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Assessment: Normal findings : Abnormal findings: Inspection: Check for general skin colour. Pallor in case of insufficient blood flow to the tissue. Inspection involves looking at the following: General skin color - abnormal findings would include pallor, cyanosis, or jaundice. Chest expansion symmetrical. At 24 - 36 hours of age, skin flaky, dry and pink in color. Okay, okay, incarceration might not be totally realistic, but there are plenty of scenarios in which your actions as a healthcare provider might be called into question. Head: Normocephalic without scalp lesions. Thin skin happens, whether it be a result of medications (anticoagulants, steroids, antibiotics, vasoconstrictors, antidepressants-to name a few), poor nutrition or dehydration, and/or age-related changes such as loss of collagen and elasticity. List six factors to consider when assessing darkly pigmented skin. Compare and contrast a normal and an abnormal finding for each wound assessment parameter. Eyebrows. Skin: normal texture, normal turgor, warm, dry, no rash . We always recommend starting with the upper extremities and moving to the lowers. Today's normal signs may be tomorrow's abnormalities. Contact ALS if ALS not already on scene/enroute. Identify the "areas" to inspect the skin for pressure ulcers and how to document abnormal findings. Breastfeeding assessment: Maternal/infant positioning and latch that may impede success Subjective/Objective Assessments Redness and/or Engorgement Nipples Protruding, flat, inverted Assessment of a. Cord clamp tight and cord drying. No involuntary muscle movements. Diaphoresis. All three structures are assessed using the modality of inspection. Chief complaint: "The rash in his diaper area is getting worse." History of Present Illness: Cortez is a 21-day-old African American male infant who presented skin color varies from light to deep brown; from ruddy pink to light pink; from yellow overtones to olive. Here are some components of a good skin assessment. First, it keeps you out of jail. Normal distribution of hair on scalp and perineum. Skin turgor assessment is easy to do by pulling up on the skin at the back of the hand, and may indicate decreased elasticity and risk for skin tears or dehydration. Eyebrows. ASSESSMENT FOLLOW UP: Notify the physician of all abnormal findings!! Normal Findings Skin of the scrotum is normally loose. Critical thinking skills applied during the nursing process provide a decision-making framework to develop and guide a plan of care for the . Assessment of Hair, Nails, and Skin. (C-1) 3-2.7 Differentiate normal and abnormal findings of the assessment of the skin. Normal and Abnormal Age-Related Skin Changes. Normal Findings Deviations From Normal Findings with probable causes Temperature: Slight increase in the first 24 hours to 38 degrees C (100.4 degrees F) due to dehydration. Table 1: Components of skin assessment and what to look for. Physical Assessment Integument. The General Dermatology Exam: Learning the Language. Upper and Lower Extremity Assessment.

both of which are considered "normal". Capillary refill can be assessed as part of the evaluation of the skin. Normal findings. Color variations - look for rashes or erythema. EARS: External auditory canals and tympanic membranes clear, hearing grossly intact. Assessment of muscle strength and tone (e.g., flaccid, cog wheel, spastic) with notation of any atrophy or abnormal movements Skin Inspection of skin and subcutaneous tissue (e.g., rashes, lesions . Absence of cyanosis or pallor. Can move facial muscles at will. with 2+ edema. A newborn infant's skin goes through many changes both in appearance and texture. Neuro Assessment Head free of abnormal lumps/bumps/scars - hair evenly distributed or absent if bald; Nose midline; nostrils open, no obvious obstrucions, patient able to breathe through each side; Ears free from wax buildup or skin abnormalities; Mouth: uvula/tongue midline, mucous membranes pink and moist + teeth status; Alert & Oriented x4 (to name, location, time/date, and situation . Chapter 26 Assessment of the Skin, Hair, and Nails Janice Cuzzell and M. Linda Workman Learning Outcomes Safe and Effective Care Environment 1 Use knowledge of integumentary changes associated with aging to protect older adult patients from skin injury. 5-18 Discuss the value of removing some of the patients clothing during assessment. Abnormal: Daily acne bumps or blemishes that cannot be controlled with over-the-counter options. Comprehensive Skin Assessment. Make sure you check out the outline attached to this lesson for more details on abnormal findings and for a list of what to assess in the integumentary system. Today We Talked About Attributes and goals of comprehensive skin VITALS (1) The skin is normally dry. Open Resources for Nursing (Open RN) Now that we have reviewed the anatomy of the integumentary system and common integumentary conditions, let's review the components of an integumentary assessment. Face is symmetrical. Abnormal findings associated with hypothyroidism. Define partial-thickness and full-thickness tissue loss. Watch the pupil response: The pupils should constrict and equally move to cross. U:\2016-17\FORMS\Physical Exam\Normal_PE_Sample_write-up.doc1 of 5 Revised 7/30/14 . These issues can be indication of infection, phlebitis or infiltration ( Wolters Kluwer, 2015). Assessment o Inspect the skin for localized hyperpigmentation, retraction or dimpling, localized hypervascular areas, swelling or edema Normal Findings o Skin uniform in color and skin is smooth and intact o Striae, moles and nevi Deviation from normal Evenly coloured skin without any unusual findings. Unusual findings should be followed up with a focused neurological system assessment. no edema.

