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Now that we have reviewed the anatomy of the integumentary system and common integumentary conditions, let’s review the components of an integumentary assessment. The standard for documentation of skin assessment is within 24 hours of admission to inpatient care. Skin assessment should also be ongoing in inpatient and long-term care.[1]
A routine integumentary assessment by a registered nurse in an inpatient care setting typically includes inspecting overall skin color, inspecting for skin lesions and wounds, and palpating extremities for edema, temperature, and capillary refill.[2]
Subjective Assessment
Begin the assessment by asking focused interview questions regarding the integumentary system. Itching is the most frequent complaint related to the integumentary system. See Table \(\PageIndex{1}\) for sample interview questions.
| Questions | Follow-up |
|---|---|
| Are you currently experiencing any skin symptoms such as itching, rashes, or an unusual mole, lump, bump, or nodule?[3] | Use the PQRSTU method to gain additional information about current symptoms. Read more about the PQRSTU method in the “Health History” chapter. |
| Have you ever been diagnosed with a condition such as acne, eczema, skin cancer, pressure injuries, jaundice, edema, or lymphedema? | Please describe. |
| Are you currently using any prescription or over-the-counter medications, creams, vitamins, or supplements to treat a skin, hair, or nail condition? | Please describe. |
Objective Assessment
There are five key areas to note during a focused integumentary assessment: color, skin temperature, moisture level, skin turgor, and any lesions or skin breakdown. Certain body areas require particular observation because they are more prone to pressure injuries, such as bony prominences, skin folds, perineum, between digits of the hands and feet, and under any medical device that can be removed during routine daily care.[4]
Inspection
Color
Inspect the color of the patient’s skin and compare findings to what is expected for their skin tone. Note a change in color such as pallor (paleness), cyanosis (blueness), jaundice (yellowness), or erythema (redness). Note if there is any bruising (ecchymosis) present.
Scalp
If the patient reports itching of the scalp, inspect the scalp for lice and/or nits.
Lesions and Skin Breakdown
Note any lesions, skin breakdown, or unusual findings, such as rashes, petechiae, unusual moles, or burns. Be aware that unusual patterns of bruising or burns can be signs of abuse that warrant further investigation and reporting according to agency policy and state regulations.
Auscultation
Auscultation does not occur during a focused integumentary exam.
Palpation
Palpation of the skin includes assessing temperature, moisture, texture, skin turgor, capillary refill, and edema. If erythema or rashes are present, it is helpful to apply pressure with a gloved finger to further assess for blanching (whitening with pressure).
Temperature, Moisture, and Texture
Fever, decreased perfusion of the extremities, and local inflammation in tissues can cause changes in skin temperature. For example, a fever can cause a patient’s skin to feel warm and sweaty (diaphoretic). Decreased perfusion of the extremities can cause the patient’s hands and feet to feel cool, whereas local tissue infection or inflammation can make the localized area feel warmer than the surrounding skin. Research has shown that experienced practitioners can palpate skin temperature accurately and detect differences as small as 1 to 2 degrees Celsius. For accurate palpation of skin temperature, do not hold anything warm or cold in your hands for several minutes prior to palpation. Use the palmar surface of your dominant hand to assess temperature.[5] While assessing skin temperature, also assess if the skin feels dry or moist and the texture of the skin. Skin that appears or feels sweaty is referred to as being diaphoretic.
