17
Comments
Excellent
Satisfactory
Needs practice
Name __________________________________________________________ Date ____________________________________
Course _________________________________________________________ Year ____________________________________
Instructor/examiner _ ____________________________________________ Position _ _______________________________
Copyright © 2014 by Wolters Kluwer Health | Lippincott Williams & Wilkins.
Checklists for Clinical Nursing Skills by Louise Sparkes, Jennifer Bassett and Elisabeth Jacob.
1. Identify the patient.
2. Check the medical order or clinical pathway/care plan.
3. Introduce yourself, explain the rationale for the
procedure to the patient and family, and obtain consent.
4. Gather the necessary equipment.
5. Undertake a risk assessment, if indicated.
6. Perform hand hygiene.
7. Put on personal protective equipment (PPE), including
gloves.
8. Ensure that patient privacy is maintained and the patient
is comfortable. Ensure that interruptions are minimal.
9. Undertake a health history, as per Skill 2-1.
10. Ask the patient to remove all clothing. The patient
remains in the sitting position for most of the
examination but will need to stand or lie on their
side when the posterior part of the body is examined,
exposing only the body part being examined. Use a
blanket or drape to cover any exposed area other than the
one being assessed.
11. Ensure the lighting is adequate. Inspect the skin for
colour, lesions, vascularity, bleeding and body odours.
If lesions are present, palpate them. Note any bruises,
scratches, cuts, insect bites and wounds. (Refer to
Skill 8-2 on assessing a wound.) If present, note the size,
shape, colour, exudates and distribution/pattern.
12. Palpate the skin using the backs of your hands to assess
temperature.
13. Palpate for texture and moisture.
14. Assess for skin turgor by gently pinching the skin under
the clavicle.
15. Palpate for oedema, which is characterised by swelling,
with taut and shiny skin over the oedematous area.
____ ____ ____
____ ____ ____
____ ____ ____
____ ____ ____
____ ____ ____
____ ____ ____
____ ____ ____
____ ____ ____
____ ____ ____
____ ____ ____
____ ____ ____
____ ____ ____
____ ____ ____
____ ____ ____
____ ____ ____
Goal:
The skin, hair and nails are assessed accurately without
the patient experiencing anxiety or discomfort, the findings
are documented and the appropriate referral is made to other
healthcare professionals, as needed, for further evaluation.
Refer to Dempsey, Hillege and Hill, Fundamentals of Nursing and Midwifery:
A Person-Centred Approach to Care 2e, Chapter 30, Comprehensive health assessment
skill 2-3
Assessing the skin, hair and nails
