14.4 Integumentary Assessment – Nursing Skills (2022)

Open Resources for Nursing (Open RN)

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 14.4a for sample interview questions.

Table 14.4a Focused Interview Questions for the Integumentary System

QuestionsFollow-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 (paleness), (blueness), (yellowness), or (redness). Note if there is any bruising () present.

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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 (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 .

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]

View the following video demonstrating Capillary Refill[7]:

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Cardiovascular Assessment Part Two | Capillary Refill Test

Skin Turgor

Skin turgor may be included when assessing a patient’s hydration status, but research has shown it is not a good indicator. 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 14.22[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 14.23[11] for an illustration of grading edema.

14.4 Integumentary Assessment – Nursing Skills (1)
14.4 Integumentary Assessment – Nursing Skills (2)

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 14.4b to review common expected and unexpected integumentary findings.

Table 14.4b Expected Versus Unexpected Findings on integumentary Assessment

AssessmentExpected FindingsUnexpected Findings (Document and notify provider if it is a new finding*)
InspectionSkin is expected color for ethnicity without lesions or rashes.

Erythema

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Cyanosis

Irregular-looking mole

Bruising (ecchymosis)

Rashes

Petechiae

Skin breakdown

Burns

AuscultationNot applicable
PalpationSkin 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

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Edema

Lymphedema

Capillary refill greater than 3 seconds

Tenting

*CRITICAL CONDITIONS to report immediatelyCool and clammy

Diaphoretic

Petechiae

Jaundice

Cyanosis

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Redness, warmth, and tenderness indicating a possible infection

  1. 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.
  2. 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
  3. 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.). https://www.ncbi.nlm.nih.gov/books/NBK207/
  4. 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.
  5. 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. https://dx.doi.org/10.1080%2F10669817.2018.1427908
  6. Johannsen, L.L. (2005). Skin assessment. Dermatology Nursing, 17(2), 165-66.
  7. Nurse Saria. (2018, September 18). Cardiovascular assessment part two | Capillary refill test. [Video}. YouTube. All rights reserved. https://youtu.be/A6htMxo4Cks
  8. 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.
  9. 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/
  10. Combinpedal.jpg” by James Heilman, MD is licensed under CC BY-SA 3.0
  11. Grading of Edema” by Meredith Pomietlo for Chippewa Valley Technical College is licensed under CC BY 4.0
  12. 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 are the physical assessment skills required for an integumentary 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.

How would you describe skin in nursing assessment? ›

The physical assessment of the skin involves inspection and palpation and may reveal local or systemic problems in the patient. When palpating the skin, it is important to note: Texture – it should be smooth and even. Thickness – very thin skin may indicate steroid therapy or arterial insufficiency.

What are 4 things to look for during a skin assessment? ›

Inspection should include assessment of the skin's colour, temperature, texture, moisture, integrity and include the location of any skin breakdown or wounds.

What is integumentary system examination? ›

An integumentary assessment, also known as a “skin test” or “skin exam”, is a head-to-toe examination of the hair, skin, and nails. The series of tests detects any wounds or conditions that might be present.

What are the five steps of patient assessment? ›

emergency call; determining scene safety, taking BSI precautions, noting the mechanism of injury or patient's nature of illness, determining the number of patients, and deciding what, if any additional resources are needed including Advanced Life Support.

Why is integumentary assessment important? ›

The condition of the skin, hair, and nails provides important information about the child's physical and emotional health. Poor personal hygiene may be an indication of depression or other mental health disorders.

How do you describe normal skin? ›

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.

How do you assess skin status? ›

A holistic skin assessment should always include a psychological and social assessment.
...
  1. Inspect the skin – general observation, site and number of lesions and pattern of distribution.
  2. Describe what you see on the skin.
  3. Palpate the skin.
  4. Include a systemic check.
10 Feb 2016

How do you describe skin moisture? ›

Skin Moisture

Normal skin is supple and non-scaly. Overhydrated skin can look swollen, wrinkly, or whitish in color. Overly dry skin can appear scaly or feel saggy to the touch.

