hesi rn case study integumentary assessment

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Open Resources for Nursing (Open RN); Ernstmeyer K, Christman E, editors. Nursing Skills [Internet]. Eau Claire (WI): Chippewa Valley Technical College; 2021.

Nursing Skills [Internet].

• About Open RN

Chapter 14 Integumentary Assessment

14.1. integumentary assessment introduction, learning objectives.

• Perform an integumentary assessment including the skin, hair, and nails
• Modify assessment techniques to reflect variations across the life span and ethnic and cultural variations
• Document actions and observations
• Recognize and report significant deviations from norms

Assessing the skin, hair, and nails is part of a routine head-to-toe assessment completed by registered nurses. During inpatient care, a comprehensive skin assessment on admission establishes a baseline for the condition of a patient’s skin and is essential for developing a care plan for the prevention and treatment of skin injuries. [ 1 ]  Before discussing the components of a routine skin assessment, let’s review the anatomy of the skin and some common skin and hair conditions.

14.2. BASIC INTEGUMENTARY CONCEPTS

The integumentary system includes the skin, hair, and nails. The skin is an organ that performs a variety of essential functions, such as protecting the body from invasion by microorganisms, chemicals, and other environmental factors; preventing dehydration; acting as a sensory organ; modulating body temperature and electrolyte balance; and synthesizing vitamin D. [ 1 ]

The skin is made of multiple layers of cells and tissues, which are held to underlying structures by connective tissue. See Figure 14.1 [ 2 ]  for an image of the layers of the skin. The skin is composed of two main layers: the uppermost thin layer called the  epidermis  made of closely packed epithelial cells, and the inner thick layer called the  dermis  that houses blood vessels, hair follicles, sweat glands, and nerve fibers. Beneath the dermis lies the  hypodermis  that contains connective tissue and adipose tissue (stored fat) to connect the skin to the underlying bones and muscles. The skin acts as a sense organ because the epidermis, dermis, and hypodermis contain specialized sensory nerve structures that detect touch, surface temperature, and pain. [ 3 ]

Figure 14.1

Layers of the Skin

The color of skin is created by pigments, including melanin, carotene, and hemoglobin.  Melanin  is produced by cells called melanocytes that are scattered throughout the epidermis. See Figure 14.2 [ 4 ]  for an illustration of melanin and melanocytes. When there is an irregular accumulation of melanocytes in the skin, freckles appear. Dark-skinned individuals produce more melanin than those with pale skin. Exposure to the UV rays of the sun or a tanning bed causes additional melanin to be manufactured and built up, resulting in the darkening of the skin referred to as a tan. Increased melanin accumulation protects the DNA of epidermal cells from UV ray damage, but it requires about ten days after initial sun exposure for melanin synthesis to peak. This is why pale-skinned individuals often suffer sunburns during initial exposure to the sun. Darker-skinned individuals can also get sunburns, but they are more protected from their existing melanin than pale-skinned individuals. [ 5 ]

Figure 14.2

Pigmentation of the Skin

Too much sun exposure can eventually lead to wrinkling due to the destruction of the cellular structure of the skin, and in severe cases, can cause DNA damage resulting in skin cancer. Moles are larger masses of melanocytes, and although most are benign, they should be monitored for changes that indicate the presence of skin cancer. See Figure 14.3 [ 6 ]  for an image of moles.

Figure 14.3

Patients are encouraged to use the  ABCDE  mnemonic to watch for signs of early-stage melanoma developing in moles. Consult a health care provider if you find these signs of melanoma when assessing a patient’s skin:

• A symmetrical: The sides of the moles are not symmetrical
• B orders: The edges of the mole are irregular in shape
• C olor: The color of the mole has various shades of brown or black
• D iameter: The mole is larger than 6 mm. (0.24 in.)
• E volving: The shape of the mole has changed

Hair is made of dead, keratinized cells that originate in the hair follicle in the dermis. For these reasons, there is no sensation in hair. See Figure 14.4 [ 7 ]  for an image of a hair follicle. Hair serves a variety of functions, including protection, sensory input, thermoregulation, and communication. For example, hair on the head protects the skull from the sun. Hair in the nose, ears, and around the eyes (eyelashes) defends the body by trapping any dust particles that may contain allergens and microbes. Hair of the eyebrows prevents sweat and other particles from dripping into the eyes.

