chapter

Patient Assessment: 51
Integumentary System
JOAN DAVENPORT

History objectives
Physical Examination Based on the content in this chapter, the reader should be able to:
Inspection
Palpation ■ Identify the assessment skill necessary for the critical care nurse
Assessment of Pressure Ulcers to use when evaluating the health of a patient’s skin.
Assessment of Skin Tumors ■ Identify expected differences in skin color related to racial or
Assessment of the Skin in Older skin tone characteristics.
Adults
■ Describe and recognize abnormal changes in skin color.
Assessment of the Skin in Children
■ Recognize and describe skin lesions resulting from increased
vascularity.
■ Describe the significance of rashes related to infection or to
allergic reaction.
■ Identify the pitting and nonpitting edema.
■ Explain the cause of pressure ulcers and at least one scale used
to assess a patient for pressure ulcer development.
■ Describe the features of malignant skin diseases.

T
he skin of a critically ill person is exposed to insults
ranging from diminished blood flow and the resul-
tant risk of pressure ulceration to rashes from hyper-
sensitivity drug reactions and opportunistic infections.
There is often ample opportunity for the critical care nurse
to assess the skin—the intimacy involved in providing care
to someone who is critically ill, the relative level of undress
of the patient, and the attention to detail implicit in critical
care nursing make integument assessment an ongoing and
vital process.
HISTORY
When caring for patients with skin disorders, it is important
to obtain information from the health history (Box 51-1).
The information is useful in guiding the physical examina-
tion and in determining appropriate interventions.
PHYSICAL EXAMINATION
The assessment techniques necessary for an evaluation of
the integument involve inspection and palpation.
Inspection
Inspection of the general appearance of the skin includes
assessment of color; determination of the presence of
lesions, rashes, or increased vascularity; and assessment
of the condition of the nails and hair.
COLOR
Skin color is expected to be uniform over the body, except
for the areas with greater degrees of vascularity. The geni-
talia, upper chest, and cheeks may appear pink or have a red-
dish tone in people with light skin. These same areas may
appear darker in people with dark skin. Additional normal
variations in skin color include those listed in Table 51-1.

1200
 CHAPTER 51
box 51-1
Patient History—Skin Disorders
Patient history relevant to skin disorders may be
obtained by asking the following questions:
When did you first notice this skin problem? (Also investi-
gate duration and intensity.)
Has it occurred previously?
Are there any other symptoms?
What site was first affected?
What did the rash or lesion look like when it first
appeared?
Where and how fast did it spread?
Do you have any itching, burning, tingling, or crawling
sensations?
Is there any loss of sensation?
Is the problem worse at a particular time or season?
How do you think it started?
Do you have a history of hay fever, asthma, hives,
eczema, or allergies?
Who in your family has skin problems or rashes?
Did the eruptions appear after certain foods were eaten?
Which foods?
When the problem occurred, had you recently consumed
alcohol?
What relation do you think there may be between a spe-
cific event and the outbreak of the rash or lesion?
What medications are you taking?
What topical medication (ointment, cream, salve) have
you put on the lesion (including over-the-counter
medications)?
What skin products or cosmetics do you use?
What is your occupation?
What in your immediate environment (plants, animals,
chemicals, infections) might be precipitating this
disorder? Is there anything new, or are there any
changes in the environment?
Does anything touching your skin cause a rash?
How has this affected you (or your life)?
Is there anything else you wish to talk about in regard to
this disorder?
From Smeltzer SC, Bare BG: Brunner: Suddarth’s Textbook of
Medical–Surgical Nursing (10th Ed), p 1645. Philadelphia, Lippincott
Williams & Wilkins, 2004.
Skin color is determined by the presence of four pig-
ments: melanin, carotene, hemoglobin, and deoxyhemo-
globin. The amount of melanin is genetically determined
and produces varying degrees of dark skin tone. Carotene,
a yellow pigment, is in subcutaneous fat and is most evident
in those areas with the most keratin, the palms and soles of
the feet. Skin color abnormalities, such as pallor, cyanosis,
jaundice, and erythema, manifest differently depending on
the person’s normal skin tone (Table 51-2).
The degree of oxygenation affects skin color. Hemo-
globin, attached to red blood cells, transports oxygen to
the tissues. A diminished flow of oxyhemoglobin through
the cutaneous circulation results in pallor. In people with
light skin, the skin appears very pale, without the usual
Patient Assessment: Integumentary System 1201
table 51-1 ■ Normal Variations in Skin Color
Normal Variation Description
Moles (pigmented nevi) Tan to dark brown; may be flat or
raised
Stretch mark (striae) Silver or pink; may be caused by
weight gain or pregnancy
Freckles Flat macules anywhere on the body
Vitiligo Unpigmented skin area; more
prevalent in people with dark skin
Birthmarks Generally flat marks anywhere on
the body; may be tan, red, or
brown
pink undertones. In people with darker skin, pallor mani-
fests as a yellowish-brown or ashen appearance (again,
because the usual pink undertones are lost).
As hemoglobin gives up its oxygen to the tissues, the
hemoglobin changes to deoxyhemoglobin. When deoxyhe-
moglobin is present in the cutaneous circulation, the skin
takes on a blue cast and the individual is said to be cyanotic.1
In light-skinned people, cyanosis may be seen as a grayish-
blue color, especially in the palms and soles of the feet, the
nail beds, the earlobes, the lips, and the mucous mem-
branes. In those with darker skin, cyanosis evidences itself
as an ashen-gray color seen easiest in the conjunctiva, oral
mucous membranes, and nail beds.2
The yellowish hue of jaundice is indicative of liver dis-
ease or of hemolysis of red blood cells. In dark-skinned
people, jaundice is seen as a yellowish-green color in the
sclera, palms of the hands, and soles of the feet. In light-
skinned people, jaundice is seen as a yellow coloration of
the skin, sclera, lips, hard palate, and underside of the
tongue. Bickley and Szilagyi recommend using a trans-
parent slide pressed against the lips to “blanch out the red
color,” making the yellow of jaundice more easily seen.1
Another skin color abnormality is erythema. Erythema
manifests as a reddish tone in light-skinned people and a
deeper brown or purple tone in dark-skinned people. It is
indicative of increased skin temperature caused by inflam-
mation. The process of inflammation increases vascularity
of the tissues and this, in turn, produces the color alteration
seen with erythema. Erythema may be expected when asso-
ciated with a surgical wound, due to the inflammatory pro-
cess inherent in any tissue trauma. It is also seen in disease
processes affecting the skin, such as cellulitis. In either case,
the erythema is indicative of inflammation.
LESIONS
Skin lesions are variously described by their color, shape,
cause, or general appearance (Table 51-3). They are con-
sidered abnormal conditions and arise from many factors.
In general, it is important to note the anatomical location,
distribution, color, size, and pattern of any abnormal skin
lesion. In addition, details about the lesion’s borders or
edges, as well as whether the lesion is flat, raised, or sunken,
should be noted. Finally, the length of time the lesion has
1202 PART 11 INTEGUMENTARY SYSTEM