What are the 5 parameters of a comprehensive skin assessment? ›

The usual practice includes a minimum of the following 5 parameters:
  • temperature.
  • color.
  • moisture.
  • turgor.
  • intact skin or presence of open areas.

Why is skin assessment important nursing? ›

A clinical assessment of the skin by a healthcare professional, taking into account any pain reported by the person, may predict the development of a pressure ulcer. The results of the skin assessment can be used to offer suitable preventative interventions to people who are at high risk of developing pressure ulcers.

What nursing interventions are essential to maintain skin integrity? ›

Nursing Interventions for Impaired Skin Integrity

Encourage the use of lifting devices like trapeze or bed linen to move the patient in bed. Common causes of impaired skin integrity is friction which involves rubbing heels or elbows toward bed linen and moving the patient up in bed without the use of a lift sheet.

What is integumentary in nursing? ›

Learning Objectives. The integumentary system includes skin, hair, and nails. The skin is the largest organ of the body and has many purposes. Our skin keeps us warm and contains nerve endings that control the ability to feel the sensations of hot, cold, pain, and pressure.

What are some questions to ask the integumentary system? ›

Critical Thinking Questions
  • What determines the color of skin, and what is the process that darkens skin when it is exposed to UV light? ...
  • Explain the differences between eccrine and apocrine sweat glands. ...
  • Why do people sweat excessively when exercising outside on a hot day? ...
  • Why do teenagers often experience acne?
27 Mar 2020

How do you measure 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 are the 4 types of nursing assessments? ›

WHEN YOU PERFORM a physical assessment, you'll use four techniques: inspection, palpation, percussion, and auscultation.

What are the 5 nursing interventions? ›

These are assessment, diagnosis, planning, implementation, and evaluation.

How do you write a nursing assessment? ›

Head-to-Toe Assessment Nursing | Nursing Physical Health ... - YouTube

What is the best technique to perform an assessment of the skin quizlet? ›

ANS: Warm the hands first before touching the patient., Start with light palpation to detect surface characteristics., Use the fingertips to examine skin texture, swelling, pulsation, and presence of lumps., Identify any tender areas, and palpate them last. Always warm the hands before beginning palpation.

How would you describe 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... destruction of skin layers (dermis), and disruption of skin surface (epidermis)" (NANDA 2013).

What is the meaning of integumentary? ›

Definition of integumentary

: of or relating to an enveloping or external layer or covering (as of skin, hair, scales, feathers, or cuticle) of an organism or one of its parts the integumentary system Were there whiskers, filaments or other integumentary structures on the snout and elsewhere?—

What are the 4 types of skin tones? ›

The 4 Main Types Of Skin Tones Are:

Light. Fair. Medium. Deep (Dark)

What is normal skin tone? ›

The varieties of normal skin color in humans range from people of "no color" (pale white) to "people of color" (light brown, dark brown, and black).

What is normal skin texture? ›

Skin texture is the condition of the surface of your skin. Ideally, the skin is smooth, soft, and supple, but it can be uneven or dull due to dry skin, blemishes, loss of collagen from aging, sun damage, or lack of exfoliation.

What is included in a skin assessment? ›

The assessment should take into account any pain or discomfort reported by the patient and the skin should be checked for: skin integrity in areas of pressure. colour changes or discoloration. variations in heat, firmness and moisture (for example, because of incontinence, oedema, dry or inflamed skin).

How do you measure skin thickness? ›

Ultrasound is a reliable tool for quantifying skin involvement in SSc. Ultrasound-measured skin thickness showed good agreement with histological skin thickness.

What is normal skin moisture? ›

The meter shows a number from 0 to 99, with 0 indicating the lowest and 99 indicating the highest moisture level. Results from 0 to 40 mean you have dry skin that needs more moisture; from 40 to 70, your skin is deemed "normal"; and from 70 to 99, your skin is oilier, with plenty of moisture.

