Unit 9
Describing Skin Changes and Speaking Up
Workplace English for Nursing Assistants
Meet Carol
Watch the video about Carol. Watch what happens.
Carol — A Sore That Was Missed
Talk about it
- Why might Carol feel no pain in the reddened area?
- Does Carol have a pressure injury? If so, what stage? How do you know?
- Should you report the red area to the nurse? When?
- Name three things that put Carol at risk for skin breakdown.
- Should you let Carol eat only desserts today? Why or why not?
How Skin Breaks Down
Chattybot · FlashcardsScan to drill these words out loud.A pressure injury starts as a red mark that does not turn white when you press it. It can become a hole to the bone. Most of these injuries are preventable. You see the skin at every bath, every brief change, every turn. It's your job to see and report.
These five forces damage skin.
| Term | Plain meaning |
|---|---|
| Shear | A sliding force — the body slides down in bed and the skin sticks to the sheets, tearing the tissue. |
| Friction | Skin rubbing against another surface (rubbing heels/elbows on the sheets); makes heat and blisters. |
| Maceration | Skin softened by constant moisture (like wrinkly skin after a long swim); softened skin tears easily. |
| Microclimate | The warm, humid space between the skin and the bed or wheelchair; heat + moisture harm the skin. |
| Immobility | The client cannot move themselves — the single biggest cause of pressure injuries. |
Keep the head of the bed at 30 degrees or less when you can. Above 30 degrees, the client slides down — causing shear injury to the sacrum.
The rule works twice: the head of the bed at 30 degrees or less, and a 30-degree side-lying tilt instead of turning the client fully onto their hip. Also use lift or slide sheets when moving a client, so skin does not drag on the sheets.
Practice 1
1.1 Match the term to its meaning
- 1. Shear
- 2. Friction
- 3. Maceration
- 4. Microclimate
- 5. Immobility
- A. The inability of the client to move themselves purposefully
- B. A force on the skin when the body slides down in bed and the skin sticks to the linens
- C. A close environment where heat and humidity are localized (skin against the bed or chair)
- D. The movement of one layer of skin against another, or against a hard surface
- E. Skin softened from constant exposure to moisture
1.2 Which force? (shear / friction / maceration / microclimate)
- A client's skin is soft and wrinkly after sitting in a wet incontinence product. ________________
- The head of the bed is at 45 degrees and the client slides down. ________________
- Heat and moisture build up between the client and the wheelchair seat. ________________
- A client rubs their heels back and forth on the sheets and gets a blister. ________________
Pressure-Injury Words
Chattybot · FlashcardsScan to drill these words out loud.| Term | Plain meaning |
|---|---|
| Bony prominence | Any bone that sticks out (tailbone/coccyx, sacrum, heels, hips, shoulder blades, ears). Injuries form here. |
| Eschar | Dead (necrotic) tissue found inside a deeper pressure injury. |
| Debridement | Removing the dead tissue (eschar) — done only by a nurse, doctor, or physical therapist, never a healthcare worker. |
A pressure injury (also called a bed sore, pressure sore, or decubitus ulcer) forms when there is constant, unrelieved pressure over a bony prominence. It should never happen — since 2008, Medicare will not pay hospitals to treat ones the facility caused, because they are preventable.
Practice 2
2.1 Match the term to its meaning
- 1. Bony prominence
- 2. Eschar
- 3. Debridement
- A. The chemical or manual removal of eschar
- B. Any area of bone that sticks out or protrudes from the body
- C. Necrotic (dead) tissue sometimes found in a pressure injury
2.2 True or False
- Pressure injuries form over bony prominences like the coccyx and heels. ________________
- A healthcare worker may perform debridement on a client's wound. ________________
- Eschar is dead tissue found in deeper pressure injuries. ________________
The Four Stages (by depth)
Chattybot · FlashcardsScan to drill these words out loud.Pressure injuries are staged by how deep they go — the same skin layers from Unit 1. Deeper = higher stage = harder to heal.
| Stage | What it looks like |
|---|---|
| Stage 1 | Skin is still closed (intact). Red and does NOT blanch (stays red when pressed); may be warm, swollen, painful. In dark skin: a blue or purple area. |
| Stage 2 | Skin is OPEN — a shallow crater. Epidermis (and maybe dermis) involved. |
| Stage 3 | A deep crater through the subcutaneous layer; may have eschar and can tunnel deeper than it looks. |
| Stage 4 | Deepest — reaches muscle, tendon, or bone. Takes months to heal; often leaves scarring. |
To blanch means to turn white when pressed. Healthy red skin blanches (turns white, then red again). A stage-1 injury is non-blanching — it stays red. That is your warning sign.
Intact skin is unbroken. Open skin is broken. These two words come up constantly, so be sure you can state clearly which one you are describing.