Figure 14.4

Hair Follicle

Hair also has a sensory function due to sensory innervation by a hair root plexus surrounding the base of each hair follicle. Hair is extremely sensitive to air movement or other disturbances in the environment, even more so than the skin surface. This feature is also useful for the detection of the presence of insects or other potentially damaging substances on the skin surface. Each hair root is also connected to a smooth muscle called the arrector pili that contracts in response to nerve signals from the sympathetic nervous system, making the external hair shaft “stand up.” This movement is commonly referred to as goose bumps. The primary purpose for this movement is to trap a layer of air to add insulation. [ 8 ]

The nail bed is a specialized structure of the epidermis that is found at the tips of our fingers and toes. See Figure 14.5 [ 9 ]  for an illustration of a fingernail. The nail body is formed on the nail bed and protects the tips of our fingers and toes as they experience mechanical stress while being used. In addition, the nail body forms a back-support for picking up small objects with the fingers. [ 10 ]

Figure 14.5

Sweat glands.

When the body becomes warm, sweat glands produce sweat to cool the body. There are two types of sweat glands that secrete slightly different products. An  eccrine sweat gland produces hypotonic sweat for thermoregulation. See Figure 14.6 [ 11 ]  for an illustration of an eccrine sweat gland. These glands are found all over the skin’s surface, but are especially abundant on the palms of the hand, the soles of the feet, and the forehead. They are coiled glands lying deep in the dermis, with the duct rising up to a pore on the skin surface where the sweat is released. This type of sweat is composed mostly of water and some salt, antibodies, traces of metabolic waste, and dermicidin, an antimicrobial peptide. Eccrine glands are a primary component of thermoregulation and help to maintain homeostasis. [ 12 ]

Figure 14.6

Eccrine Sweat Gland

Apocrine sweat glands  are mostly found in hair follicles in densely hairy areas, such as the armpits and genital regions. In addition to secreting water and salt, apocrine sweat includes organic compounds that make the sweat thicker and subject to bacterial decomposition and subsequent odor. The release of this sweat is controlled by the nervous system and hormones and plays a role in the human pheromone response. Most commercial antiperspirants use an aluminum-based compound as their primary active ingredient to stop sweat. When the antiperspirant enters the sweat gland duct, the aluminum-based compounds form a physical block in the duct, which prevents sweat from coming out of the pore. [ 13 ]

Skin Lesions

A  lesion  is an area of abnormal tissue. There are many terms for common skin lesions that may be described in a patient’s chart. These terms are defined in Table 14.2 . See Figure 14.7 [ 14 ]  for illustrations of common skin lesions.

Figure 14.7

Common Types of Skin Lesions

Medical Terms Associated with Skin Lesions and Rashes [ 15 ]

View in own window

14.3. COMMON INTEGUMENTARY CONDITIONS

Now that we have reviewed the anatomy of the integumentary system, let’s review common conditions that you may find during a routine integumentary assessment.

Acne  is a skin disturbance that typically occurs on areas of the skin that are rich in sebaceous glands, such as the face and back. It is most common during puberty due to associated hormonal changes that stimulate the release of sebum. An overproduction and accumulation of sebum, along with keratin, can block hair follicles. Acne results from infection by acne-causing bacteria and can lead to potential scarring. [ 1 ]  See Figure 14.8 [ 2 ]  for an image of acne.

Figure 14.8

Lice and nits.

Head lice are tiny insects that live on a person’s head. Adult lice are about the size of a sesame seed, but the eggs, called nits, are smaller and can appear like a dandruff flake. See Figure 14.9 [ 3 ]  for an image of very small white nits in a person’s hair. Children ages 3-11 often get head lice at school and day care because they have head-to-head contact while playing together. Lice move by crawling and spread by close person-to-person contact. Rarely, they can spread by sharing personal belongings such as hats or hair brushes. Contrary to popular belief, personal hygiene and cleanliness have nothing to do with getting head lice. Symptoms of head lice include the following:

Figure 14.9

• Tickling feeling in the hair
• Frequent itching, which is caused by an allergic reaction to the bites
• Sores from scratching, which can become infected with bacteria
• Trouble sleeping due to head lice being most active in the dark

A diagnosis of head lice usually comes from observing a louse or nit on a person’s head. Because they are very small and move quickly, a magnifying lens and a fine-toothed comb may be needed to find lice or nits. Treatments for head lice include over-the-counter and prescription shampoos, creams, and lotions such as permethrin lotion. [ 4 ]

A burn results when the skin is damaged by intense heat, radiation, electricity, or chemicals. The damage results in the death of skin cells, which can lead to a massive loss of fluid due to loss of the skin’s protection. Burned skin is also extremely susceptible to infection due to the loss of protection by intact layers of skin.

