Chapter 2. Patient Assessment

2.12 Head-to-Toe Assessment: Integument Assessment

Checklist 22 provides a guide for objective and subjective data collection in an integument assessment.

Checklist 22: Integument Assessment

Figure 2.32 Integumentary system
Disclaimer: Always review and follow your agency policies and guidelines regarding this specific skill.
Safety considerations:
  • Perform hand hygiene.
  • Introduce yourself to patient.
  • Confirm patient ID using two patient identifiers (e.g., name and date of birth).
  • Explain process to patient.
  • Be organized and systematic in your assessment.
  • Use appropriate listening and questioning skills.
  • Listen and attend to patient cues.
  • Ensure patient’s privacy and dignity.
  • Document according to your agency’s policies and guidelines.

Objective Data

Consider the following:

Steps

Additional Information
 

  • Observe the skin from head to toe for colour, moisture, temperature, hair loss
 Abnormalities in skin / sclera colour may indicate other health issues (i.e., jaundice)

Figure 2.33 Jaundiced sclera

Consider causes of excessive moisture. Excess moisture may increase the patient’s risk for skin breakdown.

Excessive temperature may indicate infection. Further assessment is required.
  • Observe condition of nails, eyes, and mucous membranes of nose and mouth
 Neglect of nails may suggest difficulty with managing activities of daily living.

Fungal infection of nails is common.

Figure 2.34 Fungal nail infection (resolving)
  • Observe condition of mouth (evidence of oral care or lack thereof)
Figure 2.36   oral herpes
Figure 2.35 Oral candida
  • Mucous membranes of the mouth should be moist. Lack of moisture may suggest dehydration. Further assessment is required.
  • Poor oral health can be evidence of larger health or social issues. Further assessment is required.
  • Oral candida can occur with antibiotic therapy and from inhaled corticosteroids.
  • Oral care should be a routine part of every patient’s care plan.
  • Herpes infections are contagious. Risk assessment and implementation of PPE should be considered.
  • Assess skin integrity for presence of lesions, rashes, or pressure injury.
 The integumentary system is our body’s first line of defense against invading organisms. Breaks in integument increase one’s risk of infection. Any concerns should be reported to the appropriate healthcare provider immediately.

Figure 2.37 Scabies
Figure 2.38 Gangrene
  • Inspect dressings and/or entry sites of all tubes, drains, and IVs.

 

 Determine the rationale for all tubes. Tubes should be secured, intact, and functioning. See Table 10.1 Guidelines for Caring for Patients with Tubes and Devices.

Dressings should be dry and intact.
  • Note the amount, colour, and consistency of drainage from any tube.
 The character of drainage provides insight into activities within the body.

Subjective Data

Ask if they have noticed any recent changes to their skin.

Focused integument assessment may also include:
Pressure Injury Risk Assessment

Braden scales for measuring risk of developing a pressure injury are widely used in North America in the adult patient population. The tool consists of six subscales: sensory perception, moisture, activity, mobility, nutrition, friction, and shear. Using each of these elements, the nurse assigns a score. Low numbers translate to high risk of pressure injury.

 

 See Braden Pressure Ulcer Risk Assessment

Some agencies have guidelines about frequency of assessment and documentation using a Braden Scale.

It is important for the nurse to remember that the Braden Scale is an assessment tool. The nursing process isn’t completed unless risk is addressed through preventative strategies and evaluation of outcomes.

Necessary interventions to prevent and treat pressure injury should be included in the plan of care.
Wound Assessment See 4.2 Wound Healing and Assessment
Potential integument related nursing diagnoses:

  • Impaired skin integrity due to incontinence.
  • Risk of pressure injury due to immobility.
  • Risk of wound infection due to contamination of coccyx wound with fecal matter.
Data sources: Braden & Bergstrom, 1989; RNAO, 2016; Potter et al., 2019

Critical Thinking Exercises

  1. Identify the six components of the Braden Scale that suggest risk of pressure injury.
  2. In five of those components, provide two possible preventative strategies to reduce risk of pressure injury.

Attribution:

Figure 2.32 Layers of Skin by Madhero88 and M. Komorniczak is used under a Creative Commons Attribution-Share Alike 3.0 Unported license.
Figure 2.33 Jaundice Caused by Hepatitis A by CDC/Dr. Thomas F. Sellers/Emory University is in the public domain.
Figure 2.34 A Patient’s Left Foot – After Ten Weeks of Terbinafine Oral Treatment by Dandandandandandandan2014 is used under a Creative Commons Attribution-Share Alike 4.0 International license.
Figure 2.35 Thrush in a Child Who Has Taken Antibiotics by James Heilman, MD is used under a Creative Commons Attribution-Share Alike 3.0 Unported license.
Figure 2.36 Herpes Labialis by Jojo is in the public domain.
Figure 2.37 Scabies by Cixia is in the public domain.
Figure 2.38 Gangrene Toe by James Heilman, MD is used under a CC BY-SA license.

License

Icon for the Creative Commons Attribution 4.0 International License

Clinical Procedures for Safer Patient Care Copyright © 2018 by Thompson Rivers University is licensed under a Creative Commons Attribution 4.0 International License, except where otherwise noted.

Share This Book