Skin integrity - assessment

Skin integrity is essential in maintaining good health because skin, also known as the integumentary system, is the largest organ of human body and provides a barrier to pathogens, toxins and radiation (Payne, 2019).

There are three layers of skin, the epidermis, dermis and subcutaneous tissue. The epidermis is the external layer, which is made up of a thin layer of epithelial cells. They produce melanin, which gives skin its colour and protects against UV rays, and keratin which gives the epidermis its water-resistant protective layer (Tortora and Derrickson, 2017). The dermis is a deeper layer made up of connective tissue containing collagen to strengthen the skin, immune cells, hair follicles, a network of nerve endings (receptors), blood vessels and lymph to assist with fluid drainage. The subcutaneous tissue contains fat cells which also have a good supply of blood vessels and lymph (Waugh and Grant, 2018).   

The skin plays a number of important roles:  

• Creates a barrier to prevent bacteria entering the body 
• Acts as a thermoregulator, secreting sweat from the glands to cool us down. Receptors send messages to constrict or dilate blood vessels

The purpose of assessment of skin integrity is to monitor the condition of the skin and identify changes at an earlier stage. As well as reduce the risk of developing further injury and other hospital acquired conditions such as infections and pressure ulcers. 

1. Explain the procedure and gain consent
2. Confirm with the patient if they would prefer the presence of a chaperone during examination
3. Wash hands and wear personal protective clothing including apron and gloves
4. Ensure privacy is maintained during the procedure by keeping the door closed if in a single room or by pulling the curtains around if in a bay with other patients
5. Expose only the body part that needs to be examined by covering body with bed linen/ sheets
6. Assess the colour, temperature, texture, and integrity of skin especially in pressure areas / bony prominences (Table 1) (National Institute for Health and Care Excellence, NICE, 2015)
7. Obtain further information on presenting complaints including the time course of rash, distribution of lesion, associated symptoms such as pain, discomfort or itch, and contributing factors. Information regarding past medical illness, previous skin treatments, allergies, current medications and family, occupational, recreational and travel history

Risks

The skin can be affected by various factors including:

• changes in temperature
• moisture/incontinence
• malnourishment
• illness, particularly comorbidities
• polypharmacy
• reduced mobility
• cognitive impairment
• age and frailty (Campbell 2016; Lister et al, 2021; NICE 2015)

These risk factors and the functions of the skin need to be considered when assessing skin integrity to provide appropriate care that is individualised to each person’s needs and context.  

Assessment of skin vulnerability and fragility is vital in the provision of nursing care. It should be performed on admission, during intra-hospital or inter-hospital transfers and at least once per shift in patients at high risk of developing skin problems during their hospital stay. 

Complications and common issues 

Wounds  

Skin integrity is compromised in open wounds. In areas of broken skin, a diagnosis is required to identify the cause of the lesion and allow accurate documentation and treatment of the skin condition to prevent further deterioration. See procedure article on

• Document assessment findings in the patient’s medical records
• Information including type (table 2), site, size, texture, consistency, pattern of vasculature of the lesion should be clearly documented
• Seek advice from tissue viability team regarding wound care
• Reassess and evaluate care. Evaluate psychological aspects as skin disorders can have an impact on body image and self-esteem causing distress
• Refer to a dermatologist for further examination and review if any concerns

References 

Bickley LS, Szilagyi PG. Bates' guide to physical examination and history taking. Wolters Kluwer: Philadelphia; 2009

Bradley P. Skin integrity – the perpetual challenge. J Wound care. 2020;29(12):736-737. https://doi.org/10.12968/jowc.2020.29.12.736

Campbell JL. The Skin Safety Model: Reconceptualizing Skin Vulnerability in Older Patients. J Nurs Scholarsh, 2016;48(1):14-22. https://doi.org/10.1111/jnu.12176

Hess CT. Performing a skin assessment. Nursing. 2010;40(7):66. https://doi.org/10.1097/01.NURSE.0000383457.86400.cc

Kumar P, Clark M. Kumar & Clark’s Clinical Medicine. (9th edn). Elsevier: Edinburgh; 2017

Kanzawa-Lee GA. Chemotherapy induced peripheral neuropathy nursing considerations. J Infus Nurs. 2020;43(3):155-166. https://doi.org/10.1097/NAN.0000000000000368

Lister S, Hofland J, Grafton H, Wilson C. The Royal Marsden Manual of Clinical Nursing Procedures: Student Edition. (10th edn). John Wiley & Sons; 2021.

Lumbers M. Moisture-associated skin damage: cause, risk and management. Br J Nurs. 2018;27(12):S6-S14. https://doi.org/10.12968/bjon.2018.27.Sup12.S6

Mervis JS, Phillips TJ. Pressure ulcers: Pathophysiology, epidemiology, risk factors, and presentation. Journal of the American Academy of Dermatology. 2019;81(4):881-890. https://doi.org/10.1016/j.jaad.2018.12.069

Mitchell A, Hill B. Moisture-associated skin damage: