Skin Assessment

[Music]

hello everyone i am shikayana aquino

maranga from bsn111a

and today i am going to perform a skin

assessment the skin is the largest organ

and the first line of defense of our

body

against the invasion of microorganisms

certain diseases manifest its symptoms

through changes in the skin

thus giving us valuable diagnostic clues

to underlying conditions of our client

here are the paraphernalia needed

alcohol

for hand hygiene and disinfection

surgical gloves

to protect the patient and the nerves

from cross-contamination

pick up forceps scissors and cotton ball

which are needed for addressing the

covered wounds and ulceration

ruler and tape measure to measure size

of skin lesions

magnifying glass pen light

plaster and goes used to cover and

protect the wound after assessment

pen and notebook where i will write and

document my subjective and objective

data

gathered prior to assessment

i'm going to close the door and fix the

curtains to secure

patients privacy provide adequate

lighting

and adjust room temperature for

patient's comfort

and perform hand hygiene to avoid

infection and contamination

good morning ma'am i'm tripana maranga

your student nurse for today

so before we begin how may i see your

hand

okay and please take your complete name

i am sherry lee

all right and your birthday please to

borrow

6752 okay thank you very much and

how would you like me to call you just

call me show

okay so sherry today i'm going to be

inspecting and palpating your hair skin

and nails

to check for any lesions or skin changes

that may give us an insight of your

current health status

okay and before that i'm gonna need to

ask you just a few questions regarding

your health history

so that will be able to give you the

necessary care that will best

suit your needs will that be all right

explain with

me okay and do you have questions or

clarifications

not so far all right thank you and so

now we'll begin

all right so sherry are you currently

experiencing

any uh skin problems like

do you have any rashes lesions or

skin changes you've noticed yes i have a

small wound on my left foot

okay and it's very

disturbing and it's quite itchy

okay and when did you

first notice it well i know this did

uh two weeks ago all right and

what do you think happened to that

how do you think did you get that well i

just

noticed last week that i had a

small small light blister

and it's very itchy so i began to

scratch it

but then i noticed after

uh two days or like that after two days

i noticed that it began to

form a small wound okay

yeah all right and when you notice it

that you already have the wound um what

did you do

did you put any ointments on it or took

medications

yeah i just put an antibacterial

ointment

because i'm afraid it might get infected

all right um so do you have any other

health issues aside from that one

do you have other skin disease or

diabetes or respiratory problems

yeah i remember my father had a

history of diabetes he was diagnosed of

diabetes and also

i have experienced

dermatitis before okay i'll take note of

that

and you said your father had diabetes

is there any other disease that has ever

affected your

family no okay and do you know if you're

allergic to

any food plants or medications

yes i have an allergy to certain foods

like

shrimps and

some months okay

and uh do you spend long periods of time

sitting standing lying in one position

not really i'm usually moving from

time to time i usually change positions

i don't remember that i stand

in much longer time okay uh

so now we're done with the questions

okay so now i'll begin assessing your

skin

i'll start from your head and work my

way down to your toes

just check for uh other lesions aside

from the one you

mentioned that you have in your foot

okay okay so let's start

so generally i see that your skin is

um consistent all over

again i don't see any unusual

discoloration

and now let me see your hair

[Music]