Capillary Refill
The capillary refill test is a test done on the nail beds to monitor perfusion, the amount of blood flow to tissue. Pressure is applied to a fingernail or toenail until it turns white, indicating that the blood has been forced from the tissue under the nail. This whiteness is called blanching. Once the tissue has blanched, remove pressure. Capillary refill is defined as the time it takes for color to return to the tissue after pressure has been removed that caused blanching. If there is sufficient blood flow to the area, a pink color should return within 2 seconds after the pressure is removed. [6]
Note
View the following video demonstrating Capillary Refill[7]:
Skin Turgor
Skin turgor may be included when assessing a patient’s hydration status, but research has shown it is not a good indicator. Skin turgor is the skin’s elasticity. Its ability to change shape and return to normal may be decreased when the patient is dehydrated. To check for skin turgor, gently grasp skin on the patient’s lower arm between two fingers so that it is tented upwards, and then release. Skin with normal turgor snaps rapidly back to its normal position, but skin with poor turgor takes additional time to return to its normal position.[8] Skin turgor is not a reliable method to assess for dehydration in older adults because they have decreased skin elasticity, so other assessments for dehydration should be included.[9]
Edema
If edema is present on inspection, palpate the area to determine if the edema is pitting or nonpitting. Press on the skin to assess for indentation, ideally over a bony structure, such as the tibia. If no indentation occurs, it is referred to as nonpitting edema. If indentation occurs, it is referred to as pitting edema. See Figure \(\PageIndex{1}\)[10] for an image demonstrating pitting edema. If pitting edema is present, document the depth of the indention and how long it takes for the skin to rebound back to its original position. The indentation and time required to rebound to the original position are graded on a scale from 1 to 4, where 1+ indicates a barely detectable depression with immediate rebound, and 4+ indicates a deep depression with a time lapse of over 20 seconds required to rebound. See Figure \(\PageIndex{2}\)[11] for an illustration of grading edema.
Life Span Considerations
Older Adults
Older adults have several changes associated with aging that are apparent during assessment of the integumentary system. They often have cardiac and circulatory system conditions that cause decreased perfusion, resulting in cool hands and feet. They have decreased elasticity and fragile skin that often tears more easily. The blood vessels of the dermis become more fragile, leading to bruising and bleeding under the skin. The subcutaneous fat layer thins, so it has less insulation and padding and reduced ability to maintain body temperature. Growths such as skin tags, rough patches (keratoses), skin cancers, and other lesions are more common. Older adults may also be less able to sense touch, pressure, vibration, heat, and cold.[12]
When completing an integumentary assessment it is important to distinguish between expected and unexpected assessment findings. Please review Table \(\PageIndex{2}\) to review common expected and unexpected integumentary findings.
| Assessment | Expected Findings | Unexpected Findings (Document and notify provider if it is a new finding*) |
|---|---|---|
| Inspection | Skin is expected color for ethnicity without lesions or rashes. | Jaundice Erythema Pallor Cyanosis Irregular-looking mole Bruising (ecchymosis) Rashes Petechiae Skin breakdown Burns |
| Auscultation | Not applicable | |
| Palpation | Skin is warm and dry with no edema. Capillary refill is less than 3 seconds. Skin has normal turgor with no tenting. | Diaphoretic or clammy Cool extremity Edema Lymphedema Capillary refill greater than 3 seconds Tenting |
| *CRITICAL CONDITIONS to report immediately | Cool and clammy Diaphoretic Petechiae Jaundice Cyanosis Redness, warmth, and tenderness indicating a possible infection |
- Medline Industries, Inc. (n.d.). Are you doing comprehensive skin assessments correctly? Get the whole picture. https://www.medline.com/skin-health/comprehensive-skin-assessments-correctly-get-whole-picture/#:~:text=A%20comprehensive%20skin%20assessment%20entails,actually%20more%20than%20skin%20deep. ↵