table 51-2 ■ Skin Color Abnormalities

Skin Color Manifestation in Manifestation in

Abnormality Underlying Cause Light-Skinned People Dark-Skinned People

Pallor Decreased blood flow Excessively pale skin Yellowish-brown or ashen

(decreased oxyhemo-
globin flow to tissues)
Cyanosis Increased deoxyhemoglo-
bin in the cutaneous
circulation
Jaundice Increased red blood cell
hemolysis, liver disease
Erythema Inflammation
color to the skin
Grayish-blue color of Ashen-gray color of the
the palms and soles conjunctiva, oral
of the feet, the nail mucous membranes,
beds, the lips, the ear- and nail beds
lobes, and the mucous
membranes
Yellow color of the sclera, Yellow-green color of the
lips, and hard palate sclera and palms and
soles of the feet
Reddish tone Deeper brown or purple
tone

table 51-3 ■ Types of Skin Lesions

Lesion Description

Blister Fluid-filled vesicle or bulla

Bulla Blister larger than 1 cm
Comedo Plugged and dilated pore, called blackhead or whitehead
Crust Dried exudate over a damaged epithelium; may be associated with vesicle, bullae,
or pustules
Cyst Semisolid or fluid-filled mass, encapsulated in deeper layers of skin
Desquamation Shedding or loss of debris on skin surface
Erosion Loss of epidermis; may be associated with vesicles, bullae, or pustules
Excoriation Epidermal erosion usually caused by scratching
Fissure Crack in the epidermis usually extending into the dermis
Macule Flat area of skin with discoloration, less than 5 mm in diameter
Nodule Solid, elevated lesion or mass, 5 mm to 5 cm in diameter
Papule Solid, elevated lesion less than 5 mm in diameter
Plaque Raised, flattened lesion greater than 5 mm in diameter
Pustule Papule containing purulent exudate
Scale Skin debris on the surface of the epidermis
Tumor Solid mass, larger than 5 cm in diameter; usually extends to dermis
Ulceration Loss of epidermis, extending into dermis or deeper
Urticaria Raised wheal-like lesion
Vesicle Small fluid-filled lesion, less than 1 cm in diameter
Wheal Transient, irregular pink elevation with
surrounding edema

From Allwood, Curry. 2000.