How do you describe normal skin temperature? ›

The normal temperature of skin is about 33 °C or 91 °F. The flow of energy to and from the skin determines our sense of hot and cold. Heat flows from higher to lower temperature, so the human skin will not drop below that of surrounding air, regardless of wind.

What is the first step in a skin analysis? ›

The skin analysis begins when a client walks through the door with a visual appraisal of their appearance, evaluating their cosmetics, and looking for clues about lifestyle habits that affect their complexion.

How can you assess to maintain skin integrity for patients? ›

Skin Assessment
  1. Color – Redness, bruising, or purpura? ...
  2. Temperature – Warm? ...
  3. Texture – Dry, cracked, excoriated, denuded, fibrotic?
  4. Moisture – What is the cause?
  5. Integrity – Epidermal stripping, blisters, open areas, skin tears?
  6. Location – Can help identify the cause of poor skin integrity.
28 Feb 2019

How do you score a Braden scale? ›

The scale consists of six subscales and the total scores range from 6-23. 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 is good skin integrity? ›

Skin integrity refers to the health of your skin. When in proper health, the skin performs various vital functions. It helps maintain optimal core temperature in your body, helps absorb and process vitamin D from the sun, keeps you hydrated by supporting electrolyte balance, among many others.

What is the purpose of conducting a skin assessment to manage pressure injuries? ›

As discussed above, one purpose of comprehensive skin assessment is to identify visible changes in the skin that indicate increased risk for pressure ulcer development. However, factors other than skin changes must be assessed to identify patients at risk for pressure ulcers.

How do you measure skin temperature by hand? ›

Use the dorsal surface of your own hands (i.e., the back of the hands), to assess the temperature of a surface (e.g., skin). For example, findings may include “warm skin temperature on arms, equal bilaterally.” Your fingertips are densely innervated and therefore sensitive to tactile discrimination.

Why is it important to identify and report early changes in skin? ›

It is extremely important to identify, report and record early changes in the skin. If we intervene quickly and appropriately to stop further damage, we can prevent tissue loss.

What is a smart goal for skin integrity? ›

GOAL: Promote circulation to tissues by reducing or eliminating pressure. Possible risk factors that decrease circulation or cause unrelieved pressure to tissues: ▪ Immobility (diagnosis that leads to immobility, such as CVA, MS, end stage Alzheimer's, etc.) ▪ Decreased sensory perception (inability to feel.

What actions can you take to maintain skin integrity for a client who has limited mobility? ›

Keeping the client clean and dry at all times to prevent moisture and skin maceration as well as debris. Turning and positioning clients at least every two hours when the client is unable to move about in bed to turn and position on their own. Maintaining the client's nutritional and fluid needs.

Which nursing interventions will prevent skin breakdown for the immobilized client? ›

Reposition the patient frequently to prevent skin breakdown and to promote healing. Turn the immobilized patient at least every two hours, according to a specific schedule. Maintain a patient's position at 30 degrees or less, as appropriate, to prevent shear. Keep bed linens clean, dry, and wrinkle free.

What are the 5 functions of the integumentary system? ›

The integumentary system includes the epidermis, dermis, hypodermis, associated glands, hair, and nails. In addition to its barrier function, this system performs many intricate functions such as body temperature regulation, cell fluid maintenance, synthesis of Vitamin D, and detection of stimuli.

What are the 7 functions of the integumentary system? ›

Terms in this set (7)
  • Protection. Microorganism, dehydration, ultraviolet light, mechanical damage.
  • Sensation. Sense pain, temperature, touch, deep pressure.
  • Allows movement. Allows movement muscles can flex & body can move.
  • Endocrine. Vitamin D production by your skin.
  • Excretion. ...
  • Immunity. ...
  • Regulate Temperature.

Why is the integumentary system important to nursing? ›

The components of the integumentary system consist of the skin, hair, and nails. The integumentary system is the first line of defense against disease and pathogens entering the body. And, the integumentary system regulates body temperature, provides sensory input and synthesizes vitamin D.