“The skin is still intact.” / “There is an open area on the heel.”
Practice 3
3.1 Which stage?
- Skin is still closed, red, warm, swollen, and does NOT turn white when pressed. Stage
- Open skin — a shallow crater in the epidermis. Stage
- The wound reaches muscle and bone. Stage
- A deep crater through the subcutaneous tissue, possibly with eschar. Stage
Risk Factors & Prevention
Six things raise the risk. Immobility is number one.
| Risk factor | Why it harms skin |
|---|---|
| Immobility (#1) | Client cannot shift off the pressure; depends on you to reposition. |
| Cannot feel pain/pressure | Pain is what makes us move; without it (coma, confusion, diabetes), the client stays put. |
| Incontinence | Urine and feces macerate and break down the skin. |
| Poor nutrition | Low protein = skin cannot build or repair tissue. |
| Poor hydration | Dry skin is brittle and tears easily. |
| High microclimate | Trapped heat and moisture (worse with a fever). |
The prevention bundle — what you do every day
- Inspect the skin twice a day (during morning and evening bathing); check heels, coccyx, and skin folds. Report any new redness, rash, or blister.
- Reposition in bed at least every 2 hours; in a wheelchair, at least every hour. Never position on an existing injury.
- Use pillows and devices to keep pressure off bony prominences — float the heels off the mattress, pillow between the knees, elbow/heel protectors, a 30-degree side-lying tilt.
- Incontinence care at least every 2 hours: use a gentle, no-rinse, pH-balanced peri-cleanser; pat dry; apply barrier cream to INTACT skin.
- Nutrition & hydration: offer protein first, protein shakes between meals; keep fluids within reach and offer them at every contact (ice water each shift; popsicles and ice cream count).
- Reduce the microclimate: reposition often, avoid too many blankets, and report fevers.
After you "float the heels" with a pillow under the calves, you should be able to slide your hand under the client's heels without touching the mattress. If you cannot, the heels are not floated. Keep the pillow off the Achilles tendon and out from behind the knee.
Practice 4
4.1 Fill in the Blank
Use a word from the word bank. Each is used once.
Word bank: bone • eschar • debridement • movement • immobility • heat • humidity • shear • prevention • rashes • hydration
- A bony prominence is any area of that sticks out from the body.
- Dead tissue sometimes found in a pressure injury is called .
- is the chemical or manual removal of eschar.
- Friction is the of one layer of skin against another.
- is the inability of the client to move themselves purposefully.
- Microclimate is related to the and between the skin and the bed or chair.
- is the force sliding against an area of the skin.
- of skin breakdown is your responsibility as a healthcare worker.
- Sometimes skin are an overgrowth of yeast (a yeast infection).
- and proper protein intake are very important to healthy skin.
The Part Nobody Teaches: Speaking Up
Turn every two hours. Inspect twice a day. Head of bed at 30 degrees. Barrier cream on intact skin only... You cannot do all of it alone. A client is turned twelve times a day by four or five different people across three shifts. Your two-hour turn is worth very little if the next person leaves the bed at 45 degrees, drags the client up without a slide sheet, or puts barrier cream on an open sore.
Most pressure injuries are preventable. They are caused by a chain of small omissions, usually by people who all meant well. The chain breaks when one person says something.
Correct the fact, not the person
The single most useful habit in this unit: talk about the thing, not the colleague.
| "You did that wrong." | "Actually, I think the bed should be at 30 or less." |
| "You're not supposed to drag her." | "Shall we grab the slide sheet? It saves her skin." |
| "That's not a rash, it's a pressure sore." | "I think you mean a rash — but it isn't blanching. Should we look again?" |
| "You can't put cream on that." | "Sorry — don't you mean on intact skin? That one's open." |
- Actually, I think you mean …
- Excuse me, but …
- Sorry, don't you mean …?
- Are you sure? / But barrier cream is for intact skin, isn't it?
Sometimes you say it politely and the person does it anyway. Do not drop it, and do not argue in front of the client.
Tell the nurse. Not to get anyone in trouble — because a client's skin is at risk and the nurse is the person who can change the care plan. Staying silent makes you part of the chain.
Bandages & Creams — Staying in Scope
A healthcare worker may change non-sterile ("clean") bandages with clean gloves, following the care plan. A healthcare worker may not change sterile bandages — that is outside your scope. Wash hands, ready your supplies, explain to the client, remove the old bandage into the trash, place the new one touching only its edges, and report any redness, drainage, or pain to the nurse.
Over-the-counter creams and barrier creams: only on intact skin. If the skin is open, stop and tell the nurse.
Families ask you to do things. They are trying to help, and their remedies are often things that worked in their own family for fifty years — powder, ointment, honey, a heat lamp. You will have to say no, kindly, and often more than once.