Initial Assessment (Primary Survey) 5-20 Describe normal and abnormal findings when assessing skin capillary refill in the infant and child. Hair: The hair of the client is thick, silky hair is evenly distributed and has a variable amount of body hair.There are also no signs of infection and infestation observed. Normal vs abnormal findings of a skin assessment on a healthy adult ? Immediately after birth, the obstetrician needs to ascertain, from a brief assessment of the infant, whether there is illness or malformation. GENERAL APPEARANCE: Well developed, well nourished, alert and cooperative, and appears to be in no acute distress. Skin integrity assessment is an essential part of nursing care and should be conducted on admission and at least daily depending on the individual's circumstances. Upon skin assessment, the patients skin color is normal for et hnicity and intact, except . Skin Assessment and Care Planning. (C-3) 3-2.8 Distinguish the importance of abnormal findings of the assessment of the skin. Neonatal Assessment Normal Anticipated Findings General Appearance Sleep/Awake/Crying Crying: strong and lusty. Explain to the participants that this comprehensive assessment will guide the health staff in counselling mother and family. generally uniform except in areas exposed to the sun; areas of lighter pigmentation (palms, lips, nail beds) in dark skinned people. Edema around eyes, feet, and genitals. 3.

Skin must be felt to determine temperature: cold, cool, warm (normal .

Used with permission Western New South Wales LHD Uses touch and palpation to . Position the patient. III.

Sample Pediatric History and Physical Exam Date and Time of H&P: 9/6/16, 15:00 Historian: The history was obtained from both the patient's mother and grandmother, who are both considered to be reliable historians. HEAD: normocephalic. No nail changes. 2 Modify techniques to assess skin changes in patients with darker skin. Zulkowski & Ayello, 2010. Any abnormal findings or life-threatening chief complaint such as major trauma/burns, seizures, diabetes, asthma attack, airway obstruction, etc (urgent) - proceed to Initial Assessment. o Evaluate the effectiveness of the plan and revise as needed. The patient should be in a sitting position with all clothing removed except the examination gown. Examine the patient in good lighting. Adjectives to describe turgor include: good elasticity (normal), poor/decreased elasticity and tenting of skin. 4. Hair normal texture and distribution. Because of fragile skin in our aging population . A skin assessment should include the presenting concern/compliant with the skin, history of the presenting concern/compliant, past medical history, family history, social history, medicines (including topical treatment) and allergies and impact on quality of life. B. impaired presentatiskin characteristics using the tool below, carry out actions if required and sign as per the reverse side of this document. A lot of things can cause pimples such as an internal imbalance, using the wrong skin care products, or even stress. No lesions or excoriations noted.

No facial asymmetry, muscles of facial expression intact. C. Purpose Use your assessment findings to determined abnormalities and the type of hygiene measures required to maintain integrity of the integument. 4.

Intact cranial nerve V and VII.

