1. The document summarizes a procedure for assessing a client's integumentary system, including inspecting and documenting the skin, color, lesions, moisture, temperature, turgor, and vascular changes.
2. Safety measures are outlined, such as handwashing and using gloves for open lesions. Equipment needed includes a ruler, gloves, and magnifying glass.
3. The procedure lists steps to interview the client, inspect various skin characteristics, document findings, and assess the student's understanding and performance of the procedure.
1. The document summarizes a procedure for assessing a client's integumentary system, including inspecting and documenting the skin, color, lesions, moisture, temperature, turgor, and vascular changes.
2. Safety measures are outlined, such as handwashing and using gloves for open lesions. Equipment needed includes a ruler, gloves, and magnifying glass.
3. The procedure lists steps to interview the client, inspect various skin characteristics, document findings, and assess the student's understanding and performance of the procedure.
1. The document summarizes a procedure for assessing a client's integumentary system, including inspecting and documenting the skin, color, lesions, moisture, temperature, turgor, and vascular changes.
2. Safety measures are outlined, such as handwashing and using gloves for open lesions. Equipment needed includes a ruler, gloves, and magnifying glass.
3. The procedure lists steps to interview the client, inspect various skin characteristics, document findings, and assess the student's understanding and performance of the procedure.
1. The document summarizes a procedure for assessing a client's integumentary system, including inspecting and documenting the skin, color, lesions, moisture, temperature, turgor, and vascular changes.
2. Safety measures are outlined, such as handwashing and using gloves for open lesions. Equipment needed includes a ruler, gloves, and magnifying glass.
3. The procedure lists steps to interview the client, inspect various skin characteristics, document findings, and assess the student's understanding and performance of the procedure.
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BUKIDNON STATE UNIVERSITY
COLLEGE OF NURSING Health Assessment RLE
Date Performed: Final Grade:
Clinical Instructor:
Assessing the Integumentary system
Definition:
Objectives: 1.
2.
3. Safety/Security Measures: 1.
2.
3. Pre-procedural Preparations: 1. Wash hands 2. Introduce yourself to the client and identify client’s identity. Explain what you are going to do, why it is necessary, and how the client can cooperate. 3. Gather the necessary equipment. 4. Provide Privacy Equipment: Millimeter Ruler, Examination gloves, Magnifying glass
Procedure Able to perform Unable to
perform
1. Inquire if client has any history of the following:
Pain or itching Presence and spread of any lesions, bruises, abrasions, or pigmented spots Skin problems Associated clinical signs Problems in other family members Related systemic conditions Use of medications, lotions, or home remedies Excessively dry or moist feel to the skin Tendency to bruise easily Any association of the problem to a season of the year Assessment 2. Inspect skin color. 3. Inspect uniformity of skin color. 4. Assess edema, if present. BUKIDNON STATE UNIVERSITY COLLEGE OF NURSING Health Assessment RLE 5. Inspect, palpate, and describe skin lesions. Apply gloves if lesions are open or draining.
6. Describe lesions according to location, distribution, color,
configuration, size, shape, type, or structure.
Assess for Malignant Lesions [2]
A=symmetry B=Border of irregularity C=Color variation D=Diameter> 0.5 cm 7. Observe and palpate skin moisture. [1] Palpate for tenderness and surface characteristics of any lesions. [2] 8. Palpate skin temperature. Compare the client’s two feet and the two hands using the dorsal part of the nurse’s hand [2] 9. Note skin turgor by lifting and pinching the skin on an extremity. 10. Check for blanching of vascular lesions 11. Document findings in the client record. Draw the location of skin lesions on body surface diagrams. 12. Ability to Answer questions 13. Definition 14. Objectives 15. Safety/Security Measures Total Score Equivalent Grade
