How to identify pressure damage on dark pigmented skin.
Many of us may have heard of the ‘react to red’ campaign and like my self having been teaching multi disciplinary teams, formal and informal carers along with residents and patients how to identify suspected pressure damage by looking for ‘red areas’. Using the blanching and non blanching technique shown in the image to the right.
Whilst this is a very straightforward and easy identifiable technique that can be taught everybody in contact with the skin, early detection is dependent on a visual prompt of redness. This clearly becomes an issue on identifying early damage darker pigmented skin.
It is important therefore to have awareness of the other reported early signs of pressure damage such as:
An area of skin over bony prominence that feels cooler or warmer to touch.
reports of pins and needles.
Report of pain. Those residents have capacity the classic ‘nurse my heel/bottom is sore’ can be a classic early warning indicator and it would be worth checking for the above symptoms as soon as possible. However, people with sensory neuropathy may not experience the pain caused by pressure damage.
The area may feel warm.
The area may be oedematous with areas of hardness.
If any of the above symptoms are indicated in dark pigmented skin but no obvious pressure damage is yet evident it would be worth carrying out a holistic assessment using your SSKIN bundle or prevention care plan along with risk reassessments e.g. Waterlow/Braden, MUST to establish if there is any changes that may contribute to increased risk of pressure damage.
It may be that your resident has gone into hospital and come home with a degree of weight loss and reduced mobility meaning the equipment they had for admission which was adequate pre-admission, is now inadequate.
A scenario I was involved with similar to this with a patient with very dark pigmentation, was with a lovely elderly gentleman with severe parkinson’s and moderate contractures. He had a excellent riser recliner chair with an in built lower lumbar support and pressure relieving cushion, which can be very hard to find nowadays!.
This patient went into hospital with a urinary infection returning with a degree of weight loss, as a result his anatomical position in his chair had changed but not been reassessed. Unfortunately as a result, the position of the chair which once supported him was now in a different position and digging in to his left hip, this caused him to develop a grade 2 pressure ulcer which later deteriorated to the grade 3 because of his poor underlying nutritional status and contracture’s.
Although he had daily personal care with documented skin inspections we believe it was difficult for the carers to have picked up the non-blanching erythema with lack of training on other symptoms of early damage and the patient had difficulty expressing himself.
Therefore those residents without capacity is vital to use a non-verbal visual analogue pain scale as part of your assessment. This may be yet another indicator.
It is important those with darkly pigmented skin and a at risk of developing pressure ulcers status to incorporate into the skin special care plan other signs of early-stage pressure damage, so that all carers and nurses and multidisciplinary teams involved with the residents may have awareness also to closely inspect the skin.
This is a matter of training and raising awareness. It is notoriously difficult to get a digital picture of the grade 1 pressure ulcer on darkly pigmented skin for above said reasons. Therefore if you are able to catch a pressure ulcer at this stage on darker skin and have gained consent do take a picture to show others in your training.
Clark M (2010) Skin assessment in dark pigmented skin: a challenge in pressure ulcer prevention. Nursing Times; 106: 30 accessed online 21st August 2018. Available at :
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