 CHAPTER 51 Patient Assessment: Integumentary System 1203

been present, and any environmental or medication expo-
sure that may be considered contributory, are also noted.3
Vascular lesions can be either a normal variation or an
abnormal finding. Vascular changes considered to be nor-
mal variants include nevus flammeus (port-wine stain),
immature hemangioma (strawberry mark), telangiectasis,
cherry angioma, and capillary hemangioma (Table 51-4).
Abnormal vascular findings include petechiae, purpura,
ecchymoses, spider angiomas, and urticaria (hives). These
findings may indicate disease or injury and warrant further
investigation by the critical care nurse.
Petechiae are purple or red, small (1- to 3-mm) lesions
easily seen on light-skinned individuals and more difficult
to see in those with dark skin (Fig. 51-1A). They may be
seen on the oral mucosa and in the conjunctiva. They do
not disappear when pressure is applied to them.2 Petechiae
result from tiny hemorrhages in the dermal or submucosal
layers. Purpura are very similar to petechiae, only larger.
Purpura may appear brownish-red.
Ecchymoses are bruises. They may appear as purple
to yellowish-green rounded or irregular lesions, and are
more easily seen in people with light skin (see Fig. 51-1B).
Ecchymoses occur as a result of trauma, when blood leaks
from damaged blood vessels into the surrounding tissue.
Spider angiomas are fiery red lesions that are most
often located on the face, neck, arms, or upper trunk (see
Fig. 51-1C). Spider angiomas are seldom seen below the
waist. They have a central body that is sometimes “raised
and surrounded by erythema and radiating legs.”1 These
lesions are most often associated with liver disease and
vitamin B deficiency.2
Urticaria is a reddened or white, raised, nonpitting
plaque that often occurs as a result of an allergic reaction.
The lesion often changes shape and size during the course
of the reaction. The edema associated with urticaria is a
result of local vasodilation and inflammation, which is
followed by transudation of serous vascular fluid into the
surrounding tissue.
RASHES
Rashes identified during inspection may indicate infection
or a reaction to drug therapy. Some of these rashes are
identified by the names listed in Table 51-3. Identifying
the type of lesion may help in identifying the cause of the
rash. Attention to the development of a rash in association
with a change in pharmacotherapy is essential to help iden-
tify the occurrence of an allergic hypersensitivity reaction.
The development of urticaria is often associated with food
or drug reactions. Urticaria usually resolves completely
over days to several weeks as the excess local fluid is re-
absorbed. These lesions are often pruritic, and patient
scratching may precipitate secondary skin abrasions, which
can place the patient at risk for localized skin infections.
Skin infections are most often caused by fungi or yeasts,
and may range from superficial tinea pedis (athlete’s foot)
to intermediate yeast infections (e.g., moniliasis resulting
from Candida albicans infection) to deep fungal infections
(e.g., aspergillosis) that invade the underlying tissues. Most
often in the critical care setting, fungal and yeast infec-
tions are of the intermediate type and are the result of an
opportunistic infection by normal flora. Antibiotics and
corticosteroids place the patient at risk for these infections.
Candidiasis presents in the groin and under the breasts of
female patients with “erythema, a whitish pseudomembrane,
and peripheral papules and pustules.” Oral candidiasis,
also known as thrush, manifests as a whitish coating of the
oral mucosa, especially the tongue. This painful condition
may produce fissures on the tongue and often restricts a
patient’s oral intake, further compromising the patient
from a nutritional perspective.
CONDITION OF THE HAIR
The patient’s terminal hair is inspected daily, noting the
hair’s quantity, distribution, and texture. Scalp hair should
be resilient and evenly distributed.
Alopecia refers to hair loss and can be diffuse, patchy,
or complete. Hair loss in the critical care setting can be
associated with pharmacotherapy. Chemotherapy used in
oncology treatment produces alopecia. Other drugs, such
as heparin, used for a prolonged time may also be respon-
sible for hair loss.6 Hirsutism or increased facial, body, or
pubic hair growth is an abnormal finding in the examina-
tion of women and children. Hirsutism has a familial pat-
tern and is associated with menopause, endocrine disorders,
and certain pharmacotherapies (e.g., corticosteroids and
androgenic medications).2
A change in the hair’s texture may indicate ongoing
health concerns. Hair that is thin and brittle occurs in

