---
name: integumentary-assessment
description: 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.
---

# Integumentary 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](https://github.com/FormExamples/form-examples/tree/main/forms/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.