- Giddens, J. F. (2007). A survey of physical examination techniques performed by RNs: Lessons for nursing education. Journal of Nursing Education, 46(2), 83-87. https://doi.org/10.3928/01484834-20070201-09↵
- McKay, M. (1990). The dermatologic history. In Walker, H. K., Hall, W. D., Hurst, J. W. (Eds.), Clinical methods: The history, physical, and laboratory examinations (3rd ed.). www.ncbi.nlm.nih.gov/books/NBK207/↵
- Medline Industries, Inc. (n.d.). Are you doing comprehensive skin assessments correctly? Get the whole picture. https://www.medline.com/skin-health/comprehensive-skin-assessments-correctly-get-whole-picture/#:~:text=A%20comprehensive%20skin%20assessment%20entails,actually%20more%20than%20skin%20deep.↵
- Levine, D., Walker, J. R., Marcellin-Little, D. J., Goulet, R., & Ru, H. (2018). Detection of skin temperature differences using palpation by manual physical therapists and lay individuals. The Journal of Manual & Manipulative Therapy, 26(2), 97-101. dx.doi.org/10.1080%2F10669817.2018.1427908↵
- Johannsen, L.L. (2005). Skin assessment. Dermatology Nursing, 17(2), 165-66. ↵
- Nurse Saria. (2018, September 18). Cardiovascular assessment part two | Capillary refill test. [Video}. YouTube. All rights reserved. https://youtu.be/A6htMxo4Cks↵
- A.D.A.M. Medical Encyclopedia [Internet]. Atlanta (GA): A.D.A.M., Inc.; c1997-2020. Skin turgor; [updated 2020, Sep 16; cited 2020, Sep 18]. https://medlineplus.gov/ency/article/003281.htm#:~:text=To%20check%20for%20skin%20turgor,back%20to%20its%20normal%20position.↵
- Nursing Times. (2015, August 3). Detecting dehydration in older people. https://www.nursingtimes.net/roles/older-people-nurses-roles/detecting-dehydration-in-older-people-useful-tests-03-08-2015/↵
- “Combinpedal.jpg” by James Heilman, MD is licensed under CC BY-SA 3.0↵
- “Grading of Edema” by Meredith Pomietlo for Chippewa Valley Technical College is licensed under CC BY 4.0↵
- A.D.A.M. Medical Encyclopedia [Internet]. Atlanta (GA): A.D.A.M., Inc.; c1997-2020. Aging changes in skin; [updated 2020, Sep 16; cited 2020, Sep 18]. https://medlineplus.gov/ency/article/004014.htm#:~:text=The%20remaining%20melanocytes%20increase%20in,the%20skin's%20strength%20and%20elasticity↵
FAQs
What is a normal assessment of integumentary system? ›
A routine integumentary assessment by a registered nurse in an inpatient care setting typically includes inspecting overall skin color, inspecting for skin lesions and wounds, and palpating extremities for edema, temperature, and capillary refill.
What are normal findings in skin assessment? ›Normal findings might be documented as: “Skin temperature is warm and equal bilaterally on arms and legs. Skin is smooth with no perspiration and no lesions. Good skin turgor. Limb circumference is equal bilaterally with no edema.
What are normal findings of hair assessment? ›Normal findings might be documented as: “Hair colour and distribution consistent with no dryness or oiliness and no lesions present.” Abnormal findings might be documented as: “Several nits located on hair strands on the posterior and left side of the head with lice behind the left ear and at the base of the neck.”
How to do an integumentary assessment? ›- Ask Questions. ...
- Symptoms or Complaints. ...
- Pain. ...
- Inspect Color of the Skin. ...
- Inspect and Palpate the Skin. ...
- Assess for Edema. ...
- Inspect and Palpate the Nails. ...
- Inspect and Palpate the Hair.
Assessment of the integumentary system is an essential part of every pediatric health care visit. The condition of the skin, hair, and nails provides important information about both physical and emotional health.
How do you assess skin assessment? ›Perform a physical assessment
This includes assessment of skin color, moisture, temperature, texture, mobility and turgor, and skin lesions. Inspect and palpate the fingernails and toenails, noting their color and shape and whether any lesions are present.
“Healthy skin is smooth, not dry or scaly, not wrinkled and non-blemished from acne or sun damage,” Dr. Longwill explains. “I characterize 'healthy skin' as hydrated, smooth, plump, and pink, meaning great circulation,” she adds.
What is normal skin integrity? ›The term 'skin integrity' refers to the skin being a sound and complete structure in unimpaired condition. Conversely, impaired skin integrity is defined as an "altered epidermis and/or dermis...