table 51-4 ■ Vascular Lesions: Normal Variations

Normal Variation Description

Nevus flammeus (port-wine stain),
immature hemangioma
(strawberry mark)
Cherry angioma
Capillary hemangioma
Telangiectasis
Range from dark red to pale pink in color and are considered
birthmarks
Small, slightly raised, bright red lesions on the face, neck, and
trunk; increase in size and number with advancing age
Red, irregular patch caused by capillary dilation in the dermis of
the skin
Irregular, fine red lines caused by permanent dilation of a group
of superficial vessels
1204 PART 11 INTEGUMENTARY SYSTEM
A. Petechiae/purpura B. Ecchyrriosis
C. Spider angioma
figure 51-1 Abnormal vascular lesions. (A, used with permission
from Kelley WN: Textbook of Internal Medicine. Philadelphia, JB
Lippincott, 1989. B, used with permission from Bickley L: Bates’
Guide to Physical Examination and History Taking [8th Ed], p 106.
Philadelphia, Lippincott Williams & Wilkins, 2003. C, used with per-
mission from Marks R: Skin Disease in Old Age. Philadelphia, JB Lip-
pincott, 1987.)
hypothyroidism. In those with severe protein malnutri-
tion, the hair color may appear reddish or bleached and
the hair texture is described as coarse and dry.7
Also not to be overlooked is the presence of infection
or infestation of the scalp and hair. The patient’s scalp and
body hair is inspected regularly for evidence of flaking,
sores, lice, louse eggs, and ringworm.7 During the inspec-
tion, the hair is parted in several areas to reveal the under-
lying scalp.
CONDITION OF THE NAILS
Nails, like hair, can be overlooked in the rush of critical
care nursing; however, a careful inspection as part of the
“routine” assessment can reveal information about the
patient’s general state of health. The nail bed is very vas-
cular and is an excellent location for assessing the ade-
quacy of the patient’s peripheral circulation. The capillary
refill test, done by blanching the nail beds and then releas-
ing the pressure, should indicate a return of the pink tones
in less than 3 seconds. Nail beds that are bluish or purplish
in tint may be indicative of cyanosis; nail beds that are pale
may indicate reduced arterial blood flow.
When the angle of the nail is 180 degrees or greater,
clubbing is said to be present (see Chapter 24, Fig. 24-2).
Clubbing is attributed to chronic hypoxemia. Other shapes
that the nail takes on may provide clues to deficient nutri-
tional states of the patient. Chronic disease states such as
cirrhosis, heart failure, and type 2 diabetes mellitus may
affect the nails by producing Terry’s nails.1 These nails are
whitish with a distal band of dark reddish-brown color,
and the lunulae may not be visible (Fig. 51-2). A spoon-
shaped nail, called koilonychias, is associated with iron-
deficiency anemia. Bands across the nails, especially in the
older adult, may indicate protein deficiency. White spots
on the nails are associated with zinc deficiency.7
figure 51-2 Terry’s nails, seen in people with chronic diseases
such as cirrhosis, congestive heart failure, and type 2 diabetes mel-
litus. (Used with permission from Bickley L: Bates’ Guide to Physi-
cal Examination and History Taking [8th Ed], p 110. Philadelphia,
Lippincott Williams & Wilkins, 2003.)
Palpation
The skin is palpated for texture, moisture, temperature,
mobility and turgor, and edema. In addition, during pal-
pation any evidence of discomfort arising from the areas
palpated is noteworthy.
TEXTURE
Texture refers to the smoothness of the skin surface. It
requires gentle palpation to assess. Rough skin occurs in
patients with hypothyroidism.
MOISTURE
The skin may be described as dry, oily, diaphoretic, or
clammy. Dry skin may be seen in the patient with hypo-
thyroidism. Skin is oily with acne and with increased
activity of the sebaceous glands, as in Parkinson’s disease.
Diaphoresis may be a response to increased temperature
or increased metabolic rate. Hyperhidrosis is the term given
to excessive perspiration. Bromhidrosis refers to foul-smelling
perspiration. Low cardiac output states may produce skin
that is referred to as clammy.
TEMPERATURE
Temperature is usually assessed with the dorsal surface of
the hand to identify the general skin temperature as warm
or cool. The skin’s temperature can also be used to assess
the possibility of reduced blood flow from an arterial insuf-
ficiency. In this case, the skin may be noticeably cooler dis-
tal to an occluding lesion.
MOBILITY AND TURGOR
Mobility and turgor provide information about the health
of the skin and may yield information about the patient’s
fluid volume balance. When assessed centrally, over the
clavicles, the skin is expected to lift up easily and quickly
return into place. Skin mobility may be decreased in scle-
roderma or in a patient with increased edema. Skin turgor
is decreased in the patient with dehydration.1
 CHAPTER 51
EDEMA
Edema is classified as either nonpitting or pitting. Nonpit-
ting edema is that which does not depress with palpation.
Nonpitting edema is seen in patients with a local inflam-
matory response and is caused by capillary endothelial
damage. In addition to the edema, the skin is usually red,
tender, and warm. Pitting edema is usually in the skin of
the extremities and in dependent body parts. Pitting edema
is identified as edema that retains the depression made
when palpated. This type of edema can be further classi-
fied by the depth of the depression and, occasionally, by the
amount of time it takes the pit to rebound (Table 51-5).
ASSESSMENT OF
PRESSURE ULCERS
The development of pressure ulcers in the critically ill
patient is a preventable complication. The difficulty arises
in the patient with multiple-system dysfunction with con-
comitant fluid, electrolyte, and nutritional deficiencies.
Common pressure ulcer points include the occiput, scapula,
sacrum, buttocks, ischium, heels, and toes. It is the pressure
applied by the weight of the body that causes a reduction in
arterial and capillary blood flow, leading to these ischemic
events. Therefore, frequent position changes are required
to prevent the development of pressure ulcers. Pressure
ulceration on the toes occurs as a result of the pressure of
the bed linen on the feet. Dressing devices and wound
appliances can place pressure on underlying skin, result-
ing in reduced blood flow. The back of the neck of the
patient with a tracheostomy tube must be assessed because
the tube holder may be applied too tightly. The tape secur-
ing a nasogastric tube must be regularly removed and the
condition of the tip of the nose and nares assessed for
changes resulting from pressure from the tube.
Assisting the patient with frequent position changes is
crucial in preventing pressure ulcers from developing. In
addition, keeping the skin clean and dry is requisite in the
prevention of pressure ulceration. Moisture increases the
risk for maceration of the skin and promotes its breakdown.
Infectious matter in wound drainage or feces increases the
risk that an ulcer will progress and become a major source
of sepsis.
Patients with decreased sensation (e.g., from brain or
spinal cord injury or from a peripheral neuropathy such as
that caused by diabetes) are at greater risk for ulceration
table 51-5 ■ Pitting Edema Scale
Scale (1+ to 4+) Measurement
1+/4 2 mm
2+/4 4 mm
3+/4 6 mm
4+/4 10 mm
Patient Assessment: Integumentary System 1205
because they do not recognize the discomfort from being
in one position for extended periods. Similarly, patients
with sedation or frequent analgesic dosing are at increased
risk for problems related to their immobility. Patients
with poor circulation, such as that caused by hypotension,
heart failure, or peripheral vascular insufficiency, are also
at higher risk because of the underlying possibility of tis-
sue hypoxia. Lack of movement then serves only to accel-
erate the process of pressure ulcer development.
Identifying those individuals most at risk for pressure
ulcer development is a focus of assessment. Recognizing
that there are certain features that increase a patient’s risk
for development of pressure ulcers allows the critical care
nurse to increase surveillance and implement preventa-
tive treatment modalities. Problems with sensory percep-
tion, moisture, activity, mobility, nutrition, and friction
and shearing forces increase the patient’s risk for develop-
ment of pressure ulcers, which are debilitating and expen-
sive to treat. Critically ill patients are among those with the
most significant limitations of these parameters, and there-
fore are at very high risk for the development of pressure
ulcers.
Many tools for assessing pressure ulcer risk use a point
system.8,9 The Braden Scale for Predicting Pressure Sore
Risk, recommended in the guidelines set forth by the U.S.
Agency for Health Care Policy and Research and widely
used in hospital settings, requires the daily assessment of
six parameters and provides a numerical score ranging
from a very high risk score of 6 to a very limited risk or
minimal risk score of 2310 (Fig. 51-3). Adults with a score
below 16 (18 for older adults) are considered at risk and
specific interventions to prevent the development of ulcer-
ation are recommended. There has been some work done
to establish the relative risk among those with darker-
pigmented skin using a higher cut-off score of 18.11 A 2002
study by Bergstrom and Braden compared cut-off scores
for black and white populations and found no difference
between scores, but a score of 18 best predicts pressure
ulcer risk for both groups.12
During assessment of the skin, the nurse must be vigi-
lant for signs of skin breakdown (Fig. 51-4).
ASSESSMENT OF SKIN TUMORS
Benign nevus and seborrheic keratosis are common, benign
skin lesions. The benign nevus or mole appears in the first
two to three decades and its appearance remains unchanged
Description Time to Rebound
Barely detectable Immediate
Deeper pit Few seconds
Deep pit 10–20 sec
Very deep pit > 20 sec
1206 PART 11 INTEGUMENTARY SYSTEM

