# A nurse is assessing a 65-year-old client for risk factors that may predispose to integumentary problems. Which assessment finding would be most concerning as a risk factor for skin breakdown?

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## 문제

A nurse is assessing a 65-year-old client for risk factors that may predispose to integumentary problems. Which assessment finding would be most concerning as a risk factor for skin breakdown?

## 보기

1. Mild xerosis on bilateral lower extremities
2. History of occasional sun exposure during gardening
3. Serum albumin level of 2.8 g/dL **✔ 정답**
4. Body mass index (BMI) of 28 kg/m²

**정답: 3**

## 해설

Hypoalbuminemia (serum albumin

## 심화 해설

Understanding the Risk for Integumentary Problems

When assessing a client's risk for skin breakdown, the nurse must differentiate between common, often benign age-related changes and critical systemic factors that directly impair tissue integrity. The integumentary system relies on adequate nutrition, hydration, and mobility to maintain its barrier function. A disruption in these foundational elements significantly elevates the risk for pressure injuries and skin failure.

Analysis of Assessment Findings

Let's examine each option through the lens of pathophysiological risk:

- **Option 1: Mild xerosis on bilateral lower extremities.** Xerosis, or dry skin, is a common finding in older adults due to decreased sebaceous gland activity. While it can cause pruritus and discomfort, and may lead to fissures if severe, mild xerosis is a localized condition and not the most powerful predictor of deep tissue breakdown compared to a systemic nutritional deficit.

- **Option 2: History of occasional sun exposure during gardening.** Ultraviolet (UV) radiation from sun exposure is a major risk factor for skin cancer and photoaging (wrinkling, loss of elasticity) over a lifetime. However, it is a long-term, cumulative risk for cellular DNA damage, not an immediate predictor of integumentary breakdown like a pressure injury. This finding is less concerning in the acute context of skin integrity risk.

- **Option 3: Serum albumin level of 2.8 g/dL.** This is the most concerning finding. A serum albumin level below 3.5 g/dL indicates hypoalbuminemia, a marker of protein-energy malnutrition. Albumin is critical for maintaining colloid osmotic pressure, which keeps fluid within the vasculature. Low albumin leads to dependent edema, reducing the diffusion of oxygen and nutrients to the tissues. Furthermore, a protein deficit directly impairs collagen synthesis and tissue repair, making the skin less tolerant to pressure, friction, and shear. Research identifies malnutrition as a primary, independent risk factor for the development and deterioration of pressure injuries, including a specific condition known as nutrition-associated skin failure [2,3].

- **Option 4: Body mass index (BMI) of 28 kg/m².** This BMI falls into the overweight category. While obesity can increase the risk of skin breakdown in skin folds due to moisture and friction, a low BMI (underweight) or recent unintentional weight loss is a far more significant risk factor for pressure injuries due to the loss of protective subcutaneous tissue and nutritional deficits. This finding is less immediately critical than a laboratory value confirming severe protein depletion.

Connecting Malnutrition to Skin Breakdown

The link between malnutrition and integumentary failure is well-established. In malnourished geriatric patients, a deficiency of energy and protein impairs tissue metabolism and microcirculation, which are direct physiological pathways to skin failure [2]. This is not merely a superficial issue; it reflects a systemic inability to sustain the body's largest organ. Predictive models for pressure injury deterioration consistently include nutritional markers like albumin as key variables, underscoring that a low serum albumin level is a modifiable and critical risk factor that demands immediate nursing intervention, such as a dietary consult and aggressive nutritional support [3,4].

References (research sources)

- [2]A multi-parameter ultrasound prediction model for nutrition-associated skin failure in hospitalized elderly patients: a prospective cohort study protocol.Research articleShen Y, Mi X, Wu Y, Wei Y, Shen H, Tan J, Chang J. (2026) · DOI: 10.1186/s12877-026-07224-0

## 임상 시나리오

Clinical Practice Guide: Nutritional Screening for Skin Integrity

Scenario

A 65-year-old client admitted for a hip fracture has a serum albumin of 2.8 g/dL. The nurse is planning care to prevent integumentary breakdown.

Key Clinical Indicator

Serum albumin < 3.5 g/dL is a critical marker for protein-energy malnutrition and a powerful independent predictor of pressure injury development. Prealbumin may be a more sensitive short-term marker.

Evidence-Based Interventions

- Initiate a formal nutrition consult for comprehensive assessment and dietary planning.

- Implement a validated risk assessment scale (e.g., Braden Scale) upon admission and at regular intervals, paying close attention to the nutrition and moisture subscales.

- Collaborate with the dietitian to provide high-protein, high-calorie oral supplements between meals if oral intake is insufficient.

- Inspect skin over bony prominences (sacrum, heels, elbows) at least every 8 hours and document findings meticulously.

- Utilize pressure-redistributing support surfaces and implement a scheduled turning and repositioning regimen (minimum every 2 hours).

- Manage moisture by using pH-balanced skin cleansers and barrier creams; avoid vigorous massage over bony prominences.

Patient Education Focus

Educate the client and family on the role of protein in wound healing. Encourage small, frequent meals that include sources of complete protein. Teach the importance of shifting weight every 15 minutes while sitting and reporting any new areas of redness or skin breakdown immediately.

## 핵심 개념

- **Hypoalbuminemia** — A serum albumin level below 3.5 g/dL, indicating protein depletion which impairs oncotic pressure, wound healing, and tissue integrity, significantly increasing pressure injury risk.
- **Xerosis** — Abnormally dry skin, often age-related due to decreased sebaceous gland activity, which can cause pruritus and fissures but is a localized condition.
- **Pressure Injury** — Localized damage to the skin and underlying soft tissue usually over a bony prominence, caused by intense or prolonged pressure combined with shear.
- **Serum Albumin** — A protein synthesized by the liver that maintains plasma oncotic pressure and serves as a marker for nutritional status and inflammation.
- **Integumentary System** — The organ system consisting of the skin, hair, nails, and exocrine glands, providing a protective barrier against the external environment.

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