Transcription
[Music]
Good day, everyone. I am Angel Sudelbaro, a student nurse from LPSC School of Health Sciences. For today, I will be performing a return demonstration and the assessment of the skin, the hair, and the nails.
So, prior to performing this procedure, we have to, of course, perform proper hand hygiene and don our PPE if necessary. After that, we can now proceed to the assessment.
Sydney, ma'am, I am Angel Sabal, and I will be your student nurse for today. Can you kindly confirm your name and your babysitter? That is the first thing that we need to do; we have to identify our patient in order to ensure that we have the correct patient in front of us.
If there are any curtains or doors in the room, we have to close them as well in order to provide privacy. After that, we have to explain the procedure to the patient.
Okay, so how do you want me to call you? This is Lily. I'm here to perform an assessment on your skin, your hair, and your nails. And why do we do this? We do this to ensure that everything is normal, and if there are any abnormalities on your skin, like discoloration or lesions, we are going to note them in order to prevent any further complications.
So, do you have any questions for me before we begin? Okay, but if you do have any, you can just ask me throughout the assessment.
Okay, so after that, we want to remove the clothes of our client and put on the examination gown on them. So let me just get this. Okay, I'm going to put this one. You also want to get a towel or a blanket in order to cover the exposed parts of our client.
We have to remember to expose only the parts that we are going to examine and cover the rest of the parts that we are not going to examine. The patient will remain seated for most of the examinations, but we'll need to stand or lie at the side if we're going to inspect the posterior part of her mouth.
So after this, we can now proceed to the first part of our assessment, which is inspection. So what do we need to inspect first? We need to inspect first the overall skin coloration of our client.
Yeah, I invite you to raise your arms like this. Okay, so what are we trying to look for here? We are trying to look for any signs of pallor, any signs of cyanosis, or jaundice, and erythema, because that may indicate abnormalities on the skin.
As I am assessing the skin of my client, this can color in just from light to deep brown, which is normal. The next thing that we want to inspect is for skin lesions.
Okay, may I invite you to release them again like this? Okay, so now what are we trying to look for here? We are trying to see for any signs of bruises, any signs of wounds, insect bites, or scratches.
Okay, any signs of lesions right here because we want to know that, because that means that there are abnormalities on the skin. 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 a skin lesion? Skin lesions can be primary, like macules and papules. It can also be secondary, like pressure ulcers or fissures.
It can also be vascular, like hematomas or angiomas, and in the worst case, it can be skin cancer, like malignant melanoma. So if you notice any signs of skin cancer, you want to evaluate it using the ABCDE pattern.
So you want to note asymmetry, its borders, its color, its diameter, and its elevation. After we inspect the skin for any discolorations or lesions, we can now proceed to the second part of the assessment, which is palpation.
So 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 the back of our hands? We use this because this is more sensitive to temperature.
Our palms and our fingers have thickened skin and have higher blood flow; hence, they are less sensitive to temperature. That is why we use the back of our hands. Okay, I will put my hands on your face if that is okay.
Okay, what are we trying to feel here? We are trying to feel for any signs of fever, shock, or any signs of infection. But it looks like my client has a normal temperature.
So if we are going to assess the open skin or the skin areas that are open, we have to don our gloves. Okay, so the next thing that we want to palpate is for the texture and also the moisture.
In palpating the texture and also in assessing the moisture of our client, we need to remember that moisture on the skin folds and moisture in the axilla is normal, but any signs of excessive dryness or excessive moisture is already abnormal, and we want to take note of that.
So for assessing the texture and also skin turgor of the client, we want to expose the area of the skin just below the clavicle of our client.
Okay, so in assessing skin turgor, we want to pinch the skin below the clavicle of our client. Okay, 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.
Okay, lastly, in assessing the skin, we want to look for edema. Just put this here. Here, I invite you to release your foot for me for a while.
So why did I invite her to raise her foot? Because this area includes the feet, the ankles, and the legs. But other areas also include the hands, the face, and the abdomen of our client.
So in assessing for edema, we want to apply pressure on the skin. Okay, if the skin becomes indented, it means there is a sign of edema. But if the skin quickly returns to normal, there are no signs of edema.
Okay, it looks like my client does not have edema, so that's good. Can you please raise your other leg? Okay, all right.
So now we are done assessing the skin of our client. So, Miss Lee, I'm going to now assess your nails. Do you have any questions before we proceed?
Okay, so can you please raise your hands like this? Okay, what do we want to see or look for here on the nails? We want to note the shape, the color, and the texture of the nails and see if there are any signs of clubbing or cyanosis on the nails.
As I am inspecting the nails of my client, they are normal, and there are no signs of any abnormalities. So the next thing that we want to assess here is the capillary refill of the nails of our client.
So in doing that, we want to apply pressure on the nails of our client. Just apply that. Okay, so if the color quickly returns to normal, that means that the nail has a fast refill; it means that it is normal.
But when you pinch it and it does not quickly return to normal, it means that it has a slow refill, and slow refill on the capillary is a sign of respiratory or cardiovascular disease that may eventually lead to hypoxia.
All right, so the next thing that we want to assess is the hair and the scalp of our client. In doing that, we want to don our gloves.
Okay, let me just put on my gloves for a while. Okay, now what do we want to look for in the hair and the scalp of our client? We are trying to see for any signs of lesions, any signs of infestation on the scalp and the hair of our client.
So if there are any flaking on the scalp or any lice in the hair, we want to take note of that as well. Okay, as I am inspecting the hair of my client, it seems that her hair and her scalp are normal, so that's good.
So after that, we want to remove our gloves, and we want to remove the PPE as well. If there are any signs of abnormalities, we want to refer them to another healthcare provider for further evaluation.
And after that, we are now done with the assessment. [Music]