FOR PREDICTING PRESSURE SORE RISK
Patient's Name Evaluator's Name
SENSORY PERCEPTION 1. Completely Limited:
Unresponsive (does not
Ability to respond meaning- moan, flinch, or grasp) to
fully to pressure-related painful stimuli, due to
discomfort diminished level of con-
sciousness or sedation.
OR
limited ability to feel pain
over most of body surface.
MOISTURE 1. Constantly Moist:
Skin is kept moist almost
Degree to which skin is constantly by perspiration,
exposed to moisture urine, etc. Dampness is
detected every time patient is
moved or turned.
ACTIVITY 1. Bedfast:
Confined to bed
Degree of
physical activity
MOBILITY 1. Completely Immobile:
Does not make even slight
Ability to change and changes in body or extremity
control body position position without assistance.
NUTRITION 1. Very Poor.
Never eats a complete meal.
Usual food intake pattern Rarely eats more than 1/3 of
any food offered. Eats 2
servings or less of protein
(meat or dairy products) per
day. Takes fluids poorly.
Does not take a liquid dietary
supplement.
OR
is NPO and/or maintained on
clear liquids or IVs for more
than 5 days.
FRICTION AND SHEAR 1. Problem:
Requires moderate to
maximum assistance in
moving. Complete lifting
without sliding against sheets
is impossible. Frequently
slides down in bed or chair,
requiring frequent repositioning
with maximum assistance.
Spasticity, contractures or
agitation leads to almost
constant friction.
Braden Scale
2. Very Limited:
Responds only to painful
stimuli. Cannot communicate
discomfort except by moaning
or restlessness.
OR
has a sensory impairment
which limits the ability to feel
pain or discomfort over 1/2
of body
2. Very Moist:
Skin is often, but not always,
moist. Linen must be changed
at least once a shift.
2. Chairfast:
Ability to walk severely limited
or nonexistent. Cannot bear
own weight and/or must be
assisted into chair or wheel-
chair.
2. Very Limited:
Makes occasional slight
changes in body or extremity
position but unable to make
frequent or significant changes
independently.
2. Probably Inadequate:
Rarely eats a complete meal
and generally eats only about
1/2 of any food offered.
Protein intake includes only 3
servings of meat or dairy
products per day. Occasionally
will take a dietary
supplement.
OR
receives less than optimum
amount of liquid diet or tube
feeding.
2. Potential Problem:
Moves feebly or requires
minimum assistance. During
a move skin probably slides to
some extent against sheets,
chair, restraints, or other
devices. Maintains relatively
good position in chair or bed
most of the time but occasion-
ally slides down.
3. Slightly Limited:
Responds to verbal com-
mands, but cannot always
communicate discomfort or
need to be turned.
OR
has some sensory impairment
which limits ability to feel
pain or discomfort in 1 or 2
extremities.
3. Occasionally Moist:
Skin is occasionally moist,
requiring an extra linen change
approximately once a day.
3. Walks Occasionally:
Walks occasionally during day,
but for very short distances,
with or without assistance.
Spends majority of each shift
in bed or chair.
3. Slightly Limited:
Makes frequent though slight
changes in body or extremity
position independently.
3. Adequate:
Eats over half of most meals.
Eats a total of 4 servings of
protein (meat, dairy products)
each day. Occasionally will
refuse a meal, but will usually
take a supplement if offered.
OR
is on a tube feeding or TPN
regimen which probably meets
most of nutritional needs.
3. No Apparent Problem:
Moves in bed and in chair
independently and has
sufficient muscle strength to lift
up completely during move.
Maintains good position in bed
or chair at all times.
Date of
Assessment
4. No Impairment:
Responds to verbal com-
mands. Has no sensory deficit
which would limit ability to feel
or voice pain or discomfort.
4. Rarely Moist:
Skin is usually dry, linen only
requires changing at routine
intervals.
4. Walks Frequently:
Walks outside the room at least
twice a day and inside room at
least once every 2 hours
during waking hours.
4. No Limitations:
Makes major and frequent
changes in position without
assistance.
4. Excellent:
Eats most of every meal.
Never refuses a meal. Usually
eats a total of 4 or more
servings of meat and dairy
products. Occasionally eats
between meals. Does not
require supplementation.