Can move facial muscles at will. Skin exam is not separate from the rest of the physical examination. Information. The skin of a healthy newborn at birth has: Deep red or purple skin and bluish hands and feet. These are considered normal in the aging process. These common pathologic disorders are described in Table II (Health Assessment Handbook 1992). Medical Rec No: Surname: Forename: Gender: D.O.B: Complete initial skin assessment within 8 hours of on. Shape may be oval or rounded.

clinical assessment): Assessed findings from evaluation of body systems, muscle and subcutaneous fat wasting, oral health, hair, skin and nails, signs of edema, suck/swallow/breath ability, appetite and affect." Differentiate normal vs non-normal findings Assess and intervene in findings that are relevant to the patient's care

6. . Peripheral IV Site. Physical assessment. COM Library resources are strongly encouraged, for suitable resources based on topic of Absence of accessory muscle use, retractions, and/or nasal flaring 5th Floor Fisher Hall 600 Forbes Avenue Pittsburgh, PA 15282 Email: nursing@duq.edu Phone: 412.396.6550 Fax: 412.396.6346 Your patient may report that his/her skin seems thinner and looser, less elastic, than before. Sensation intact over face. abnormal findings to HCP and notify & educate patient and family on findings. After retracting the skin for a circumcision, this anomaly of the meatus was noted.

If all these findings are normal you can document PERRLA. The skin darkens before the infant takes their first breath (when they make that first vigorous cry). 3. Skin: Good turgor, no rash, unusual bruising or prominent lesions Hair: Normal texture and distribution.

Normal Findings. The assessment: Is a head to toe visual inspection and focuses on the skin overlying bony prominences, in skin folds, and around and under medical devices. Identify a common Pain Assessment tool and if mnemonic, what each letter stands for. The incidence of ecchymosis was similar in the first three assessments (18.5%), and it was not observed at the fourth assessment. Regular breathing pattern. 2. 1. o Plan and implement appropriate interventions. No involuntary muscle movements. Each client's response to the Skin Observation Protocol will be unique to that client and should reflect their individualized assessment and care needs. Normal: Few, small bumps or papules throughout adolescence and young adulthood. 14.4 Integumentary Assessment. PHYSICAL EXAMINATION WITH ALL NORMAL FINDINGS (COMPLETE H&P) GENERAL APPEARANCE: (include general mental status) 45 y/o female who is awake and alert and who appears healthy and looks her stated age .

At the first assessment, the evaluators assigned the same total score on the scale REEDA to 44 (81.5%) women. Old appendectomy scar right lower abdomen 4 inches long, thin, and white. Respiratory rate within normal range for age. One additional facet of global assessment is the relation of physical findings to the time of their occurrence. CHARTING EXAMPLES FOR PHYSICAL ASSESSMENT SKIN, HAIR AND NAILS Skin pink, warm, dry and elastic. Skin findings in newborns. 2. If a danger sign is found during the initial assessment it is necessary to perform the complete examination immediately. All three structures are assessed using the modality of inspection. she does have brown hyperpigmentation bilaterally from the knees and down both sides . Check for any unusual door . The text in this sample documentation can be considered an outline to use when you follow the Skin Observation Protocol. 1. Distinguish between wound assessment and evaluation of healing. Ambulating without difficulty. Usually history taking is completed before physical examination.

Reassess the (C-3) 3-2.9 Describe the normal and abnormal assessment findings of the head (including the scalp, skull, face and skin . Normal vs abnormal findings of a skin assessment on a healthy adult ?

HOW NORMAL FINDINGS. Stoma Assessment A. Take a thorough history Obtain a history of the patient's skin condition from the patient, caregiver, or previous medical records . Document any .

6. Normal Findings (cont'd) Skin color: often more deeply pigmented than body skin. Skin that remains tented indicates poor hydration and nutritional status. normal findings inspection of facial and body hair men: lower face, neck, nares, ears, chest, axilla, back, shoulders, arms, legs and pubic region (upright triangle with hair extending to umbilicus) women: arms, legs, axillae, pubic region (inverse triangle and hair may also extend to umbilicus) and around nipples (some facial and chin hair)

Intact cranial nerve V and VII. Findings: Normal - Transient (resolves in minutes to hours) Findings: Normal - Short-term (resolves in days to months) Findings: Normal - Birthmarks, Long-term (Persists for months to years - some do not resolve) Findings: Important Infections; Findings: Abnormal or lesions that require evaluation, specific management or observation; References Instruct the patient. School of Nursing. Cord with one vein and two arteries.