How do you document skin integrity? ›Information gathered from the skin inspection and aspects of management should be clearly documented in the patient's notes and care plan. Inspection should include assessment of the skin's colour, temperature, texture, moisture, integrity and include the location of any skin breakdown or wounds.
What are normal findings of nails? ›Normal findings might be documented as: “Nails are smooth, firm, clean with translucent colour, and no presence of clubbing. Capillary refill within 2 seconds.” Abnormal findings might be documented as: “Nail angle on thumbs is slightly greater than 180 degrees, capillary refill time is 5 seconds.”
What are the 4 most important factors to consider in hair analysis? ›
The four most important factors to consider in analysis are texture, porosity, elasticity, density. Other factors that you should also be aware of are growth pattern as well as dryness and oiliness.
What are abnormal findings in nail assessment? ›Abnormalities of the fingernail
See your doctor if you have any of these symptoms: discoloration (dark streaks, white streaks, or changes in nail color) changes in nail shape (curling or clubbing) changes in nail thickness (thickening or thinning)
Risk screening and risk assessment of skin integrity generally refer to the same process, which is used to identify patients who are at risk of developing skin problems or who have skin problems. The results of screening or assessment are used to inform the implementation of prevention and management strategies.
What is integumentary in nursing? ›Open Resources for Nursing (Open RN) The integumentary system includes the skin, hair, and nails.
How do you assess clients on the skin? ›There are six areas to examine when looking at the skin: color, temperature and moisture, texture, turgor or edema, hygiene, and lesions. Skin color is genetically determined, but it may be affected by sun exposure, circulation, and disease.
How often do you do a skin assessment? ›Inspect the skin at least daily, or more often if high risk, using a risk assessment tool, such as the Braden Scale.
What equipment is needed for assessing the integument? ›Gather supplies: penlight, nonsterile gloves, magnifying glass (optional), and wound measuring tool (optional). Perform safety steps: Perform hand hygiene. Check the room for transmission-based precautions.
Why do we need assessment of the skin? ›A complete skin assessment is essential for holistic care and must be completed by nurses and other health professionals on a regular basis. Providing patients and relatives with information on good skin hygiene can improve skin integrity and reduce the risk of pressure damage and skin tears.
How do you describe skin problems? ›| Condition | What it looks like |
|---|---|
| Patch | Flat, large (greater than 1 cm) discolored area |
| Plaque | A raised or depressed area of skin that is greater than 1 cm in diameter |
| Pustule (pimple) | Inflamed, raised lesions that contain pus |
| Scales | A buildup of dead skin cells that form flakes |
The Braden Scale should be utilized each time a patient is admitted and then once daily or more often if there is a significant change in the condition of the patient's skin. It is imperative to assess intently as changes within the skin can happen rapidly especially in acute care settings.
What are 12 skin conditions you should know about? ›
- Alopecia Areata.
- Breast Cancer.
- Cancer.
- Eczema (Atopic Dermatitis)
- Hemorrhoids.
- High Blood Pressure.
- IBS.
- Multiple Sclerosis.
What is my skin health age score? Your skin health score will reveal your current home skincare routine's impact on your skin health age. The result will help you understand if you need to improve your home skincare routine and skin treatments for that younger firmer-looking skin that you want.
What is normal skin information? ›Normal Skin
This skin is neither too dry nor too oily. It has regular texture, no imperfections and a clean, soft appearance, and does not need special care.
Skin integrity refers to skin health. A skin integrity issue might mean the skin is damaged, vulnerable to injury or unable to heal normally. A pressure wound (also called a pressure sore, bed sore or pressure ulcer) is an injury to the skin and surrounding tissue.
What is skin integrity status? ›Altered skin integrity increases the chance of infection, impaired mobility, and decreased function and may result in the loss of limb or, sometimes, life. Skin is affected by both intrinsic and extrinsic factors. Intrinsic factors can include altered nutritional status, vascular disease issues, and diabetes.
How do you assess skin hair and nails? ›- Inspect scalp for lesions; hair and scalp for presence of lice and/or nits.
