Examine body folds and pressure points for any breakdowns
13
Document findings
14
Compare findings with baseline assessment
15
Communicate any concerns/changes to the healthcare team
16
Approval: Healthcare provider
17
Inform patient about the findings and further plan
18
Remove gloves and dispose properly
19
Sanitize hands
20
Store equipment properly
Prepare for the procedure
Before starting the nursing skin assessment, make sure to gather all the necessary equipment and prepare the setting. This task sets the stage for a smooth and efficient assessment process.
Obtain necessary equipment
Collect all the equipment required for the nursing skin assessment. This task ensures that you have everything you need to perform a thorough assessment.
1
Sterile gloves
2
Flashlight
3
Measuring tape
4
Magnifying glass
5
Skin assessment chart
Explain the procedure to the patient
It is important to inform the patient about the nursing skin assessment procedure. Explain what you will be doing, why it is necessary, and what they can expect. This task ensures clear communication and patient understanding.
Wash hands thoroughly
Proper hand hygiene is essential before conducting any procedure. Make sure to wash your hands following the recommended guidelines to prevent the spread of infection.
Put on gloves
Wearing gloves is crucial to maintain a sterile environment during the nursing skin assessment. This task ensures that you have properly donned gloves before proceeding.
Inspect overall skin condition visually
Visually assess the patient's skin for any abnormalities, such as discoloration, redness, or wounds. This task allows you to gather initial observations about the overall skin condition.
1
Normal
2
Abnormal
3
Unsure
Palpate the skin for temperature and texture
Use your hands to assess the temperature and texture of the patient's skin. This task helps you gather additional information about the skin condition.
1
Warm and smooth
2
Cold and rough
3
Hot and dry
4
Cool and clammy
5
Other
Check skin for elasticity and turgor
Assess the skin's elasticity and turgor by gently pinching the skin and observing how quickly it returns to its normal position. This task helps evaluate hydration levels and overall skin health.
1
Normal
2
Decreased elasticity
3
Poor turgor
4
Other
Note any skin color changes
Pay attention to any changes in the patient's skin color, such as pallor, cyanosis, or jaundice. This task helps identify potential underlying health issues.
1
Normal
2
Pale
3
Bluish
4
Yellowish
5
Other
Check for skin moisture or dryness
Assess the patient's skin for moisture levels. This task helps determine if the skin is adequately hydrated or excessively dry.
1
Moist
2
Dry
3
Combination
4
Other
Observe for any swelling, lesions, or rashes
Look for any signs of swelling, lesions, or rashes on the patient's skin. This task helps identify potential infections, allergic reactions, or other dermatological conditions.
1
Swelling
2
Lesions
3
Rashes
4
None
5
Other
Examine body folds and pressure points for any breakdowns
Carefully inspect the patient's body folds and pressure points, such as under the breasts, between the toes, and at the sacrum, for any signs of skin breakdowns or pressure ulcers. This task helps prevent complications and promotes skin integrity.
Document findings
Record all the findings from the nursing skin assessment accurately. This task ensures that the assessment data is properly documented for future reference and continuity of care.
Compare findings with baseline assessment
Compare the current skin assessment findings with the patient's baseline assessment. This task helps identify any changes or deterioration in the skin condition.
Communicate any concerns/changes to the healthcare team
Share any concerns or changes in the patient's skin assessment findings with the healthcare team. This task promotes collaboration and timely intervention.
Approval: Healthcare provider
Will be submitted for approval:
Inspect overall skin condition visually
Will be submitted
Palpate the skin for temperature and texture
Will be submitted
Check skin for elasticity and turgor
Will be submitted
Note any skin color changes
Will be submitted
Check for skin moisture or dryness
Will be submitted
Observe for any swelling, lesions, or rashes
Will be submitted
Examine body folds and pressure points for any breakdowns
Will be submitted
Document findings
Will be submitted
Compare findings with baseline assessment
Will be submitted
Communicate any concerns/changes to the healthcare team
Will be submitted
Inform patient about the findings and further plan
Discuss the nursing skin assessment findings with the patient and develop a plan for further care or interventions. This task involves effective communication and patient engagement.
Remove gloves and dispose properly
Take off the gloves following the recommended guidelines and dispose of them appropriately. This task ensures proper infection control measures.
Sanitize hands
Thoroughly sanitize your hands using an alcohol-based hand sanitizer. This task helps maintain hand hygiene after completing the nursing skin assessment.
Store equipment properly
Organize and store all the equipment used during the nursing skin assessment in their designated places. This task promotes proper inventory management and readiness for future assessments.
