Integumentary Assessment

A patient's skin needs to be assessed often for breakdown. A common scale for rating a person's tendency to have skin breakdown is called the Braden Scale (listed below). The six main categories looked at in this scale are sensory perception, moisture, activity, mobility, nutrition, and friction & shear.

The breakdown of the scoring is as follows: 

  • Very High Risk: Total Score 9 or less
  • High Risk: Total Score 10-12
  • Moderate Risk: Total Score 13-14
  • Mild Risk: Total Score 15-18
  • No Risk: Total Score 19-23

During my assessment, I look over the patient's skin. Are they any rashes, bruises, or other abnormalities? How is the temperature of their skin? Do they have any drains? What is draining and how much? Do they have any wounds or pressure sores? What dressings are in place for these wounds?

Example assessment: The patient has a heat rash on their chest from their fever. They have a skin tear on their right wrist from an old IV bandage that is covered with gauze, antibiotic ointment, and a Kerlix wrapping. They have a stage I (non-blanchable area) skin on their coccyx that is red and intact. I have been repositioning them every two hours to avoid further breakdown.