Burns are classified by the degree of their severity. A  first-degree burn , also referred to as a superficial burn, only affects the epidermis. Although the skin may be painful and swollen, these burns typically heal on their own within a few days. Mild sunburn fits into the category of a first-degree burn. A  second-degree burn , also referred to as a partial thickness burn, affects both the epidermis and a portion of the dermis. These burns result in swelling and a painful blistering of the skin. It is important to keep the burn site clean to prevent infection. With good care, a second degree burn will heal within several weeks. A  third-degree  burn, also referred to as a full thickness burn, extends fully into the epidermis and dermis, destroying the tissue and affecting the nerve endings and sensory function. These are serious burns that require immediate medical attention. A  fourth-degree burn , also referred to as a deep full thickness burn, is even more severe, affecting the underlying muscle and bone. Third- and fourth-degree burns are usually not as painful as second degree burns because the nerve endings are damaged. Full thickness burns require debridement (removal of dead skin) followed by grafting of the skin from an unaffected part of the body or from skin grown in tissue culture. [ 5 ]  See Figure 14.10 [ 6 ]  for an image of a patient recovering from a second-degree burn on the hand.

Figure 14.10

Recovering Second-Degree Burn

Severe burns are quickly measured in emergency departments using a tool called the “ rule of nines ,” which associates specific anatomical locations with a percentage that is a factor of nine. Rapid estimate of the burned surface area is used to estimate intravenous fluid replacement because patients will have massive fluid losses due to the removal of the skin barrier. [ 7 ]  See Figure 14.11 [ 8 ]  for an illustration of the rule of nines. The head is 9% (4.5% on each side), the upper limbs are 9% each (4.5% on each side), the lower limbs are 18% each (9% on each side), and the trunk is 36% (18% on each side).

Figure 14.11

Rule of Nines

Most cuts and wounds cause scar formation. A scar is collagen-rich skin formed after the process of wound healing. Sometimes there is an overproduction of scar tissue because the process of collagen formation does not stop when the wound is healed, resulting in the formation of a raised scar called a  keloid . [ 9 ]  Keloids are more common in patients with darker skin color. See Figure 14.12 [ 10 ]  for an image of a keloid that has developed from a scar on a patient’s chest wall.

Figure 14.12

Skin cancer.

Skin cancer is common, with one in five Americans experiencing some type of skin cancer in their lifetime. Basal cell carcinoma is the most common of all cancers that occur in the United States and is frequently found on areas most susceptible to long-term sun exposure such as the head, neck, arms, and back. Basal cell carcinomas start in the epidermis and become an uneven patch, bump, growth, or scar on the skin surface. Treatment options include surgery, freezing (cryosurgery), and topical ointments. [ 11 ]

Squamous cell carcinoma presents as lesions commonly found on the scalp, ears, and hands. If not removed, squamous cell carcinomas can metastasize to other parts of the body. Surgery and radiation are used to cure squamous cell carcinoma. See Figure 14.13 [ 12 ]  for an image of squamous cell carcinoma. [ 13 ]

Figure 14.13

Squamous Cell Carcinoma

Melanoma  is a cancer characterized by the uncontrolled growth of melanocytes, the pigment-producing cells in the epidermis. A melanoma commonly develops from an existing mole. See Figure 14.14 [ 14 ]  for an image of a melanoma. Melanoma is the most fatal of all skin cancers because it is highly metastatic and can be difficult to detect before it has spread to other organs. Melanomas usually appear as asymmetrical brown and black patches with uneven borders and a raised surface. Treatment includes surgical excision and immunotherapy. [ 15 ]

Figure 14.14

Fungal (tinea) infections.