Which part of your hand is best for assessing skin temperature? ›

The dorsa (backs) of the hands and fingers are best for determining temperature because the skin is thinner on the dorsal surfaces than on the palms. Fingertips are best for fine, tactile discrimination.

What are the layers of skin? ›

It is made up of three layers, the epidermis, dermis, and the hypodermis, all three of which vary significantly in their anatomy and function.

How many layers of skin are in the epidermis? ›

The epidermis is the thinnest layer of skin, but it's responsible for protecting you from the outside world, and it's composed of five layers of its own.

What are 4 things to look for during a skin assessment? ›

Inspection should include assessment of the skin's colour, temperature, texture, moisture, integrity and include the location of any skin breakdown or wounds.

How would you describe skin in nursing assessment? ›

The physical assessment of the skin involves inspection and palpation and may reveal local or systemic problems in the patient. When palpating the skin, it is important to note: Texture – it should be smooth and even. Thickness – very thin skin may indicate steroid therapy or arterial insufficiency.

How do you describe normal skin? ›

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.

Which technique should the nurse use to properly assess a client's skin turgor? ›

Palpation: The temperature, level of moisture, turgor and the presence or absence of any edema or swelling on the skin are assessed.

Which components would the nurse assess during palpation of the skin? ›

Palpation is used to make judgments about abnormal and normal findings of the skin or underlying tissue, muscle, and bones. In the inspection technique, the nurse observes the size, shape, color, symmetry, position, and abnormality of various body parts.

Which physical assessment technique involves listening to the sounds of the body? ›

Auscultation is listening to the sounds of the body during a physical examination.

Which technique would the nurse use to assess the elasticity of the patient's skin? ›

Light palpation

Assess for texture, tenderness, temperature, moisture, elasticity, pulsations, and masses.

How do you assess skin and hygiene status? ›

A skin assessment in adults should take into account:
  1. any pain or discomfort reported by the patient.
  2. skin integrity in areas of pressure.
  3. colour changes or discoloration.
  4. variations in heat, firmness and moisture (for example because of incontinence, oedema, dry or inflamed skin).
11 Jun 2015

What is the best technique to perform an assessment of the skin quizlet? ›

ANS: Warm the hands first before touching the patient., Start with light palpation to detect surface characteristics., Use the fingertips to examine skin texture, swelling, pulsation, and presence of lumps., Identify any tender areas, and palpate them last. Always warm the hands before beginning palpation.

What is included in a skin assessment? ›

The assessment should take into account any pain or discomfort reported by the patient and the skin should be checked for: skin integrity in areas of pressure. colour changes or discoloration. variations in heat, firmness and moisture (for example, because of incontinence, oedema, dry or inflamed skin).

How do you describe normal skin? ›

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.

How would you describe 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... destruction of skin layers (dermis), and disruption of skin surface (epidermis)" (NANDA 2013).

How do you assess a skin lesion? ›

The assessment of a suspicious skin lesion typically begins with a physical examination and inspection of the skin. Many dermatologists use dermoscopy (also known as dermatoscopy epiluminescence microscopy or surface microscopy) to better examine the lesion.

What is the correct order for physical assessment? ›

The four techniques that are used for physical assessment are inspection, palpation, percussion, and auscultation.

What are the 4 types of palpation? ›

The front of the fingers are used for light palpation, deep palpation, light ballottement and deep ballottement. Let's look at these in more detail.

Which assessment should the nurse complete first? ›

A thorough medical history and physical assessment will be useful but is not the first action the nurse must take. The physician should be notified but the nurse must assess vital signs first.

How do you write a nursing assessment? ›

Head-to-Toe Assessment Nursing | Nursing Physical Health ... - YouTube

Which assessment finding of the skin refers to elasticity? ›

Skin turgor is the skin's elasticity. It is the ability of skin to change shape and return to normal.

Which techniques can the nurse use for collecting patient assessment data? ›

A structured physical examination allows the nurse to obtain a complete assessment of the patient. Observation/inspection, palpation, percussion and auscultation are techniques used to gather information.

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