Braden Scale Scores Total Score

1 = Highly Impaired NPO: Nothing by Mouth
3 or 4 = Moderate to Low Impairment
Total Points Possible: 23 IV: Intravenously
Risk Predicting Score: 16 or Less TPN: Total parenteral nutrition

figure 51-3 The Braden Scale is a widely used screening tool to identify people at risk for pressure ulcers.
(Courtesy of Barbara Braden and Nancy Bergstrom. Copyright, 1988. Reprinted with permission.)

over time. These lesions have clearly defined borders, are
uniform in color, and round or oval in shape. The nevus is
periodically assessed for changes because a change may
indicate dysplasia of the tissue and the risk of melanoma.
Seborrheic keratoses are common, yellow to brown lesions
that are described as velvety when touched1 (Fig. 51-5A).
These lesions are often multiple and often symmetrically
distributed on the trunk and face. Precancerous lesions
(actinic keratoses) are thick, rough patches that develop on
sun-exposed areas of the skin, especially in fair-skinned
people (see Fig. 51-5B). They are described as “white, scaly
keratotic (horny) lesions on the exposed areas of the body.”
These lesions require attention because there is a risk for
development of squamous cell carcinoma.4 1 LINE
 CHAPTER 51 Patient Assessment: Integumentary System 1207

figure 51-4 Stages of pressure ulcers. (Used with permission from Weber J, Kelley J: Health Assessment in
Nursing [2nd Ed], p 133. Philadelphia, Lippincott Williams & Wilkins, 2003. Illustrations used with permission
from Makelbust J, Sieggreen MY: Pressure Ulcers: Guidelines for Prevention and Management. Springhouse, PA,
Springhouse, 2001.)

Skin cancer is the most common type of cancer in the
United States. It is estimated that 40% to 50% of those
who live to age 65 years will be diagnosed with skin cancer
at least once.14 Basal cell and squamous cell cancers are
often grouped as nonmelanoma skin cancers. Basal cell
carcinomas are found exclusively in light-skinned people,
and arise from the hair follicles on the head and neck. Pro-
longed and cumulative exposure to the sun is recognized
as the cause of basal cell carcinoma. These tumors are slow
growing and rarely metastasize but do cause local skin
destruction and disfigurement. Basal cell carcinomas appear
with pearly borders, depressed centers, and rolled edges3,13
(see Fig. 51-5C).
Squamous cell carcinomas affect the skin and the mucous
membranes. Like basal cell cancers, the primary cause is
exposure to ultraviolet light. Radiation and tissue damage
from scars, ulcers, and fistulas may give rise to squamous
cell carcinomas. These cancers can be invasive and are more
malignant than basal cell cancers if not treated promptly. As
it develops, the carcinoma takes on a hyperkeratotic appear-
ance and may ulcerate and bleed3 (see Fig. 51-5D).
Malignant melanomas are highly metastatic lesions
that come from the melanin-producing cells of the body.
The worldwide frequency of malignant melanomas is
growing more rapidly than any other cancer except lung
LONG cancer. Those at highest risk include those with fair com-
plexions, those prone to sunburn, and those with a family
history of melanoma.14 The most common location for the
development of these lesions is on the trunk in men and on
the legs in women. The tumors have irregular borders, are
dark brown or black, and are usually larger than 6 mm. The
American Cancer Society (ACS) recommends a monthly
self-assessment for melanoma using the “ABCDs.”15 A is
for asymmetry; B is for borders (are they irregular, ragged,
notched, or blurred?); C is for color (dark brown or black,
red, white, or blue?); and D is for diameter.
Figure 51-5 provides pictures and descriptions of these
benign, premalignant, and malignant lesions. While in a
critical care setting, it is possible to do a thorough assess-
ment for suspect skin lesions that may be cancerous, refer
the patient to a dermatologist or oncologist, and have
treatment initiated much sooner than would otherwise
be the case.
ASSESSMENT OF THE SKIN IN
OLDER ADULTS
With aging there are some expected changes to the integu-
ment (Box 52-2). With loss of underlying fat tissue and
decreased vascularity of the dermal layer, the skin thins,
1208 PART 11 INTEGUMENTARY SYSTEM

A. Seborrheic Keratosis B. Actinic Keratosis C. Basal Cell Carcinoma

D. Squamous Cell Carcinoma E. Malignant Melanoma

figure 51-5 Benign, premalignant, and malignant skin lesions. (A, B, and D courtesy of Sauer GC: Manual of Skin
Diseases [5th Ed]. Philadelphia, JB Lippincott, 1985. C, Bickley L: Bates’ Guide to Physical Examination and History
Taking [8th Ed], p 107. Philadelphia, Lippincott Williams & Wilkins, 2003. E, American Cancer Society.)