Tinea is the name of a group of skin diseases caused by a fungus. Types of tinea include ringworm, athlete’s foot, and jock itch. These infections are usually not serious, but they can be uncomfortable because of the symptoms of itching and burning. They can be transmitted by touching infected people, damp surfaces such as shower floors, or even from pets. [ 16 ]  Ringworm (tinea corporis) is a type of rash that forms on the body that typically looks like a red ring with a clear center, although a worm doesn’t cause it. Scalp ringworm (tinea capitals) causes itchy, red patches on the head that can leave bald spots. Athlete’s foot (tinea pedis) causes itching, burning, and cracked skin between the toes. Jock itch (tinea cruris) causes an itchy, burning rash in the groin area. Fungal infections are often treated successfully with over-the-counter creams and powders, but some require prescription medicine such as nystatin. See Figure 14.15 [ 17 ]  for an image of a tinea in a patient’s groin. [ 18 ]

Figure 14.15

Fungal Infection in the Groin

Impetigo is a common skin infection caused by bacteria in children between the ages two and six. It is commonly caused by  Staphylococcus  (staph) or  Streptococcus  (strep) bacteria. See Figure 14.16 [ 19 ]  for an image of impetigo. Impetigo often starts when bacteria enter a break in the skin, such as a cut, scratch, or insect bite. Symptoms start with red or pimple-like sores surrounded by red skin. The sores fill with pus and then break open after a few days and form a thick crust. They are often itchy, but scratching them can spread the sores. Impetigo can spread by contact with sores or nasal discharge from an infected person and is treated with antibiotics.

Figure 14.16

Edema is caused by fluid accumulation within the tissues often caused by underlying cardiovascular or renal disease. Read more about edema in the  “Basic Concepts” section  of the “Cardiovascular Assessment” chapter.

Lymphedema  is the medical term for a type of swelling that occurs when lymph fluid builds up in the body’s soft tissues due to damage to the lymph system. It often occurs unilaterally in the arms or legs after surgery has been performed that injured the regional lymph nodes. See Figure 14.17 [ 20 ]  for an image of lower extremity edema. Causes of lymphedema include infection, cancer, scar tissue from radiation therapy, surgical removal of lymph nodes, or inherited conditions. There is no cure for lymphedema, but elevation of the affected extremity is vital. Compression devices and massage can help to manage the symptoms. See Figure 14.18 [ 21 ]  for an image of a specialized compression dressing used for lymphedema. It is also important to remember to avoid taking blood pressure on a patient’s extremity with lymphedema. [ 22 ]

Figure 14.17

Figure 14.18.

Compression Dressing for Lymphedema

Jaundice  causes skin and sclera (whites of the eyes) to turn yellow. See Figure 14.19 [ 23 ]  for an image of a patient with jaundice visible in the sclera and the skin. Jaundice is caused by too much bilirubin in the body. Bilirubin is a yellow chemical in hemoglobin, the substance that carries oxygen in red blood cells. As red blood cells break down, the old ones are processed by the liver. If the liver can’t keep up due to large amounts of red blood cell breakdown or liver damage, bilirubin builds up and causes the skin and sclera to appear yellow. New onset of jaundice should always be reported to the health care provider.

Figure 14.19

Many healthy babies experience mild jaundice during the first week of life that usually resolves on its own, but some babies require additional treatment such as light therapy. Jaundice can happen at any age for many reasons, such as liver disease, blood disease, infections, or side effects of some medications. [ 24 ]

Pressure Injuries

Pressure injuries  also called bedsores, form when a patient’s skin and soft tissue press against a hard surface, such as a chair or bed, for a prolonged period of time. The pressure against a hard surface reduces blood supply to that area, causing the skin tissue to become damaged and become an ulcer. Patients are at high risk of developing a pressure injury if they spend a lot of time in one position, have decreased sensation, or have bladder or bowel leakage. [ 25 ]  See Figure 14.20 [ 26 ]  for an image of a pressure ulcer injury on a bed-bound patient’s back. Read more information about assessing and caring for pressure injury in the “ Wound Care” chapter .

Figure 14.20

Pressure Ulcer Injury

Petechiae  are tiny red dots caused by bleeding under the skin that may appear like a rash. Large petechiae are called purpura. An easy method used to assess for petechiae is to apply pressure to the rash with a gloved finger. A rash will blanch (i.e., whiten with pressure) but petechiae and purpura do not blanch. See Figure 14.21 [ 27 ]  for an image of petechiae and purpura. New onset of petechiae should be immediately reported to the health care provider because it can indicate a serious underlying medical condition. [ 28 ]

Figure 14.21

Petechiae and Purpura

14.4. INTEGUMENTARY ASSESSMENT

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

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 ]

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.

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 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 ]

View the following video demonstrating Capillary Refill [ 7 ] :

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.  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 ]

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.

