Tuesday, October 30, 2012

Assessing the Skin, Hair, and Nails

Goal: The assessment is completed without the patient experiencing anxiety or discomfort, the findings are documented, and the appropriate referral is made to the other healthcare professionals, as needed, for further evaluation.

1. Perform hand hygiene and put on PPE, if indicated.

2. Identify the patient.

3. Close curtains around bed and the door to room, if possible. Explain the purpose of the integumentary examination and what you are going to do. Answer any questions.

4. Ask the patient to remove all clothing and put on an examination gown (if appropriate). The patient remains in the sitting position for most of the examination but will need to stand or lie on the side when the posterior part of the body is examined, exposing only the body part being examined.

5. Use the bath blanket or drape to cover any exposed area other than the one being assessed. Inspect the overall skin coloration.

6. Inspect skin for vascularity, bleeding, or bruising.

7. Inspect the skin for lesions. Note bruises, scratches, cuts, insect bites, and wounds (Refer to Wound Assessment [Fundamentals Review 8-3] in Chapter 8, Skin Integrity and Wound Care). If present, note size, shape, color, exudates, and distribution/pattern.

8. Palpate skin using the backs of your hands to assess temperature. Wear gloves when palpating any potentially open area of the skin.

9. Palpate for texture and moisture.

10. Assess for skin turgor by gently pinching the skin under the clavicle.

11. Palpate for edema, which is characterized by swelling, with taut and shiny skin over the edematous area.

12. If lesions are present, put on gloves and palpate the lesion.

13. Inspect the nail condition, including the shape and color as well as the nail angle, noting if any clubbing is present.

14. Palpate nails for texture and capillary refill.

15. Inspect the hair and scalp. Wear gloves for palpation if lesions or infestation is suspected or if hygiene is poor.

16. Remove gloves and any additional PPE, if used. Perform hand hygiene. Continue with assessments of specific body systems, as appropriate or indicated. Initiate appropriate referral to other healthcare practitioners for further evaluation, as indicated.

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