Integumentary Assessment
Use when asked to administer, score, or explain an Integumentary Assessment — skin/hair/nails evaluation combining a head-to-toe inspection with the Braden Scale for pressure ulcer risk — grounded in FormExamples/form-examples; related to waterlow-pressure-ulcer-risk-assessment and dermatology-assessment.
Structured integumentary (skin, hair, nails) clinical assessment combining a head-to-toe skin inspection with the Braden Scale for pressure ulcer risk and wound TIME assessment, to grade pressure-ulcer risk and characterize integumentary findings.
Scoring
Instrument: Braden Scale for Pressure Ulcer Risk. Range 6–23 — lower score means higher risk (the inverse of most clinical scales).
- ≤ 9 — Very High Risk.
- 10–12 — High Risk.
- 13–14 — Moderate Risk.
- 15–18 — Mild Risk.
- 19–23 — No Risk.
What it covers
Demographics; presenting skin concern; skin inspection (colour, moisture, integrity, turgor, lesions); hair and scalp examination; nail examination; wound assessment (stage, TIME) if applicable; Braden Scale scoring (sensory, moisture, activity, mobility, nutrition, friction/shear); photography and documentation; and clinical impression with a care plan.
Relationship to other assessments
This shares pressure-ulcer risk scoring territory with Waterlow Pressure Ulcer Risk Assessment — the Braden Scale used here is inverted relative to Waterlow (lower Braden = worse risk; higher Waterlow = worse risk), so never compare the two scores directly without converting to risk band first. For skin-quality-of-life focus specifically, see Dermatology Assessment.
Common pitfalls
- Confusing Braden's inverted scale with a normal higher-is-worse scale — this is the single most consequential mistake when working across both this assessment and Waterlow; always interpret via the named risk band, not the raw number, when comparing across instruments.
- Assessing skin only where a wound is already present — the head-to-toe inspection exists specifically to catch pressure damage or skin changes before they progress to an open wound.
- Skipping photography/documentation for a stable-looking wound — photographic documentation over time is what actually shows whether a wound is healing, static, or deteriorating; verbal description alone is much harder to compare across visits.
Learn more
- FormExamples: integumentary-assessment for the full implementation, clinical references, and worked examples.
- Waterlow Pressure Ulcer Risk Assessment for the alternative (non-inverted) pressure-ulcer risk tool.
- Dermatology Assessment for the quality-of-life-focused skin assessment.