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PUB/NURSINGSKILLS/CHAPTER/14-1-
INTEGUMENTARY-ASSESSMENT-INTRODUCTION/

INTEGUMENTARY ASSESSMENT
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

Questions Follow-up

Use the PQRSTU method to gain additional

Are you currently experiencing any skin
information about current symptoms. Read
symptoms such as itching, rashes, or an
more about the PQRSTU method in the
unusual mole, lump, bump, or nodule?[3]
“Health History” chapter.

Have you ever been diagnosed with a

condition such as acne, eczema, skin cancer,
Please describe.
pressure injuries, jaundice, edema, or
lymphedema?
 Are you currently using any prescription or
over-the-counter medications, creams,
Please describe.
vitamins, or supplements to treat a skin, hair,
or nail condition?

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.  While assessing skin temperature, also assess if the skin feels dry or moist and the
[5]

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.  Skin turgor is not a reliable
[8]

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  for an image demonstrating pitting edema. If
[10]

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  for an illustration of grading edema.
[11]

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

Unexpected Findings
(Document and notify
Assessment Expected Findings
provider if it is a new
finding*)

Jaundice

Erythema

Pallor

Cyanosis
Skin is expected color for ethnicity
Inspection Irregular-looking mole
without lesions or rashes.
Bruising (ecchymosis)

Rashes

Petechiae

Skin breakdown

Burns

Auscultation Not applicable

Diaphoretic or clammy

Cool extremity

Edema
Skin is warm and dry with no edema.
Palpation Capillary refill is less than 3 seconds. Skin Lymphedema
has normal  turgor with no tenting.
Capillary refill greater
than 3 seconds

Tenting
 Cool and clammy

Diaphoretic

Petechiae
*CRITICAL
CONDITIONS to Jaundice
report immediately
Cyanosis

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 ↵

SAMPLE DOCUMENTATION
OPEN RESOURCES FOR NURSING (OPEN RN)

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.

CHECKLIST FOR INTEGUMENTARY

ASSESSMENT
OPEN RESOURCES FOR NURSING (OPEN RN)

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

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

1. Gather supplies: penlight, nonsterile gloves, magnifying glass (optional), and wound
measuring tool (optional).
2. Perform safety steps:
o Perform hand hygiene.
o Check the room for transmission-based precautions.
o Introduce yourself, your role, the purpose of your visit, and an estimate of the
time it will take.
o Confirm patient ID using two patient identifiers (e.g., name and date of birth).
o Explain the process to the patient and ask if they have any questions.
o Be organized and systematic.
o Use appropriate listening and questioning skills.
o Listen and attend to patient cues.
o Ensure the patient’s privacy and dignity.
o Assess ABCs.
3. Ask the patient if they have any known skin conditions or concerns.
4. Inspect the general color of the skin and look for any discolorations. Inspect the skin for
lesions, bruising, edema, or rashes.
5. Verbalize the ABCE format for evaluating skin lesions.
6. Inspect the scalp for lesions and hair for lice or nits.
7. Inspect the nail beds for color and palpate for capillary refill.
8. Palpate the skin to assess for temperature, moisture, and turgor. Apply gloves prior to
palpation as indicated.
 9. Assess pressure points for skin breakdown: back of head, ears, elbows, sacrum, and heels.
10. Palpate for edema on lower extremities bilaterally. If edema is present, determine the
grade of edema.
11. Assist the patient to a comfortable position, ask if they have any questions, and thank
them for their time.
12. Ensure safety measures when leaving the room:
o CALL LIGHT: Within reach
o BED: Low and locked (in lowest position and brakes on)
o SIDE RAILS: Secured
o TABLE: Within reach
o ROOM: Risk-free for falls (scan room and clear any obstacles)
13. Perform hand hygiene.
14. Document the assessment findings. Report any concerns according to agency policy.

LEARNING ACTIVITIES
OPEN RESOURCES FOR NURSING (OPEN RN)

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?

Answer Key to Chapter 14 Learning Activities

1. A patient admitted with diarrhea is at risk for skin breakdown and dehydration.
Assessment of the patient’s skin condition and hydration status would be important for
assessing the severity of the patient’s illness. Hydration status can be assessed through
evaluation of skin turgor with this patient due to normal skin elasticity in this age group.

Answers to interactive elements are given within the interactive element.