RN, MSN, Chief Nursing Officer
An integumentary assessment often called a “skin exam” consists of an examination of an individual’s skin, hair, and nails. The assessment can be completed by visual acuity, specific lights and skin measuring devices that accurately measure any wounds that may be present.
The evaluation is typically a painless assessment that is often completed to determine if there are any alterations or breakdowns noted throughout the integumentary system. The integumentary system is the largest organ in the body. It is important that all areas of the skin are not overlooked.
As with any other medical issue, disease, or disorder, the key to preventing long-term complications is early identification.
An integumentary skin assessment can be conducted due to the following factors:
Risk screening and assessment allows identification of those patients at high risk for the development of skin problems and allows prevention and management to be implemented. Nurses providing thorough skin assessments are utilizing holistic care by providing both the patient/family with useful information on adequate skin hygiene and ways to improve skin integrity which in turn reduces the risk of skin tears and pressure ulcers.
Performing a general assessment of the skin allows nurses to determine the overall general condition of the skin and to identify factors that increase the risks for pressure injuries.
The integumentary system is extremely important in that it protects the body against foreign pathogens, maintains body temperature, and provides sensory input.
Assessment of the integumentary system involves a combination of gathering information regarding the hairs, skin, and nails.
It is imperative that nurses perform a thorough and detailed inspection of these areas. If any deviations are noted, they should be documented and reported in a timely manner.
The following areas are important to focus on when completing an integumentary exam:
Nurses must ask the patient or family member questions regarding any history of skin problems, allergic reactions, and family history of skin disorders.
Questions should be asked about the onset, duration, and frequency of symptoms. It is important to ask specific questions about the skin, hair, and nails.
Ask specific questions about any pain relating to the skin, hair, and nails. It is important to ask about the type of pain, duration, any triggers, pain level on a scale of 0-10, and any treatments that have been used.
Is the color the same all over? Or different? Are there areas of hyperpigmentation or hypopigmentation? Look carefully at the skin tones and be mindful that these can range from pink to darkish brown. Observe for any lesions, rashes, moles, and freckles.
Are there any skin discolorations such as pallor – the loss of the pinkish tones of the skin due to decreased blood flow to the surface of the skin; erythema – a reddish color to the skin due to a rush of blood to the surface of the skin typically due to inflammation; cyanosis – a bluish tone to the skin due to a decrease in oxygenation to the tissues which usually indicates hypoxemia; jaundice – a yellow tint to the skin, sclera of the eye, or mucous membranes due to increased levels of bilirubin in the blood.
Assess for temperature, moisture, thickness, texture, and turgor.
Edema is due to the accumulation of fluid in the intercellular spaces. It is important to assess for pitting edema and grade the edema on a scale based on mild, moderate, deep, and very deep pitting edema.
Assess the nail beds, length of nails, appearance, and nail edges.
Analyze color, texture, and distribution of the hair.
As nurses and other healthcare providers perform routine head-to-toe assessments, it is imperative to carefully assess integumentary needs.
The Braden Scale measures elements of risk that contribute to higher intensity and duration of pressure or lower tolerance of pressures. The following are important parameters when using the Braden Scale:
Each of these areas is scored between number 1 and number 4 with each score accompanied by a description. The lower the score, the greater the risk for skin breakdown. The Braden Scale is designed to be used in conjunction with one’s clinical judgements in an effort to help identify risks that can lead to proactive treatment.
The Braden Scale can quickly notify nurses of any issues thus preventing any further issues from becoming worse and receiving the proper care needed. Nurses are often the first ones to notice any abnormalities and can sometimes eradicate an issue in time before it becomes too aggressive.
Nurses must understand that integumentary assessments should be completed with accuracy, thoroughness, and a complete and full understanding of the anatomy and physiology of the skin, hair, and nails.
The assessments serve to detect an injury or disorder, must be documented and reported, and assist to monitor the progression or regression to determine the type of care that is needed.
It is important that nurses perform an integumentary assessment initially with each patient and each time a routine check-up is scheduled in order to ensure that continuity of care is being given and that no negative changes have occurred. The integumentary status of a patient can change suddenly so ensuring that “skin checks” are being performed and reported helps predict positive outcomes.
It also gives reassurance to the family that the best care possible is being administered and that any subtle changes will be noted. Assessments should not be delayed or skipped when dealing with integumentary issues. Deterioration of the patient’s skin condition can unfortunately take place quickly and lead to skin breakdown and other skin disorders that are more difficult to manage.
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