Let us start with a basic skin assessment.
Skin Turgor : This can be referred to as the fullness or the elasticity of the skin.
Normal Skin Turgor: When you pick up a small skin fold slightly and release. The skin will quickly bounce back returning to its original state(shape)A difficult lifting of a skin fold may be an indication of edema.
Abnormal Skin Turgor:When you pick up slightly a small skin fold and release the skin will slowly return to its original shape. This is due to old age and dehydration.
+1 = Trace.
+3 = Deep.
+4 = Very deep.
HOW DO YOU SUPPORT THE SKIN TO WIN?.
A daily skin care routine can help you to maintain your overall skin health and improve specific concerns . Report denuded skin,redness, purple mark or bruised skin, blisters, rashes.What kind of rash is it?.Report an unusual areas of the skin,dead areas that is black or brown tissue.,black heel with dry eschar . Assess in between digital areas for sore ,blisters and opening. Do daily routine of the feet and keep your feet healthy. It is important to report any areas with open sores.Look and inspect your feet well.
Skin may vary from smooth and soft to dry rough skin. As for a dehydrated skin, the texture, wrinkled, loose, and the mucous membranes remain dry and cracks. Encourage adequate fluid intake.
The nails should be inspected for color, shape and texture. The nails are differentiated tissue but are still part of the skin. The shape of the nails are convex that follows the natural curvature of the finger.It should be in 160 angle(normal)Check for nails abnormalities such springy,floating nail,flattened angle 180 degree,swollen, floating, angle greater than 180 degree. Paronychia infection.Take note of late clubbing.
The hair should be evenly distributed, resilient, neither dry or oily. You examine hair for color, texture and distribution. Separate the hair to assess scalp,lumps, lesions, dryness,and scaliness. It is also important to assess the head ,the skull, face, nose,sinuses, mouth pharynx,trachea, the lymph nodes and the thyroid gland. It is the skull that protects the brain and all the neurotransmitters, allowing use of sensory and motor skills. The skulls and facial cavities are covered by facial muscles. Understand the cranial nerves V and V11 of the face.Check face for color, symmetry, contour, size, eyes, eyebrows, puffiness. Check the ear,sensory organ and auditory stimuli. Any abnormalities?.Eye structure, pupils, Irish. Pupils should be black,equal in size, visualization, eyebrows, eyelashes.Inspect every part of the skin.
Inspect the anterior chest, breast are they symmetrical, inspect the posterior chest, the back.Is there abnormalities that need to be reported?.The risk factors to consider when assessing the breast include age,pain ,change in breast tissue, discharges from breast nipple, and the patient knowledge and ability to practice breast self examination. Inspect and palpate the breast.The size of breast varies but should be smooth and round. The purpose of palpation is to uncover abnormal mass or lump. The breast is divided into four quadrant. The axillary palpate for lymph nodes which on a normal circumstances cannot be dictated and are not tender.The Abdomen. The abdominal cavity has so many important organs .These include the stomach, large intestine, and small intestine ,liver ,the pancreas, kidney each organ has a job to perform for the whole system. The abdomen upon assessment is divided into four quadrant.
It is important to check Male and female genitalia,you have to discuss with patient before inspection and palpation. You will need flashlight, and gloves and vagina speculum. Patient should have any empty bladder.
Inspect the lower back,the anterior and posterior thighs for any abnormalities.Assess and inspect the legs and feet for any abnormalities.Inspect and assess for cracked skins because any cracked skin can be a freeway for germs to penetrate into the skin even with a proper hand hygiene.
Report and document any abnormal findings. Do the patient need further evaluation of the condition such as wound consult, Orthopedic Consultation, or plastic surgery consult. If there are wounds, take pictures with the designated camera for wound management and document all your findings and put pictures in patient chart well secured.