NUR 221 MODULE 2_SKIN, HAIR AND NAIL ASSESSMENT_1ST SEM 1441 3 PROCEDURE GUIDE INSPECTION OF THE SKIN Procedure and Rationales Normal Findings 1. Skin, hair, and nails: Inspect for lesions, bruising, and rashes. Normal findings. Assessment Expected Findings Unexpected Findings (Document and notify provider if a new finding*) Inspection: Work of breathing effortless. Discharge was observed within 40 hours after birth (3.7%). 5. Performed by inspection (looking), palpation (touching), listening, and smell. and puffy at birth. - Normal: Skin should be congruient with culture, texture should be smooth-Abnormal: Lesions, mobility, turgor, edema, vitiligo, jaundice, rash, dryness etc -It is important to do a thorough skin assessment because the skin holds tells information about: Circulatory Status Medications, sun exposure and increased sunlight . Often reddened in red-haired red- individuals. Documentation serves two very important purposes. This article will explain how to assess the upper and lower extremities as a nurse. A SKIN ASSESSMENT captures the patient's general physical condition, based on careful inspection and palpation of the skin and documentation of your findings. Shape may be oval or rounded. F:\2012-13\FORMS\Normal_PE_Sample_write-up.doc 1 of 5 Revised 1/28/13 DATA BASE SAMPLE: PHYSICAL EXAMINATION WITH ALL NORMAL FINDINGS GENERAL APPEARANCE: (include general mental status) 45 y/o female who is awake and alert and who appears healthy and looks her stated age VITALS Inspect the abdomen for contour and symmetry: Observe the abdominal contour (profile line from the rib margin to the pubic bone) while standing at the client's side when the client is supine. Symmetrical and in line with each other. Make the lights normal and have patient look at a distant object to dilate pupils, and then have patient stare at pen light and slowly move it closer to the patient's nose. Appropriate site prep utilizing a Chloraprep scrub.

Although the meatus starts in a normal distal position, it extends down the ventral surface of the glans all the way to the corona. Evaluating the skin, hair, and nails is an ongoing element of a full body assessment as you work through steps 3-9. Once you've finished your skin assessment, make sure you document any abnormal findings, dress any wounds as appropriate, and make sure the patient is comfortable. Identify the tool for assessment of Level of Consciousness and how tool is used and scored. This language, reviewed here, can be used to describe any skin finding. Ears: Inspect the ears for: Jaundice may be seen which is yellowish discolorization of skin. SKIN, HAIR AND NAILS Skin color and texture commonly change as a person ages. 39. a systematic data collection method that uses the senses of sight, hearing, smell and touch to detect health problems.There are four techniques used in physical assessment and these are: Inspection, palpation, percussion and auscultation. Symmetrical and in line with each other. Moderate in tone and pitch Can be awake or asleep Vital Signs/Measurements Temperature Axilla: 36.4-37.2C(97.5-99F) Heavier newborns have a higher temperature/ Pulse 110-160 bpm.

