Skin, Hair, and Nails Assessment | Return Demonstration
Summary
TLDRIn this instructional video, Angel Sudelbaro, a student nurse, demonstrates the assessment of skin, hair, and nails. The procedure begins with proper hygiene and patient identification, followed by a detailed inspection of skin color, lesions, and texture. Angel emphasizes the importance of assessing temperature, moisture, and potential edema, alongside examining the nails for abnormalities and capillary refill. Finally, the hair and scalp are inspected for signs of infestation. The demonstration highlights essential nursing practices, ensuring patient privacy and safety throughout the assessment.
Takeaways
- 👩⚕️ Introduce yourself and your role as a student nurse before starting the assessment.
- 🧼 Perform proper hand hygiene and wear PPE when necessary to ensure safety.
- 🔍 Always confirm the patient's identity to ensure you are assessing the correct individual.
- 🚪 Ensure privacy by closing curtains or doors before conducting the assessment.
- 📋 Explain the assessment procedure to the patient and address any questions they may have.
- 🩺 Inspect the skin for overall coloration, checking for abnormalities such as pallor or cyanosis.
- ✋ Palpate the skin to assess temperature, texture, moisture, and turgor, using the back of your hand for temperature sensitivity.
- 🔎 Assess the nails for shape, color, texture, and capillary refill time to identify potential issues.
- 💇♀️ Examine the hair and scalp for signs of infestation or abnormalities.
- ✅ Refer any abnormalities or concerns to a healthcare provider for further evaluation.
Q & A
What is the first step in performing a skin, hair, and nails assessment?
-The first step is to perform proper hand hygiene and don personal protective equipment (PPE) if necessary.
How do you confirm the identity of the patient?
-You confirm the patient's identity by asking them to state their name and any other identifiers, such as their babysitter's name.
Why is it important to close curtains or doors during the assessment?
-Closing curtains or doors provides privacy for the patient during the assessment.
What are the key abnormalities to look for during the skin inspection?
-Key abnormalities include discoloration, lesions, bruises, insect bites, scratches, and signs of skin cancer.
What does the ABCDE pattern refer to in skin assessment?
-The ABCDE pattern refers to Asymmetry, Borders, Color, Diameter, and Elevation, used to evaluate potential skin cancer.
Why do we use the back of the hands to assess skin temperature?
-The back of the hands is more sensitive to temperature due to thinner skin and lower blood flow compared to the palms.
What does a prolonged skin pinch indicate?
-A prolonged skin pinch indicates dehydration, as the skin should quickly return to normal if hydrated.
What signs are assessed during the nail examination?
-During the nail examination, the shape, color, texture of the nails, and any signs of clubbing or cyanosis are assessed.
What does a slow capillary refill indicate?
-A slow capillary refill indicates potential respiratory or cardiovascular issues that may lead to hypoxia.
What should be done if abnormalities are found during the assessment?
-If abnormalities are found, they should be referred to another healthcare provider for further evaluation.
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