Summary
Highlights
The student nurse introduces herself, identifies the patient using two identifiers (name and birth date), and explains the purpose of the examination – to check overall skin health, identify infections or wounds, and provide appropriate care. She then performs hand hygiene and asks for the patient's consent.
The nurse begins inspecting the skin for coloration, looking for jaundice (yellowing), cyanosis (bluish), pallor (paleness), and erythema (redness). She also checks for vascularity (bleeding, bruising) and lesions, noting their size, shape, color, and pattern. The skin coloration of the extremities is compared bilaterally for any abnormalities, as skin color provides initial clues about the patient's health.
Using the dorsal part of the hand, the nurse palpates the skin for temperature. If open wounds are present, gloves are worn to prevent cross-contamination. Assessing temperature helps identify inflammation, circulatory compromise, or poor blood flow. Next, the skin is palpated for texture and moisture to gain insight into hydration and general skin health, noting if the skin is dry, rough, flaky, or excessively moist.
Skin turgor is assessed by gently pinching the skin under the clavicle, which is an important test for hydration and elasticity. Following this, the nurse palpates for edema, which is characterized by swelling or shiny skin, often seen in the lower extremities, indicating an abnormal accumulation of fluid in the tissues.
The nurse states that if any lesions were present, she would put on gloves and palpate them. However, in this case, the patient has no lesions, so palpation is not necessary.
The nail angle is inspected for clubbing using the Shamroth sign (creating a heart symbol with the fingers to check for a diamond-shaped gap). The shape and color of the nails are also observed. The nails are then palpated for texture and capillary refill time, which helps assess peripheral circulation.
The hair and scalp are inspected and palpated. Gloves are worn if lesions, infestations, or poor hygiene are noted. This step is important as it can reveal clues about overall health, such as thyroid disorders, nutritional deficiencies, alopecia, dandruff, lice, or fungal infections.
After completing the assessment, the nurse removes gloves, performs hand hygiene to prevent infection spread, and documents all findings. Documentation is crucial for record-keeping, evaluation, and continuity of care.