- Inspect skin for lesions, bruising, and rashes.
- Inspect for pressure areas.
- Inspect nails for clubbing fingers, consistency, color, and capillary refill.
It is used to monitor dehydration and the amount of blood flow to tissue. The nail blanch test, also called the capillary nail refill test, is performed on the nail beds as an indicator of tissue perfusion (the amount of blood flow to tissue) and dehydration.
What is a normal healthy nail but? ›Healthy fingernails are smooth, without pits or grooves. They're uniform in color and consistency and free of spots or discoloration. Sometimes fingernails develop harmless vertical ridges that run from the cuticle to the tip of the nail.
What are 3 ways to analyze hair? ›Forensic scientists perform 3 major types of hair analysis: (1) testing the hair shaft for drugs or nutritional deficiencies in a person's system, (2) analyzing DNA collected from the root of the hair, and (3) viewing hair under a microscope to determine if it's from a particular person or animal.
What are the 3 main things we determine from hair evidence? ›Characteristics within these regions are used to determine whether the hair is human or animal, racial origin and body area. A microscopic hair examination can also determine if a hair was forcibly removed, artificially treated or diseased.
What factors determine hair type? ›
Genetic factors appear to play a major role in determining hair texture—straight, wavy, or curly—and the thickness of individual strands of hair. Studies suggest that different genes influence hair texture and thickness in people of different ethnic backgrounds.
What are the nail findings in Lupus? ›Red or brown stripes: Lupus may cause red or brown stripes to appear below the nail bed. Also known as splinter hemorrhages, these stripes occur due to damage to the blood vessels. Grooves across the nails: Grooves across the nails, known as Beau's lines, can occur due to lupus or Raynaud's phenomenon.
What are 4 common nail conditions? ›Brittle nail syndrome, onychomycosis, paronychia, nail psoriasis (NP), longitudinal melanonychia (LM), Beau's lines, onychomadesis and retronychia are common nail disorders seen in clinical practice.
What are nail signs of deficiencies? ›- A deficiency in B-complex vitamins, especially biotin, will produce ridges along the nail bed. - A diet lacking in calcium contributes to dry, brittle nails. - A lack of folic acid and vitamin C can lead to hangnails. - Insufficient dietary essential oils, like omega-3, cause cracking.
What is a risk factor for poor skin integrity? ›Pressure, shear, and friction from immobility put an individual at risk for altered skin integrity. Patients who are overweight, paralyzed, with spinal cord injuries, those who are bedridden and confined to wheelchairs, and those with edema are also at the highest risk for altered skin integrity.
What are five 5 main criteria that should be included when examining and assessing a pressure injury? ›- Temperature.
- Color.
- Moisture level.
- Turgor.
- Skin integrity (skin intact or presence of open areas, rashes, etc.).
A lower Braden score indicates higher levels of risk for pressure ulcer development. Generally, a score of 18 or less indicates at-risk status.
What are the 3 main diseases of the integumentary system? ›- Acne, blocked skin follicles that lead to oil, bacteria and dead skin buildup in your pores.
- Alopecia areata, losing your hair in small patches.
- Atopic dermatitis (eczema), dry, itchy skin that leads to swelling, cracking or scaliness.
- Acne. What is acne? ...
- Alopecia Areata. What is alopecia areata? ...
- Atopic Dermatitis. What is atopic dermatitis? ...
- Epidermolysis Bullosa. ...
- Hidradenitis Suppurativa (HS) ...
- Ichthyosis. ...
- Pachyonychia Congenita. ...
- Pemphigus.
Your integumentary system is your body's outer layer. It consists of your skin, hair, nails and glands. These organs and structures are your first line of defense against bacteria and help protect you from injury and sunlight.
Why do nurses do a skin assessment? ›
Skin assessment is used to predict the development of pressure ulcers, and therefore is an extremely useful preventative tool.
How do you assess patient skin color? ›Skin color also can be assessed through digital image analysis or measured with such instruments as a spectrophotometer or colorimeter. These techniques generally are used in research, to collect forensic evidence, or during dermatologic procedures.
