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.
- 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)
- Perform hand hygiene.
- Document the assessment findings. Report any concerns according to agency policy.