- I'm afraid that's not something I can do.
- I'm not allowed to put anything on open skin — it has to be the nurse.
- Sorry, that's not possible — but here's what I can do.
- I'd like to help, but that's outside what I'm allowed to do.
Four-part refusal: refuse → give the reason → offer what you CAN do → refer to the nurse. Never just "no."
Practice 5 — Correcting Without Offending
5.1 Hardest to softest
Put these five corrections in order, 1 (hardest) to 5 (softest).
- "Are you sure?" ________________
- "That's wrong." ________________
- "Shall we double-check?" ________________
- "Actually, it's 30 degrees." ________________
- "It's 30 degrees, isn't it?" ________________
5.2 Person or fact?
Write P if the sentence corrects the PERSON, or F if it corrects the FACT.
- "You did that wrong." ________________
- "Actually, I think the bed should be at 30 or less." ________________
- "You're not supposed to drag her like that." ________________
- "Shall we grab the slide sheet? It saves her skin." ________________
- "Sorry — don't you mean on intact skin?" ________________
5.3 Rewrite it
Rewrite each correction so it corrects the FACT, politely.
- "You can't put cream on that, it's open." →
______________________________________________________________
- "You forgot to turn her again." →
______________________________________________________________
- "That's not a bruise, it's a pressure sore." →
______________________________________________________________
- Which force happens when a client slides down the bed?
- What is the number-one cause of pressure injuries?
- Say the 30-degree rule in your own words — both halves.
- Which stage is red, closed skin that does not blanch?
- Which stages are OPEN skin?
- You find an open area. Name the four things you do — and the one thing you must not do.
- How often do you reposition in bed? In a wheelchair?
- How do you check that the heels are really floated?
- Which food do you offer first to a client at risk?
Dialogue Practice
Read these dialogues out loud with a partner.
Dialogue 1 —"Speaking Up About Nonblanching Redness"
Chattybot · DialogueScan to read this script out loud.You are bathing Mr. Sørensen with Yolanda, who has worked here eleven years. On his coccyx there is a red patch. You press it. It does not turn white.
Yolanda: Oh, that's just a rash. He gets it. I'll put some barrier cream on and it'll be gone by Friday.
You: Are you sure? I pressed it and it didn't go white.
Yolanda: (pausing) Didn't it?
You: Could you press it and tell me if it blanches? I'd rather have another pair of eyes on it before I write anything.
Yolanda: (presses) … Hm. No, you're right. It's staying red.
You: Actually, I think that makes it a stage one, doesn't it? The skin's still closed, so the cream is fine — but the nurse needs to see it today.
Yolanda: Good catch. I'd have just creamed it and moved on.
You: And we shouldn't lay him back on that side, should we?
Yolanda: No. Let's tilt him the other way and put a pillow between his knees.
Dialogue 2 —Politely Stopping an Unsafe Skin Treatment
Chattybot · DialogueScan to read this script out loud.Mrs. Baptiste's daughter has brought a jar of ointment from home. Her mother has an open stage-2 area on her heel. The daughter has already taken the dressing off and is reaching toward it.
Daughter: This is what my grandmother always used. It healed everything. I'll just put a little on.
You: Please wait — I'm afraid that's not something I can let happen. I'm sorry.
Daughter: It's only ointment. It's natural.
You: I know you're trying to help her, and I can see it matters to you. But that area is open, and nothing at all goes on open skin — not by me, and not by family. It has to be the nurse. Anything else can push germs in.
Daughter: So we just leave it? Nobody does anything?
You: No — plenty is being done. I keep it clean and dry, I keep her weight off that heel, and I float her heels off the mattress with a pillow. Let me show you — first, the pillow goes under her calves, not under the heel itself.
Daughter: Like that?
You: That's it. Then slide your hand under her heel — if it touches the bed, the pillow needs moving. Can you show me how you'd check it?
Daughter: (checks) It's off the bed.
You: Perfect. That's something you can do every time you visit. And I'm getting the nurse now so she can look at the ointment and tell you properly.
Role Plays
Work with a partner.
Situation
You and an experienced healthcare worker are bathing Mrs. Fontaine. You see a dark purple patch on her hip. Mrs. Fontaine has dark skin, and your colleague says it is an old bruise from a fall last month.
Your Goals:
- Use the SOFTEST correction first — a question, not a statement.
- Ask for a second pair of eyes on it.
- Say the blanch test out loud and ask your colleague to do it.
- Mention that stage 1 can look purple or blue on dark skin.
- Correct the FACT, never the person.
- Say what happens next — nurse, and no positioning on that side.