What is a common nursing diagnosis for integumentary system? ›A commonly used NANDA-I nursing diagnosis for patients experiencing alterations in the integumentary system is Impaired Tissue Integrity, defined as, “Damage to the mucous membrane, cornea, integumentary system, muscular fascia, muscle, tendon, bone, cartilage, joint capsule, and/or ligament.”
What are normal signs of aging for the integumentary system? ›...
Sunlight can cause:
- Loss of elasticity (elastosis)
- Noncancerous skin growths (keratoacanthomas)
- Pigment changes such as liver spots.
- Thickening of the skin.
Normal findings might be documented as: “Nails are smooth, firm, clean with translucent colour, and no presence of clubbing. Capillary refill within 2 seconds.” Abnormal findings might be documented as: “Nail angle on thumbs is slightly greater than 180 degrees, capillary refill time is 5 seconds.”
How do you conduct a skin integrity assessment on a patient? ›Information gathered from the skin inspection and aspects of management should be clearly documented in the patient's notes and care plan. Inspection should include assessment of the skin's colour, temperature, texture, moisture, integrity and include the location of any skin breakdown or wounds.
What are 4 diseases of the integumentary system? ›- Acne. What is acne? ...
- Alopecia Areata. What is alopecia areata? ...
- Atopic Dermatitis. What is atopic dermatitis? ...
- Epidermolysis Bullosa. ...
- Hidradenitis Suppurativa (HS) ...
- Ichthyosis. ...
- Pachyonychia Congenita. ...
- Pemphigus.
A skin assessment should include the presenting concern/compliant with the skin, history of the presenting concern/compliant, past medical history, family history, social history, medicines (including topical treatment) and allergies and impact on quality of life.
What are 3 normal skin aging changes? ›Healthy age-related skin changes are inevitable and include thinning, sagging, wrinkling and the appearance of age spots, broken blood vessels and areas of dryness. Unhealthy skin changes, such as skin cancer, are also more common as we age and are usually made worse by exposure to the sun.
What are 3 physical signs of aging? ›- Fine lines and wrinkles. Fine lines, crow's feet and wrinkles are the most evident and often most concern-causing signs of ageing for men and women. ...
- Dullness of skin. ...
- Uneven skin tone. ...
- Dry skin. ...
- Blotchiness and age spots. ...
- Rough skin texture. ...
- Visible pores.
What are three of the most common age related skin issues? ›
However, we do know that two studies of health records for large groups of older adults show that the most common skin diseases in older people are eczema, skin infections, and pruritus (severely dry and itchy skin).
What are abnormal findings of hair? ›- Alopecia (nonscarring). Skin disorders, certain drugs, certain diseases, autoimmunity, iron deficiency, severe stress, scalp radiation, pregnancy, or pulling at your own hair.
- Alopecia (scarring). ...
- Hirsutism. ...
- Hair shaft disorders. ...
- Inflammation.
Nail abnormalities are problems with the color, shape, texture, or thickness of the fingernails or toenails. Yellow nail syndrome is characterized by yellow nails that lack a cuticle, grow slowly, and are loose or detached (onycholysis).
What is the skin integrity score? ›Nursing Assessment for Impaired Skin Integrity
The patient is scored on six categories: Sensory perception, Moisture, Activity, Mobility, Nutrition, Friction and Shear. A score is calculated between 9-23. The lower the score, the higher the risk of tissue injury.
Use Braden Scale scores as part of comprehensive clinical assessment and decision making to determine pressure ulcer risk. TARGET POPULATION: The Braden Scale is commonly used with medically and cognitively impaired older adults.
What is evidence of impaired skin integrity? ›Signs and Symptoms of impaired tissue integrity
Affected area suspected of impaired skin integrity may be hot and tender to touch. There may be observations of fever. Visible damage to integumentary tissues like the cornea, mucous membranes, subcutaneous skin, etc.