Nurses’ Association of Ontario (2005). Risk assessment and prevention of pressure ulcers. (Revised). Toronto, Canada: Registered Nurses’ Association of Ontario. Updated 2011.

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