Checklists for Clinical Nursing Skills

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Name __________________________________________________________ Date ____________________________________ Course _________________________________________________________ Year ____________________________________ Instructor/examiner _ ____________________________________________ Position _ _______________________________

skill 2-3 Assessing the skin, hair and nails

Refer to Dempsey, Hillege and Hill, Fundamentals of Nursing and Midwifery: A Person-Centred Approach to Care 2e, Chapter 30, Comprehensive health assessment

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.

Comments

Excellent

Satisfactory

Needs practice

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