Situation
For the third shift running, a colleague has left Mrs. Okpara sitting in her wheelchair for over three hours without repositioning. She has a stage-1 area on her coccyx. You have already mentioned it twice, politely. Handle it today.
Your Goals:
- Try ONE more polite correction, with the reason.
- Do not argue in front of the client.
- Find out WHY it keeps happening — ask, don't assume.
- Escalate to the nurse, framed around the CLIENT, not the coworker.
- Report with a Summarizing phrase: where, what, since when.
Cumulative Review
Multiple Choice
1. Preventable skin rashes most often appear
- across the chest and abdomen
- beneath breasts, under arms, and between skin folds
- on the legs and feet
2. A rash found under a client's arms may be caused by
- shearing
- pressure
- infection
3. An intact area on the coccyx that is red, painful, swollen, and does not blanch is a
- stage-one pressure injury
- stage-two pressure injury
- stage-three pressure injury
4. You are helping a client to the toilet and see an OPEN area on their coccyx. You should
- clean it and apply barrier cream
- report your finding to the nurse
- apply a little cornstarch
5. The factor that puts a client MOST at risk for a pressure injury is
- inability to sense pain
- incontinence
- immobility
6. A client at risk for skin breakdown should be repositioned in bed at least every
- 30 minutes
- 2 hours
- 4 hours
7. To help a client's skin heal, you should offer
- sweets first for energy
- protein first
- only fluids
Back to Carol
Read the case and answer in complete sentences. Use the sentence starters if you wish.
Carol is 91, has diabetes and dementia, and is incontinent of urine and feces. While bathing Carol today, you notice a red area on their bottom that does not go away when pressed. You ask if it hurts; Carol says no. After the bath, you use a gait belt and a second assistant to help Carol into the wheelchair. At breakfast, Carol says they only want to eat desserts.
1. Why might Carol feel no pain in the reddened area?
______________________________________________________________
2. Does Carol have a pressure injury? If so, what stage? How do you know?
______________________________________________________________
3. Should you report the red area to the nurse? When?
______________________________________________________________
4. Name three things that put Carol at risk for skin breakdown.
______________________________________________________________
5. How often should you reposition Carol, and how often should you do peri-care? What cleanser should you use?
______________________________________________________________
6. Should you let Carol eat only desserts today? Why or why not?
______________________________________________________________
Instructor Answer Key
Unit 9 — Describing Skin Changes and Speaking Up
This unit introduces the causes, warning signs, stages, and prevention of pressure injuries. Learners study shear, friction, moisture, immobility, blanching, skin depth, positioning, nutrition, and other factors that affect skin integrity. A case study about Carol connects diabetes, dementia, incontinence, nutrition, and nonblanching redness to the need for prompt reporting. Through illustrated readings, flashcards, knowledge checks, dialogues, and role-plays, learners practice describing a skin change by location, color, depth, and condition, reporting concerns immediately, and speaking up tactfully when a coworker suggests an unsafe treatment or positioning practice.
Practice 1–5 and Review
Practice 1.1: 1-B, 2-D, 3-E, 4-C, 5-A. Practice 1.2: 1. maceration 2. shear 3. microclimate 4. friction.
Practice 2.1: 1-B, 2-C, 3-A. Practice 2.2: 1. True 2. False 3. True.
Practice 3.1: 1. Stage 1 2. Stage 2 3. Stage 4 4. Stage 3. Practice 3.2: answers vary — each sentence must give the location, the colour, and whether the skin is intact or open (e.g. “A red area on the left heel, still red when pressed, skin intact.”).
Practice 4.1 (fill in): 1. bone 2. eschar 3. debridement 4. movement 5. immobility 6. heat, humidity 7. shear 8. prevention 9. rashes 10. hydration.
Multiple Choice: 1-b, 2-c, 3-a, 4-b, 5-c, 6-b, 7-b.
Back to Carol Case Study (sample): (1) Diabetes (and possibly dementia) can reduce pain sensation, so Carol may not feel the pressure. (2) Yes — a stage-one pressure injury: the skin is intact, red, and non-blanching. (3) Yes — report it to the nurse immediately. (4) Any three: immobility, incontinence, diabetes/loss of pain sensation, poor nutrition (desserts only), age, dementia. (5) Reposition at least every 2 hours (every hour in the wheelchair) and do peri-care at least every 2 hours, using a gentle, no-rinse, pH-balanced peri-cleanser; pat dry and apply barrier cream to intact skin. (6) No — offer protein first; protein builds and repairs skin tissue. Encourage a balanced diet and fluids; report the poor intake to the nurse.
Call out a wrong statement ("Barrier cream goes on the sore." "Turn her every four hours." "The bed can go to 60." "Just drag her up, she's light."). The learner must correct it three times — first with "Are you sure?", then with a tag question, then firmly. Same content, three temperatures.