wrinkles, and loses turgor. Prolonged or repeated sun expo-
sure results in a yellowed or thickened appearance. Purple
patches or macules from blood leaking into the tissues after
minimal injury may appear. These lesions are called actinic
purpura and occur because the underlying capillaries lose
the protection from hypodermal fat. Dry and flaking skin
results from decreased sebaceous and sweat gland activity
and is not unexpected in the older adult patient.1,2 Solar
lentigo, sometimes called “liver spots,” appear as light to
box 51-2
Expected Changes in the Integument
of Older Patients
■ Loss of underlying fat tissue and decreased vascularity of
the dermal layer lead to thinning of the skin, increased
wrinkling, loss of skin turgor, and actinic purpura.
■ Sun exposure over a long period of time leads to yel-
lowing and thickening of the skin and the development
of solar lentigo.
■ Decreased sebaceous and sweat gland activity leads to
dry and flaking skin.
■ Decreased melanin leads to graying of the hair.
■ Reduced hormone levels lead to thinning of the hair
and transition from terminal to vellus hair.
■ Decreased peripheral circulation leads to slowed nail
growth and brittle nails that split easily.
dark brown, flat macules and may be seen in isolation or in
clusters on sun-exposed areas of the face or hands.4
In the older adult, hair color often transitions to gray
because of diminished melanin. Reduced hormone levels
result in a change in the size of the hair follicle and pro-
duce the change from coarse terminal hair to softer vellus
hair and the thinning of hair seen in both sexes. However,
the opposite change, from vellus to terminal, occurs in the
hair of the nares and on the tragus of men’s ears.2
Decreased peripheral circulation produces changes in
the nails. They grow more slowly but are often thicker and
more brittle, and have a tendency to split into layers. Mobil-
ity restrictions over time may result in an unkempt appear-
ance of nails in the older patient and may require attention
and care by a podiatrist.
The risk of pressure ulcer formation in the older adult
is increased because of greater mobility limitations and
impaired peripheral circulation from cardiovascular, neuro-
logical, and metabolic disorders. Once developed, pressure
ulcers in this population heal more slowly and are often
complicated by the older patient’s diminished immune
response.
ASSESSMENT OF THE SKIN
IN CHILDREN
The assessment of a child’s skin is much the same as that of
an adult’s, but it is important to recognize that some find-
ings take on a different significance because of the nature of
 CHAPTER 51
the child’s skin. Normally, the skin of a child is soft, smooth,
and slightly dry. Skin that is locally very dry may indicate
eczema, cradle cap, or diaper rash. Skin that is excessively
dry throughout the body may indicate a vitamin A defi-
ciency or may be related to frequent bathing.16
Because of reduced total sun exposure, dark lesions,
considered an expected finding in an older adult, may indi-
cate a malignant change in a child. Bruises in a child may
indicate nonaccidental trauma and attention is paid to the
location of the bruises and to the color. As a bruise ages,
it changes color from purplish to greenish. The critical
care nurse must be sure that special attention is paid to the
skin of children in critical care settings related to lesions
from infectious disease; the skin is assessed for any rashes
that may indicate bacterial or viral infection.
clinical applicability challenges
Self-Challenge: Critical Thinking
Mrs. Louise Hooper, a 62-year-old widow, has been in
the medical-surgical intensive care unit (ICU) for the past
2 weeks after a diagnosis of respiratory failure and pneu-
monia. This patient’s medical history includes obesity, type
2 diabetes mellitus, and chronic obstructive pulmonary dis-
ease (COPD). She has been intubated and on mechanical
ventilation. She has received continuous enteral feed-
ings through a nasogastric tube, numerous antibiotics, and
dopamine for blood pressure support during her first 3 days
in the ICU. She has a triple-lumen central venous access
catheter.
Mrs. Hooper is scheduled for a tracheostomy tomorrow
and, at that time, will also have a percutaneous gastric feed-
ing tube inserted. She has a continuous bladder catheter and
an incontinence fecal bag in place draining liquid stool.
Over the past 5 days, Mrs. Hooper has received a benzodi-
azepine for sedation at least once per day. Physical ther-
apy consultation was made on day 3, and she is assisted
by two caregivers with a pivot to a chair twice each day.
Mrs. Hooper’s family visits daily and helps her to commu-
nicate with a pencil and paper tablet.
1. What is the role of the critical care nurse in the prevention
of pressure ulcers for Mrs. Hooper?
2. What are Mrs. Hooper’s risk factors for development of
pressure ulcers?
3. How might the medications indicated (dopamine, numerous
antibiotics, and benzodiazepine sedation) affect Mrs. Hooper’s
integument status?
Study Questions
1. The color change of erythema is related to
a. increased oxyhemoglobin content.
