RETURN DEMO CHECKLIST

SKIN, HAIR, SCALP, AND NAILS

ASSESSMENT SKILL RATIONALE

1. Gather equipment (gloves, exam light, Plan ahead of time to avoid inconvenience and
penlight, magnifying glass, centimeter prepare the needed equipment to save more
ruler, Wood's lamp if available). time. Make sure all materials are within reach
to avoid time consumption.
2. Explain procedure to client. Explaining the procedure to the patient is a
must for them to understand and be aware of
the procedure. In this way, we can get their
cooperation and the procedure will proceed
smoothly.

Note: Assure the confidentiality of their

documents.
3. Ask client to put on gown. The gown serves as a protective equipment
which protects the patient from transmission
and cross contamination of microorganisms.
SKIN
1. Note any distinctive odor. Foul odor may indicate disorder of sweat
glands. In this way, the nurse will know if the
patient needs client teaching or assistance of
daily living in case of indication of poor
hygiene.
2. Inspect for generalized color variations Skin color may reflect a patient’s overall
(brownness, yellow, redness, pallor, health. Inspection of skin reveals patient’s
cyanosis, jaundice, erythema, vitiligo). current condition depending on the findings
observed.

3. Inspect for skin breakdown. Inspection of skin breakdown is important to

assess if the skin is intact and if there are no
reddened areas that may progress to serious
and painful pressure ulcers.
4. Inspect for primary, secondary, or This would assess the smoothness and state of
vascular lesions, (Note size, shape, the skin. Note that the skin is smoother without
location, distribution, and lesions. Lesions may indicate local or systemic
configuration). problems.

Note: Primary lesions arise from normal

skin due to irritation or disease. Secondary
lesions arise from changes in primary
lesions. Vascular lesions reddish-bluish
lesions, are seen with bleeding, venous
pressure, aging, liver disease, or
 pregnancy.
5. Palpate lesions Palpation determines the lesion’s mobility,
contour, and consistency
6. Palpate texture (rough, smooth) of Texture would determine if smooth and even.
skin, using palmar surface of three Rough, flaky, dry skin is seen in
middle fingers. hypothyroidism. Obese clients often report
dry, itchy skin. Very thin skin may be seen in
clients with arterial insufficiency or in those on
steroid therapy. Palmar surface is preferred
because it is more sensitive to assess skin
texture.
7. Palpate temperature (cool, warm, hot) This would reveal the patient’s skin state if it
and moisture (dry, sweaty, oily) of is within the normal state. Palmar side of the
skin, using dorsal side of hand. hand is not preferred because it has thicker skin
and higher blood flow that may lead to warmer
temperature.
8. Palpate thickness of skin with finger Palpation of the skin may reveal if the skin is
pads. normally thin but note that calluses are
common.
9. Palpate mobility and turgor by This would assess the skin’s elasticity.
pinching up skin over sternum. Normally, the skin lifts normally and snaps
back immediately to its resting position.
10. Palpate for edema, pressing thumbs Palpating edematous skin would assess
over feet or ankles. mobility, consistency, and tenderness of the
skin. The formation of edema separates the
skin surface from the pigment and vascular
layers.
SCALP AND HAIR
1. Inspect color. This would assess the skin’s variation of color
from the normal terminal of hair color such as
black, brown red, yellow, and white.
2. Inspect amount and distribution. It shows any hair abnormalities in quantity.
Lower extremities of hair may result from
aging and arterial insufficiency.
3. Inspect and palpate for thickness, Hair is normally distributed evenly, in neither
texture, oiliness, lesions, and parasites. excessively dry nor oily, and is pliant or
flexible. This would assess the all over state of
the scalp and hair.
NAILS
1. Inspect for grooming and cleanliness. Condition of nails may reveal the patient’s
hygiene or patient’s hobby or occupation.
2. Inspect for color and markings. Nail color may indicate patient’s condition
such as hypoxia or anemia, or fungal infections
can be detected by yellow discoloration. Pink
tones should be seen.
3. Inspect shape. The shape of the nails may reveal patient’s
condition such as hypoxia or iron deficiency
anemia. Normally, there is a 160-degree angle
between the nail base and the skin.
4. Palpate texture and consistency. This would allow us to assess the attachment
of nail plate to nail bed.
5. Test for capillary refill. Assessing the capillary refill would determine
the patient’s condition in terms of respiratory
and cardiovascular system.
ANALYSIS OF DATA
1. Formulate nursing diagnoses It helps nurses to see the patient in a holistic
(wellness, risk, actual) perspective, which facilitates the decision of
specific nursing interventions. The use of
nursing diagnoses can lead to greater quality
and patient safety and may increase nurses’
awareness or nursing and strengthen their
professional role.
2. Formulate collaborative problems. It allows the nurse with the physician and other
health care providers to monitor, plan and
implement patient’s care.
3. Make necessary referrals. This is to ensure that clients are seeing the
correct health care providers for further
diagnosis.