Skin. 5. Adults are not immune to breakouts. EYES: PERRL, EOMI. The diagnosis of any skin lesion starts with an accurate description of it. Sprinkling of freckles noted across cheeks and nose. Expected Findings: Skin reddish in color, smooth. profuse sweating occuring during exertion, fever, pain and emotional stress, hyperthyroidism; may also indicate an impending medical crisis such as myocardial infarction. 5-19 Describe normal and abnormal findings w hen assessing skin color, temperature and condition. Recommendations for assessing dark-skinned patients When assessing a patient's skin, use natural light or a halogen lamp rather than fluorescent light, which may alter the skin's true color and give the illusion of a . Eyebrows, Eyes, and Eyelashes. Take a thorough history. During the extremity assessment you will be assessing the following structures: Eyebrows, Eyes, and Eyelashes. (2) Wet, moist, or excessively dry and hot skin is considered abnormal. The standard for documentation of skin assessment is within 24 hours of admission to inpatient care. Healthy, elastic tissue rapidly resumes its normal position without creases or tenting. NOSE: No nasal discharge. This assessment is part of the nursing head-to-toe assessment you have to perform in nursing school and on the job. (3) In descriptions of the skin, it is usually listed as color, condition, and temperature (CCT). A variety of normal and abnormal lesions may be present on newborn skin .2 - 6 Although these findings are often benign, it is important to visualize the entire skin surface to distinguish these . Dry Skin. Here are some components of a good skin assessment. ABNORMAL FINDINGS. Maintaining skin integrity. Table 19-1 identifies skin findings during the physical assessment that are abnormal and their related pathology. Turgor good with quick recoil. To do that, you need to know how to describe a lesion with the associated language. Face is symmetrical. Afebrile after 24 hours Temperature: greater than 38 degrees C (100.4 degrees F) after 24 hours can be indicative of infection (mastitis, endometritis, A skin assessment should include the presenting concern/compliant with the skin, history of the presenting concern/compliant, past medical history, family history, social history, medicines (including topical treatment) and allergies and impact on quality of life. The initial nursing assessment, the first step in the five steps of the nursing process, involves the systematic and continuous collection of data; sorting, analyzing, and organizing that data; and the documentation and communication of the data collected.

INSPECTION Inspect Skin for: ruddy dark tan or fligColor: While inspecting skin coloration, note any odors emanating from the skin brown and many have yellow or olive Thickness Symmetry Describe how to measure the length, width, depth . 3-2.6 Describe the examination of skin and nails. And, in the medical world, if you didn't write it down, it didn't happen. Please note there are many other skin issues not mentioned here such as irregular skin area such as boggy or mushy skin area, discoloration area(s). In this video we're going to review the peripheral vascular assessment. Use the nursing process to: o Analyze subjective and objective findings. - Normal: Skin should be congruient with culture, texture should be smooth-Abnormal: Lesions, mobility, turgor, edema, vitiligo, jaundice, rash, dryness etc -It is important to do a thorough skin assessment because the skin holds tells information about: Circulatory Status Medications, sun exposure and increased sunlight . Normal Findings. Skin warm, dry, with good turgor, No abnormal pigmentation, bleeding, rash, or other lesions. This is a variant of hypospadias, but it occurs with a normal foreskin. generalized dryness; may have rough, scaly, dry skin. findings that identify the presence of chronic venous insuf ficiency. 1 A nurse working in the community should conduct a skin assessment when the . Fundi normal, vision is grossly intact. A SKIN ASSESSMENT captures the patient's general physical condition, based on careful inspection and palpation of the skin and documentation of your findings. Inspect the abdomen for skin integrity 2. Gait and station normal, Rhomberg negative. For clinical skin-color assessment, visual inspection and asking patients about their normal skin color are the best methods. Tool 3A Page 128. Documenting Cheat Sheet: Normal Physical Exam Template Read . Not only are we looking at actual blood vessels and pulses, but we're looking at other signs of perfusion as well, like skin and nail color and condition. hours so e mother and baby can have skin to skin contact without interference. During an initial assessment, the skin surrounding an IV cannula should be examined for any redness, swelling, warmth or induration (hardening). incorporate your findings into the assessment and plan of your writeup in the form of 12 paragraphs and 3) list the resources used. Assess general appearance: This is not a specific step. NURS 221 MODULE 2 SKIN, HAIR AND NAIL ASSESSMENT, 2ND SEM 2018-2019 3 Inspect And Palpate the Skin Procedure & Rationales Normal Findings 1. Skin turgor is best assessed on the abdomen. Skin: The client's skin is uniform in color, unblemished and no presence of any foul odor.He has a good skin turgor and skin's temperature is within normal limit. 1 A nurse working in the community should conduct a skin assessment when the . Blue colorization of skin, otherwise called cyanosis. Hair brown, shoulder length, clean, shiny. Normal findings of Skin Assessment.

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