t’ s been my passion project over the past three years to study the topic of skin assessments on all skin tones so I can help educate nurses. I fly a lot, and I fly Southwest, so I get to pick my own seats, and I have made it a point to sit next to people who are not of my same skin tone. I have blanched about 200 forearms in the last couple of years just to understand the blanch-ability of different skin tones, and I will tell you, it gets harder and harder after Monk Skin Tone Scale stage 6 to see that blanching. It was very non-scientific, but it was an eye opener to me.

Another firsthand experience with skin assessments happened when my mother fell and broke her femur. The initial skin assessment was cursory at best. Only after I advocated for her did the staff return for a more thorough evaluation. This encounter reinforced my belief that we must do better— not just for our loved ones, but for every patient. This issue isn’ t just academic; it’ s a matter of equity, quality care and reducing health disparities.

Why skin assessments matter The population is getting more diverse. Yet, people with dark skin tones are often diagnosed with pressure injuries at later stages. This is well documented and deeply concerning. Textbooks and educational materials have historically favored light-skinned patients, instructing nurses to look for redness— a sign that may not be visible in non-white skin.

There are significant gaps in nursing and medical education regarding skin tone diversity. Many clinicians lack confidence in assessing dark skin, and unconscious bias or outdated language persists in training. It’ s not about race— it’ s about skin tone. For example, a patient who identifies as Black may have very light skin, or vice versa. Assessments must be tailored to the individual’ s skin tone, not assumptions about race. And of course we all are acutely aware of the financial penalties that can exist when missing those pressure injuries and not seeing what we’ re supposed to see, especially for non-white skin patients.

Finding the native skin tone The full webinar is available to watch through the NPIAP website. Here, we share some of the topics that Dr. Black and James discussed during the question-and-answer session.

Finding the native skin tone is really where the discussion part starts. Before that it ' s sort of build up to it. We can ' t always see that blanching on dark skin, but the person’ s race and ethnicity are not predictive of skin pigmentation. For instance, you can have a patient who

identifies as Black, who is actually an albino, or who has very light skin. Erythema only reflects one description of change in skin color, and it’ s seen in early PIs, but it is not a universal, it’ s one predictor. It really is about the skin tone, not the race of the patient that we are addressing. So you have to use your other senses.

When it comes to identifying a patient’ s baseline skin tone, I always suggest looking at areas that haven’ t been sun-damaged, like the inner arm. That’ s where you’ ll find the native skin tone. Of course, tattoos and other markings can complicate things, so find undisturbed skin wherever you can. And this isn’ t something you need to reassess every time you assess the skin. Once you’ ve documented it, it becomes part of the patient’ s profile.

Choosing a skin tone scale Now, having talked about where to assess skin tone, what do you do with that? Well, there are a lot of scales out there, but we honed in on the Monk scale

early on in our research at Medline. It’ s very clean, very inclusive and doesn’ t get out of control with too many options. I think we could make it so complicated that nobody’ s going to do it. Our goal is to make it easier to assess skin, not more complex. We can be good with looking at 10 options.

Some people are still prone to the Fitzpatrick scale, but that was really designed for skin cancer risk in light skin tones. When you get to the 5 or 6 on the Fitzpatrick, there’ s not a lot of differentiation, so you have a bunch of people in 5 and a bunch of people in 6. That’ s where Monk really breaks it out to a more even distribution of the various skin tones. Until technology catches up with this issue, if a patient has a Monk 7 or higher, start them on pressure injury prevention protocols within your facility. I don ' t think there ' s anything wrong with that.

The power of four I’ m a big believer in the four eyes, four hands approach to skin assessments. It’ s not yet universal, but it’ s gaining traction in a lot of hospitals. They

28 Healthy Skin Issue 16 / Fall 2025