Figure 14.22

Assessing Lower Extremity Edema

Figure 14.23

Grading of 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 14.4b to review common expected and unexpected integumentary findings.

Table 14.4b

Expected Versus Unexpected Findings on integumentary Assessment

14.5. SAMPLE DOCUMENTATION

Sample documentation of expected findings.

Skin is expected color for ethnicity without lesions or rashes. Skin is warm and dry with no edema. Capillary refill is less than 3 seconds. Normal skin turgor with no tenting.

Sample Documentation of Unexpected Findings

Mother brought the child into the clinic for evaluation of an “itchy rash around the mouth” that started about three days ago. Crusted pustules are present around the patient’s mouth. Dr. Smith evaluated the patient and a prescription for antibiotics was provided. Mother and child were educated to use good hand hygiene practices to prevent the spread of infection.

14.6. CHECKLIST FOR INTEGUMENTARY ASSESSMENT

Use this checklist to review the steps for completion of an “Integumentary Assessment.”

Disclaimer: Always review and follow agency policy regarding this specific skill.

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.
• Introduce yourself, your role, the purpose of your visit, and an estimate of the time it will take.
• Confirm patient ID using two patient identifiers (e.g., name and date of birth).
• Explain the process to the patient and ask if they have any questions.
• Be organized and systematic.
• Use appropriate listening and questioning skills.
• Listen and attend to patient cues.
• Ensure the patient’s privacy and dignity.
• Assess ABCs.

Ask the patient if they have any known skin conditions or concerns.

Inspect the general color of the skin and look for any discolorations. Inspect the skin for lesions, bruising, edema, or rashes.

Verbalize the ABCE format for evaluating skin lesions.

Inspect the scalp for lesions and hair for lice or nits.

Inspect the nail beds for color and palpate for capillary refill.

Palpate the skin to assess for temperature, moisture, and turgor. Apply gloves prior to palpation as indicated.

Assess pressure points for skin breakdown: back of head, ears, elbows, sacrum, and heels.

Palpate for edema on lower extremities bilaterally. If edema is present, determine the grade of edema.

Assist the patient to a comfortable position, ask if they have any questions, and thank them for their time.

Ensure safety measures when leaving the room:

• CALL LIGHT: Within reach
• BED: Low and locked (in lowest position and brakes on)
• SIDE RAILS: Secured
• TABLE: Within reach
• ROOM: Risk-free for falls (scan room and clear any obstacles)

Document the assessment findings. Report any concerns according to agency policy.

14.7. LEARNING ACTIVITIES

Learning activities.

(Answers to “Learning Activities” can be found in the “Answer Key” at the end of the book. Answers to interactive activity elements will be provided within the element as immediate feedback.)

Mr. Curtis is a 47-year-old patient admitted with a one-week history of progressive fatigue and ongoing diarrhea. You are completing his admission assessment.  Based upon his presenting condition, what integumentary assessments might be important?

Check your knowledge about integumentary assessment using this flashcard activity:

Check your knowledge about integumentary conditions using this flashcard activity:

Attributions

“ Cholangitis Jaundice.jpg ” by  Bobjgalindo  is licensed under  CC BY-SA 4.0

“ 508 Moles.jpg ” by  OpenStax  is licensed under  CC BY 3.0 . Access for free at  https://openstax.org/books/anatomy-and-physiology/pages/5-1-layers-of-the-skin .

“ 1Veertje hand-burn-do8.jpg ” by  1Veertje  is licensed under  CC BY-SA 3.0

“ Purpura.jpg ” by  User:Hektor  is licensed under  CC BY-SA 3.0

“ Squamous cell carcinoma (3).jpg ” by unknown photographer, provided by  National Cancer Institute  is licensed under  CC0 . Access for free at  https://openstax.org/books/anatomy-and-physiology/pages/5-4-diseases-disorders-and-injuries-of-the-integumentary-system

“ Tinea cruris.jpg ” by  Robertgascoin  is licensed under  CC BY-SA 3.0

“ Keloid-Butterfly, Chest Wall.JPG ” by  Htirgan  is licensed under  CC BY-SA 3.0

“ Melanoma (2).jpg ” by unknown photographer, provided by  National Cancer Institute  is in the  Public Domain . Access for free at  https://openstax.org/books/anatomy-and-physiology/pages/5-4-diseases-disorders-and-injuries-of-the-integumentary-system