b. increased tissue vascularity.
c. decreased hemoglobin levels.
d. decreased interstitial pressures.
2. Urticaria is best described as a
a. purple, irregular lesion caused by tissue trauma.
b. fiery red, raised lesion with a central body and radiat-
ing legs.
Patient Assessment: Integumentary System 1209
c. reddened or white, raised inflamed lesion with transu-
date vascular fluid in the surrounding tissue.
d. small, pinpoint, nonblanching lesion.
3. Which one of the following statements about oral candidiasis
is true?
a. It is a painless manifestation of an opportunistic infection.
b. It manifests itself as a white, crusty lesion of the patient’s
lips and hard palate.
c. It is a painful white coating of the oral mucosa and
tongue.
d. It is the result of systemic Staphylococcus infection.
4. Skin turgor is best assessed
a. peripherally over the patient’s forearms and shins.
b. peripherally at the nail beds.
c. centrally over the trunk.
d. centrally over the patient’s clavicles.
5. Which of the following phrases describes basal cell carci-
noma?
a. Depressed center, rolled edge, pearly border
b. Scaly white lesion
c. Large, dark black lesion with irregular border
d. Light brown lesion that feels velvety when touched
6. Cyanosis in an African-American patient can best be identi-
fied by assessment of the
a. palms of the hands and soles of the feet.
b. earlobes.
c. conjunctiva and oral mucous membranes.
d. dorsal surface of the forearm.
REFERENCES
1. Bickley LS, Szilagyi PG: The skin. In Bickley LS (ed): Guide to
Physical Examination and History Taking (8th Ed), pp 95–113.
Philadelphia, Lippincott Williams & Wilkins, 2003
2. Wilson SF, Giddons JF: Skin, hair, and nails. In Wilson SF, Gid-
dons JF (eds): Health Assessment for Nursing Practice (2nd Ed),
pp 257–287. St. Louis, Mosby, 2002
3. Allwood J, Curry K: Normal and altered functions of the skin. In
Bullock BA, Henze RL (eds): Focus on Pathophysiology, pp 837–873,
Philadelphia, Lippincott Williams & Wilkins, 2000
4. American Academy of Dermatology: Agingskinnet. In Skincare
physicans.com. 2000. Available at http://www.skincarephysicians.com/
agingskinnet/Q&A. Accessed July 1, 2003
5. Stawiski MA, Price SA: Cutaneous infections. In Price SA, Wilson
LM (eds): Pathophysiology (6th Ed), pp 1087–1096. St. Louis,
Mosby, 2003
6. Buttry TS: Anticoagulant and antiplatelet drugs. In Gutierrez K (ed):
Pharmacotherapeutics: Clinical Decision-Making in Nursing,
pp 774–789. Philadelphia, WB Saunders, 1999
7. Kozier B, Erb G, Berman AJ, et al: Health assessment. In Kozier B,
Erb G, Berman AJ, et al. (eds): Fundamentals of Nursing (6th Ed),
pp 531–629. Upper Saddle River, NJ, Prentice-Hall, 2000
8. Bergstrom N, Braden BJ, Laguzza A, et al: The Braden Scale for
predicting pressure sore risk. Nurs Res 36:205–210, 1987
9. Gosnell DJ: An assessment tool to identify pressure sores. Nurs Res
22(1):55, 1973
10. Agency for Health Care Policy and Research, Panel for the Predic-
tion and Prevention of Pressure Ulcers in Adults: Pressure Ulcers in
Adults: Prediction and Prevention. Clinical Practice Guideline no. 15,
AHCPR publication no. 92-0047. Rockville, MD: Agency for Health
Care Policy and Research, Public Health Service, U.S. Department
of Heath and Human Services, 1992
11. Lyder CH, Yu C, Emerling J, et al: The Braden Scale for pressure
ulcer risk: Evaluating the predictive validity in black and Latino/
Hispanic elders. Appl Nurs Res 12(2):60–68, 1999
1210 PART 11 INTEGUMENTARY SYSTEM
12. Bergstrom N, Braden BJ: Predictive validity of the Braden Scale
among black and white subjects. Nurs Res 51:398–403, 2002
13. Huether SE: Structure, function, and disorders of the integument.
In McCance KL, Huether SE (eds): The Biological Basis for Dis-
ease in Adults and Children (4th Ed), pp 1434–1468. St. Louis,
Mosby, 2002
14. National Cancer Institute: What you need to know about skin can-
cer? 2002. Available at http://www.cancer.gov/cancerinfor/wyntk/
skin. Accessed July 1, 2003
15. American Cancer Society: Detecting skin cancer. 2003. Available at
http://www.cancer.org. Accessed July 1, 2003
16. Hockenberry MJ, Wilson D, Winkelstein ML, et al. (eds): Wong’s
Nursing Care of Infants and Children (7th Ed). St. Louis, Mosby, 2003
OTHER SELECTED READING
Byers PH, Carta SG, Mayrovitz HN: Pressure ulcer research issues in
surgical patients. Adv Skin Wound Care 13:115, 2000
Cuzzell JZ: Wound assessment and evaluation. Dermatol Nurs 13(4):289,
2001
Hayes KVD: Skin wellness and illness. In Condon MC (ed): Women’s
Health. Upper Saddle River, NJ, Prentice-Hall, 2004
Finch A: Assessment of skin in older people: As the largest organ in the
body, the skin can offer valuable information about the general health
of an older person. Nurs Older People 15(2):29, 2003
Strayer SM, Reynolds P: Diagnosing skin malignancy: Assessment of
predictive clinical criteria and risk factors. J Fam Pract 53:210, 2003
Chapter 51—Author Queries
1. Please cite ref. 4 in the text, in numerical order. It is cited later,
between refs. 13 and 14, but presumably it should be cited first
between refs. 3 and 5.
2. Refs. 13 and 14 were switched to preserve numerical order of citation.