A skin assessment needs to be repeated whenever a person is identified as at high risk as a result of a pressure ulcer risk assessment, to take account of any changes to the skin and to ensure patient and service user safety.

A routine integumentary assessment by a registered nurse in an inpatient care setting typically includes inspecting overall skin color, inspecting for skin lesions and wounds, and palpating extremities for edema, temperature, and capillary refill.

A skin assessment should include the presenting concern/compliant with the skin, history of the presenting concern/compliant, past medical history, family history, social history, medicines (including topical treatment) and allergies and impact on quality of life.

Information gathered from the skin inspection and aspects of management should be clearly documented in the patient's notes and care plan. Inspection should include assessment of the skin's colour, temperature, texture, moisture, integrity and include the location of any skin breakdown or wounds.

Skin. Skin appendages. Hairs. Nails. Sweat glands. Sebaceous glands. Subcutaneous tissue and deep fascia. Mucocutaneous junctions. Breasts.

How do I do the assessment? Explain to the patient and family that you will be looking at his or her entire skin and explain the purpose to identify potential problems. Perform the assessment in private. Minimize exposure of body parts during the skin assessment.

A skin assessment should include an actual observation of the entire body surface, including all wounds*, inspection of hair, nails, skin folds and web spaces on hands and feet, systematically from head to toe.

Information gathered from the skin inspection and aspects of management should be clearly documented in the patient's notes and care plan. Inspection should include assessment of the skin's colour, temperature, texture, moisture, integrity and include the location of any skin breakdown or wounds.

Temperature. Color. Moisture level. Turgor. Skin integrity (skin intact?)