“ Impetigo2020.jpg ” by  James Heilman, MD  is licensed under  CC BY-SA 4.0

“ Acne vulgaris on a very oily skin.jpg ” by  Roshu Bangal  is licensed under  CC BY-SA 4.0

“ Lymphedema_limbs.JPG ” by medical doctors is licensed under  CC BY-SA 4.0

“ Decubitus 01.jpg ” by  AfroBrazilian  is licensed under  CC BY-SA 3.0

“ Fig.5. Louse nites.jpg ” by  KostaMumcuoglu  at  English Wikipedia  is licensed under  CC BY-SA 3.0

• XIV. GLOSSARY

A mnemonic for assessing for melanoma developing in moles: Asymmetrical, Borders are irregular in shape, Color is various shades of brown or black, Diameter is larger than 6 mm., and the shape of the mole is Evolving.

Sweat glands associated with hair follicles in densely hairy areas that release organic compounds subject to bacterial decomposition causing odor.

To make white or pale by applying pressure.

A bluish discoloration caused by lack of oxygenation of the tissue.

The inner layer of skin with connective tissue, blood vessels, sweat glands, nerves, hair follicles, and other structures.

Excessive, abnormal sweating.

Sweat gland that produces hypotonic sweat for thermoregulation.

The thin, uppermost layer of skin.

A red color of the skin.

A superficial burn that affects only the epidermis.

Severe burn damaging the dermis and the underlying muscle and bone.

The layer of skin beneath the dermis composed of connective tissue and used for fat storage.

A yellowing of the skin or sclera caused by underlying medical conditions.

A raised scar caused by overproduction of scar tissue.

An area of abnormal tissue.

A type of swelling that occurs when lymph fluid builds up in the body’s soft tissues due to damage to the lymph system.

Skin pigment produced by melanocytes scattered throughout the epidermis.

Skin cancer characterized by the uncontrolled growth of melanocytes that commonly develops from a mole. Melanoma is the most fatal of all skin cancers because it is highly metastatic. Melanomas usually appear as asymmetrical brown and black patches with uneven borders and a raised surface.

Tiny red dots caused by bleeding under the skin.

Skin breakdown caused when a patient’s skin and soft tissue press against a hard surface for a prolonged period of time, causing reduced blood supply and resulting in damaged tissue.

A tool used in the emergency department to assess the total body surface area burned to quickly estimate intravenous fluid requirements.

Burn affecting both the epidermis and a portion of the dermis, resulting in swelling and a painful blistering of the skin.

The skin’s elasticity and its ability to change shape and return to normal when gently grasped between two fingers.

Severe burn that fully extends into the epidermis and dermis, destroying the tissue and affecting the nerve endings and sensory function.

Licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit https://creativecommons.org/licenses/by/4.0/ .

• Cite this Page Open Resources for Nursing (Open RN); Ernstmeyer K, Christman E, editors. Nursing Skills [Internet]. Eau Claire (WI): Chippewa Valley Technical College; 2021. Chapter 14 Integumentary Assessment.
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• INTEGUMENTARY ASSESSMENT INTRODUCTION
• BASIC INTEGUMENTARY CONCEPTS
• COMMON INTEGUMENTARY CONDITIONS
• INTEGUMENTARY ASSESSMENT
• SAMPLE DOCUMENTATION
• CHECKLIST FOR INTEGUMENTARY ASSESSMENT
• LEARNING ACTIVITIES

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14.4 Integumentary Assessment

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

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]

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.

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 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]

View the Cardiovascular Assessment Part Two | Capillary Refill Test YouTube video   for a demonstration of 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]

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.

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

• 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.). https://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. https://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 ↵

A reduced amount of oxyhemoglobin the skin or mucous membranes. Skin and mucous membranes present with a pale skin color.

A bluish discoloration of the skin, lips, and nail beds. It is an indication of decreased perfusion and oxygenation.

A yellowing of the skin or sclera caused by underlying medical conditions.

A red color of the skin.

The whiteness that occurs when pressure is placed on tissue or a nailbed, causing blood to leave the area.

Excessive, abnormal sweating.

The skin's elasticity and its ability to change shape and return to normal when gently grasped between two fingers.

Nursing Skills - 2e Copyright © 2023 by Chippewa Valley Technical College is licensed under a Creative Commons Attribution 4.0 International License , except where otherwise noted.

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