Friday, April 12, 2013

Physical Assessment: Skin, Hair and Nail

In the field of nursing or in any medical field, it is essential to do the physical assessment because this will serve as the basis for giving the patient the right intervention. When regards to assessing the skin, hair and nail, I want to share this information with you from the book that I have read authored by Janet Weber, Jane Kelley and Ann Sprengel, Health Assessment in Nursing Laboratory Manual, 3rd Edition on page 51. 

Assessment Skill
1. Gather equipment (gloves, exam light, pen light, magnifying glass, centimeter ruler, Wood's land if available).
2. Explain the procedure to the client. 
3. Ask client to gown.

1. Note any distinctive odor. 
2. Inspect for generalized color variations (browness, yellow, redness, pallor, cyanosis, jaundice, erythema, vitiligo).
3. Inspect for skin breakdown. 
4. Inspect for primary, secondary or vascular lesions. (Note size, shape, location, distribution and configuration.) Use Wood's lamp if fungus is suspected. 
5. Palpate lesions.
6. Palpate texture (rough, smooth) of skin, using palmar surface of three middle fingers. 
7. Palpate temperature (cool, warm, hot) and moisture (dry, sweaty, oily) of skin, using dorsal side of hand.
8. Palpate thickness of skin with finger pads.
9. Palpate mobility and turgor by pinching up skin over sternum.
10. Palpate for edema, pressing thumbs over feet of ankles.

Scalp and Hair
1. Inspect color. 
2. Inspect amount and distribution.
3. Inspect and palpate for thickness, texture, oiliness, lesions and parasites.

1. Inspect for grooming and cleanliness.
2. Inspect for color and markings.
3. Inspect shape.
4. Palpate texture and consistency.
5. Test for capillary refill.

Analysis of Data
1. Formulate nursing diagnoses (wellness, risk, actual)
2. Formulate collaborative problems.
3. Make necessary referrals.

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