okay so basically i'm just looking for

any scars or lotion which you don't have

okay skin is intact

all right i don't see any headlights or

dandruff

okay okay hair moisture is good

and as well as a texture okay so let's

move on to your face

i see that your hair is evenly

distributed in your

scalp and in your eyebrows and eyelashes

as well

okay um you've got three flat

molds here in the side of your face

borders are um regular and they're

symmetrical

they're small on flat molds

about 0.2 centimeters

okay and you've got

two ear piercings one on each side let's

move down to your neck

so um these molds have it been there for

a while or did this just pop up

no it's been there for a very long time

already

okay and you haven't noticed any odd

moles in your body

no okay good so let's move on to your

neck

neck is good i don't see any

discolorations

so let's check for your skin surgery i

just need to

pinch slightly your skin here on top of

your collarbone

i'll note that your skin trigger is

elastic because

it just went back to its place after i

lightly pinch it

which indicates that you are well

hydrated

okay okay let's move to your back

all right i don't see anything any

rashes and emissions okay

back and neck is clear may i see your

hand man

okay okay

you feel warm and moisture is good

your hand um it's a bit thicker here

skin is a bit thicker

your nails i don't see any clubbing or

any

normal signs in your nails

okay capillary refill is good can i see

your other hand

okay same as the other hand it's warm

and

you don't have any redness or scars

okay nail is good here too no clubbing

and capillary refill is good too okay so

now i'm gonna have to

inspect your lower return piece so

um can you please lay down for me now

okay

thank you

okay so i'm now going to inspect your

lower extremities

okay let me see your right leg

okay right leg looks fine

okay but you have a scar here can you

tell me of what happened to this and

when did this happen

well it happened during my childhood

years we were

playing and then suddenly

i got crushed on the ground that's why i

got the

story okay and here on your left leg

i see this is where you got your um that

you

complained to me a while ago i'll have

to

openly cover up to see your wound okay

foreign

okay

so you've got an ulceration here

all right it's pinkish and reddish in

color

there's a light exudation too

okay let me measure it it's about

seven centimeter in height and

six centimeter in length

okay and does it hurt when i

try to put some force around it

for sure does it hurt

just a little bit okay

all right

all right so i'm i'm gonna cover it up

again

and i advise you not to touch it with

your bare hand so it won't get

infected okay

so

okay so i'm done with my assessment

right and we may now sit back up

okay

so i'm going to sum up everything that

i've

noticed during my skin assessment so

first i've

noticed that your skin is constant or

consistent all over you don't have any

unusual color

hair and scalp is great moisture is good

that's true too and hair is evenly

distributed

okay and in your face i noticed three

flat molds or macules

with um which are symmetrical and

regular has regular borders

and which are about um 2.2 centimeters

okay and they are in the

lateral side of your

mandible and temporal area okay and i

i've also noticed that you've got two

ear piercings one on each side

and the back and neck is clear

no redness no lesions no bruises

your arms their good texture and good

moisture

um good capillary refill good skin

turgor

um i also didn't see any tattoos on your

body okay

you don't have any happens and in your

feet

um there's a

alteration in your left leg which is

about

six centimeters in length and

5.5 centimeter wide which already has a

light oxidation

and is reddish and pinkish in color

so now i have the results i'm going to

head out to give it to the doctor and

he'll come in and

see you and i'll be back

after he's done okay okay okay thank you

very much

okay so now i'm back and the doctor has

ordered for some

um laboratory tests for you and he also

gave me your prescriptions

okay your medical prescriptions here but

before i go

i'm gonna have to give you some

important

health reminders okay so first since you

already have this one in your feet

i highly advise you not to touch it or

scratch it

even if it's itchy because you might

introduce some bacteria to it and it

might get infected okay

you must keep it always clean and dry as

well as

all the other parts of your body

secondly um you told me a while ago that

you have a

family history of diabetes right right

so um i highly advise you

to watch out and regulate for your diet

okay minimize your consumption of

sugar as well as salt and caffeine

okay okay and third

um keep your

level of mobility and range of motion

okay you you shouldn't um stay for long

periods of time

sitting lying or standing in one

position

because the weight of your body will

exert

pressure on your lower extremities which

could

um exacerbate your

condition or your wound or you might

develop

other pressure source too okay and

third um i advise

that you don't massage your bony

prominences

which are the back of your ears your

shoulders your scapula here at the back

and

your elbows too um

your knees your knees your ankles and

heels

okay okay you don't massage it so

because you don't want to

have have it scratch or um you don't

want to develop another

wound or ulcer okay and

i think that's basically it and i'm done

and here are your medical prescriptions

so i'm gonna go

goodbye thank you so much for your

cooperation man

thank you okay

you