H.

A Integumentary Skin, Hair, and Nails

Good day everyone I am Adrianne Ryuto Reyes, a student

nurse from Our lady of Fatima University, and for today I will
be performing return demonstration and the assessment of
the skin, hair and the nails. The prior of performing this
procedure, first, we need to perform hand hygiene and
wear PPE if necessary. After that we will proceed to the
assessment. Good morning ma’am/sir I am Adrianne Ryuto
Reyes and I will be your student nurse for today, can you
kindly confirm your name? (after stating) okay, so how do
you want me to call you? ( response) So, mr/ms (Name of
the patient) I’m here to perform an assessment of your skin,
your hair and your nails. And why we should do that? We do
this to ensure that everything is normal and if there are
abnormalities on your skin like, discoloration or skin lesions.
We are going to note them in order to prevent any further
complications, so do you have questions for me? (response)
Okay, but if you do have you can ask me throughout the
assessment. So after that we want to remove the clothes of
the patient and put on the examination gown on them, so
let me just get this and I’m going to put this one on you.
Also you can get a blanket/towel in order to cover the
exposed parts of our client. So we have to remember that
we just need to cover the exposed parts that we are not
going to examine, and the patient will be remained seated
most of the examinations, but we will need to stand or lie at
the side of the patient if we we’re going to inspect the
posterior part of her body. So after this we can now proceed
to the first assessment of our assessment which is
inspection, so what do we need to inspect first? First, we
need to inspect the overall skin coloration of our client, May
I invite your arms to raise like this? (Action of nurse first
then the client) So what are we trying to look here is to look
any signs of pallor, any signs of cyanosis of jaundice because
that may indicate abnormalities in the skin. But as I am
assessing the skin of my client, the skin color of my client
ranges from light to brown which is normal. Next that we
will inspect is for Skin lesions, may I ask you again to raise
your arm like this? ( Action) Okay, so what are we trying to
look here, we are trying to see for any signs of bruises, any
signs of wounds of insect bites or scratches or any signs of
skin lesions right here because, we want to know if there is
signs of abnormalities on the skin. But as I am inspecting the
skin of my client, there are no skin lesions. But if there are,
we want to note their size, their shape and their color as
well. So what is skin lesions? Skin lesions can be primer like
macula and papule, it can be also a secondary like fresher
ulcer or fissure it can also be a skin cancer. So if you notice
any signs of skin cancer you can evaluate it using the ABCDE
pattern it is Asymmetry, Borders, Color, Diameter and its
Elevation. So after we inspect the skin to any discolorations
or lesions, we can now proceed to the second part of the
assessment which is Palpation. The first thing that 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 back
of our hands? We use this because this is more sensitive to
temperature our palms and our fingers have thickened skins
and have a higher blood flow hence, they are less sensitive
to temperature that is why we use the back of our hands. I
will put my hands around your face, okay so what are we
trying to feel here, we are trying to feel any signs of fever or
shock of any signs of infection, but it looks like that my
client has a normal temperature. So if we are going to
assess the open skin, the skin area which are open you have
to our gloves. So the next thing that we want to palpate is
for the texture and also the moisture, so in palpating the
texture and assessing the moisture of our client we need to
remember that moisture on the skin folds and moisture on
the axilla is normal but any signs of excessive dryness or
excessive moisture is already abnormal and we want to take
more than that. So for assessing the texture and also skin
turgor of the client, we want to expose the pore or the skin
just below the clavicle of our client. So in the sensing skin
trigger we want to pinch the skin below the clavicle of our
client, So if the skin returns immediately to normal, that
means that there is an absence of skin turgor, but if the skin
stays pinched that means there is a presence of skin turgor
and the presence of skin turgor indicates dehydration so
you want to take note of that. Lastly in assessing the skin,
we want to palpate for edema. Let me just put this here,
May I invite you to raise your foot for me for a while? So
why do I invite her to raise her foot? Because its about this
area include the feet, the ankles and the legs. So in
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
sign of edema. (then same procedure with right foot). So we
are done in assessing the skin of our client So mr/ms (name
of the client) I’m going to assess now your nails, do you have
questions before we proceed to your nails assessment? So
can you raise your arms like this? So what do we want to
see here/look here on the nails is 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 slimes of
the nails. So as I am inspecting the nails of my client there
are no signs of any abnormalities, so the next thing that we
want to assess here is the capillary refill of our client so in
doing that we want to apply pressure on the nails of our
client so if the color quickly returns to normal that means
that the capillary has fast refill and it mean that is normal.
But when you pinch it and it does not quickly return to
normal, it means that it has slow refill on capillary and slow
refill on the capillary means that it has a sign of respiratory
and cardiovascular disease that may eventually lead to
hypoxia. So the next thing that we need to assess is the hair
and scalp of our client and in doing that we need to don our
gloves. Now, what we do we want to look for in the hair and
the scalp of our client? We are trying to see for any signs of
lesion, any signs of infestation on the skull and the hair of
our client. So if there are any flakings in the skull if there are
any lice on the hair we want to take note of that as well.
Okay, as I am inspecting the hair of my client, my client
seems that her hair and her skull is normal. So that’s good,
so after that we want to remove our gloves and we want to
remove the PPE. Also, if there are any signs of abnormalities
we want to refer them to other healthcare provider for
further evaluation, and after that we are done with the
assessment.