Sequence not checked yetPlace all eight regions, then check.
Eyes are washed first and with no soap. Use a separate corner of the cloth for each eye and wipe from the inner canthus outward, so debris is never dragged toward the tear duct and across to the other eye.
Set a temperatureThen tell me who is in the bed.
Never massage over a reddened bony prominence. Friction over an already-injured microcirculation deepens the injury. Pat fragile skin dry — do not rub — and moisturize dry areas only.
How to chart itVague: Bath given, skin ok.
Precise: 0930 Complete bed bath with assist of 1. Skin assessed head to toe. 2 cm area of non-blanchable erythema over left ischial tuberosity, intact, no induration, patient reports tenderness 3/10 with palpation. All other surfaces intact. Repositioned to right 30-degree lateral, heels floated on pillow, offloading schedule initiated q2h. Braden rescored 14. Wound care consult requested via order entry.
Make a callPick a bucket for the finding on the left.
Every skin toneRedness is not the finding — the tissue change is. In darker skin an early pressure injury is more often purple, violaceous, dark blue, gray or simply darker than the surrounding skin, and blanching may not be observable at all. Compare temperature with the mirror-image site using the back of your hand, feel for bogginess or firmness, ask about pain, and use bright white light. For general color change, look where pigment is thin: cyanosis and pallor at the oral mucosa, conjunctivae, palms, soles and nail beds; jaundice at the sclera, hard palate and palms.