Good day Maam .

Im Andro Estal BSN1 11E and now I will be

performing a Skin, Nails and Hair assessment return demonstration.
Prior to the procedure I have to do the pre-introductory phase
which are to review client’s medical record, prepare the necessary
equipment and perform hand washing. As if im done with that
phase and now I will introduce myself to the patient.

Good Morning Maam! Im Andro Estal .Your student nurse for

today. You look so beautiful today maam. May know your name
please and also your birth date. Thank you Maam! How would you
like me to call you? Okay. Thank you.
May I ask what language you prefer using? This is not part of the
assessment but may I ask if you watch Korean dramas or series? (if
yes, what can you recommend for me, okay I will watch it after this
assessment haha) (Thank you in Korean, GAMSAHABNIDA)
But before that Kate id like to ask some of your information.
So kate im here to perform an assessment on your skin,hair and
also your nails and we do this to ensure that everything is normal
and if there are any abnormalities on your skin like discoloration or
skin lesions and we are going to note them in order to prevent any
further complications. And also I will ask some questions regarding
to your current lifestyle. Is that okay with you kate? This
information that you will share are strictly confidential, so no need
to worry.
Any questions or clarifications maam? But if you do have you can
just ask me throughout the assessment.

Do you have any piercing or tattoos?

Are you experiencing any problems regarding your skin? (Rashes,
lesions, dryness of the skin, swelling, increased of pigmentation)
Things like that?
Do you have moles or birthmarks, and have you noticed some
changes?
How about the condition of your hair? Are you experiencing some
hair loss or baldness?
How about your nails? Any changes in their appearance or
discolorations?
(Past Health History)
Do you have allergic skin reactions?
(Lifestyle Practices)
Are you always exposed to sunlight?
When you go out do you use sunblock products? Pag No, Okay so
you are not applying any products
(Family History)
Does your family have any history or skin cancer?

After that we will proceed to the first part of our assessment which
is inspection, so what do we need to inspect. first we need to
inspect the overall skin coloration of our client. May I invite you to
raise your arms (demo) like this. So what we are trying to look here,
we are trying to look here for any signs of pallor/palor, any signs of
cyanosis or jaundice because that indicate abnormalities on the
skin. But as iam assessing the skin of the client, the skin color is just
light to brown which is normal.

The next thing that we want to inspect is for skin lesions. May I
invite you to raise your arms (demo) like this. So now what we are
trying to look here , we are trying to see for any signs of bruises,
any signs of wounds or insect bites or scratches. Any signs of lesions
because we want to know that because that means that there are
abnormalities on the skin. but as iam inspecting the skin of my
client there are no skin collisions, but if there are we want to note
their size, shape, and the color as well.

And we will proceed the next part of our assessment is palpation

the first thing we want to assess is the temperature of our client
and we want to palpate the skin using the back of our hands, now
why the back of our hands we use this because this is more
sensitive to temperature. So maam I will going to put my hands into
your face. Is that okay maam? We are trying feel any signs of fever
or shock or any signs of infection, but it looks like that my client has
normal temperature.
The next thing to palpate is for the texture and also the moisture.
So for assessing the texture and also the skin trigger of the client we
want to expose the part of the skin just below clavicle. So in
assessing skin trigger we want to pinch the skin below the clavicle
of the client. If the skin returns immediately to normal that means
that there is an absence of skin trigger but if the skin stays pinched
that means there is a presence of dehydration.
Okay lastly in assessing the skin we want to palpate for edema. May
I invite you to raise your foot for me. For assessing for edema we
want to apply pressure on the skin , if the skin becomes intended it
means there is a sign of edema but if the skin quickly returns to
normal there is no signs of edema. It looks like my client does not
have edema so that’s good. And now were done in assessing the
skin of our client
And now im going to assess the clients nails. Can you raise your
hands please. What do we want to see here or look here on nails
we want to note the shape, the color, and the texture of the nails
and see if there are any presence of clubbing on the nails or blue
slime on the nails.

So as Im inspecting the nails of the client are normal and there are
no signs of abnormalities. So the next thing we want to assess here
if the capillary refill of the nails of our client. We just apply pressure
to nails of the client, f the color quickly returns to normal that
means that the nail has a fast refill which is normal but if its not
quickly return to normal that means has slow refill this sign of
respiratory or cardiovascular disease that may eventually lead to
hypoxia

And next we want to assess is the hair and scalp of our client. In
doing that we mus put gloves . we are trying to see for any signs of
lesions, any signs of infestation, on the skull and the hair of our
client so if there are any flicking in the skull, if there any lies on the
hair we want to take note of that as well. So as I inspect the clients
hair and scalp are normal.

And if there any signs of abnormalities we want to refer them to

other healthcare provider for further evaluation.