Integumentary Assessment

Nurse: - May I come in and knock the door!

Patient: - Yes, come in….
Nurse: - “Hello my name is Ekam I am your nurse.
“How are you?”
Patient: - Doing well thank you.
Nurse: - I am here for your skin assessment. Before begin how may I see your
hand? (Watching wrist band to confirm the right patient). Please take your complete
name.
Patient: - I am Arshdeep Sidhu.
Nurse: - All right and your birthday please?
Patient: - 16 February,1992
Nurse: - Okay thank you very much.
Nurse: - How would you like me to call you?
Patient: - Just call me Arsh.
Nurse Closing the door and fix the curtains to secure patients’ privacy. Provide
adequate lighting and adjust room temperature for patient’s comfort. Perform hand
hygiene to avoid infection and contamination.
Nurse: - Okay Arsh today I’m going to be inspecting and palpating your hair, skin and
nails to check for any lesions or skin changes that may give us an insight of your
current health status. Okay and before that I’m going to need to ask you just a few
questions regarding your health history. So that will be able to give you the
necessary care that will best suit your needs. Will that be all right?
Patient: - Explain with me okay.
Nurse: - okay and do you have questions or clarifications?
Patient: - not so far
Nurse: - all right thank you and so now we will begin. All right so Arsh are you
currently experiencing any skin problems like Do you have any rashes, lesions or
skin changes you have noticed.
Patient: - Yes, I have a small wound on my left foot.
Nurse: - Okay…
Patient: - it’s quite disturbing and itchy.
Nurse: - okay and when did you first notice it.
Patient: - well I know this did two weeks ago.
Nurse: - how do you think did you get that?
Patient: - well! I just noticed last week that I had a small light blister and its very itchy
so I scratch it but then I noticed after two days or like that after two days I noticed to
begin to form a small wound.
Nurse: - okay when you notice it that you already have the wound what did you do?
did you put any ointments on it or took medications.
Patients: - yeah, I just put an antibacterial ointment because I’m afraid it might get
infected.
Nurse: - alright, do you have any other health issues aside from that one? Do you
have any other skin disease or diabetes or respiratory problems?
Patient: - Yeah, I remember my father had a history of diabetes. He was diagnosed
of diabetes and also, I have experienced dertmitis before.
Nurse: - Okay I will take note of that and you said your father had diabetes is there
any other disease that has ever affected your family?
Patient: - No….
Nurse: - Do you know if you are allergic to any food, plants or medications?
Patient: - Yes, I have an allergy to certain foods like nuts and tomato.
Nurse: - Do you spend long periods of time sitting, standing and lying in one
position?
Patient: - Not, really, I’m usually moving from time to time I usually change positions.
I don’t remember that I stand in much longer time.
Nurse: - Okay, so now we are done with questions. So now I will be assessing your
skin. I will start from your head and work my way down to your toes. Just check for
other lesions aside from the one you mentioned that have in your foot.
Okay….
Nurse: - So, let’s start. Generally, see that your skin is consistent all over again I
don’t see any unusual discoloration. And now let mee see your hair. okay, so
basically, I’m just looking for any scars or lesions which you don’t have, skin is intact
all right I don’t see any headlights or dandruff. Hair moisture is good as well as
texture okay so, lets move on to your face. You have got three molds here in the side
of your face.
Nurse: - Let’s move down to your neck, its good i don’t see any discoloration.
So, let’s check your skin surgery I just need to pinch slightly your skin here on the
top of your collarbone.
Okay I note your skin trigger is elastic because it just went back to its place after I
lightly pinch it which indicates that you are well hydrated.
Patient: - Okay……
Nurse: - Let’s move to your back. all right I don’t see anything any rashes any
emissions okay.
May I see your hand now
Patient: - Yes sure….
Nurse: - Thank you, you feel warm and moisture is good your hand its bit thicker
here skin is a bit thicker.
Your nails, I don’t see any clubbing or any abnormal signs in your nails.
Now, I’m going to have to inspect your lower return piece. So, can you please lay
down for me now?
Patient: - Okay…
Nurse: - Let me see your right leg, okay right leg looks fine but you have a scar here
can you tell me of what happened to this and when did this happen.
Patient: - Well, it happened during my childhood years we were playing and then
suddenly I got crushed on the ground that’s why I got the scar.
Nurse: - Okay your left I see this where you got wound that you complained to me
while ago. I have to openly cover up to see your wound okay.
Patient: - Okay….
Nurse: - So, you got an ulceration here. All right its pinkish and reddish in color.
There is a light exudation too.
Let’s me measure it. It’s about 7 centimeter in height and 6 centimeter in length.
Does it hurt when I try to put some force around it?
Patient: - Just little bit.
Nurse: - So, I’m going to cover it again and advice you not to touch it with your hands
so it would not get infected.
Patient: - Okay nurse…
Nurse: - I done with my assessment and we may now sit back up okay.
I’m going to sum up everything that I have not noticed during my skin assessment.
First, I have noticed that your skin is constant or consistent all over you don’t have
any unusual color hair and scalp is great.
Thank you very much!
Doctor ordered some laboratory test for you and he also gave me your prescriptions.
Your medical precipitations here but before I go, I’m going have to give you some
important health reminders okay.
Patient: - Yes please….
Nurse: - So first since you already have wound one in your feet I highly advice you
not to touch it or scratch if its itchy you might introduce some bacteria to it and it
might get infected. You must it always clean and dry as well as all the other part of
body.
Nurse: - Here is your medical prescription. so, I’m going. Good bye and thank you for
your cooperation.
Patient: - Thank you, nurse, …