CHOLECYSTECTOMY
CEPHALOCAUDAL ASSESSMENT
Fundamentals of Nursing
1/22/2013
Submitted to: Ms. Azenith Lupig RN., MAN.
Submitted by: Apryll Rose Mayo
SKIN
Assessment Procedure
Normal Findings
Actual Finding
Significance
Inspection
Inspect general skin coloration
Inspect for color variations
Check for skin integrity
Inspect for lesions
Palpation
Assess texture
Assess thickness
Assess moisture
Assess mobility and turgor
Detect edema
Evenly colored skin tones without usual or prominent discoloration.
Some clients have suntanned areas, freckles, or white patches known as vitiligo. Variation is due to different amount of melanin.
Skin is intact, and there is no reddened areas
Without lesions
Skin is smooth and even
Skin is normally thin but calluses are common on the areas exposed to pressure.
Skin moisture may vary from moist to dry depending on the area.
Skin pinches easily and returns to its position.
Skin rebounds and does not remain indented when pressure is released.
Skin is pale in appearance
Skin is rough
Poor skin turgor
Edema in the lower extremeties
Pallor is seen in arterial insufficiency, decreased blood supply and anemia.
Erythema is seen in inflammation or trauma
Skin breakdown may progress to ulcer
Lesions may indicate local or systemic problem
Roughening of the skin may be a sign of dehydration
Very thin skin may seen in client with arterial insufficiency
Diaphoresis may occur with fever or hypothyroidism
Seen in dehydration
Decreased mobility may be seen in edema
Due to renal failure
SCALP AND HAIR
Assessment Procedure
Normal Findings
Actual Finding
Significance
Inspection and Palpation
Inspect for general color or condition
Palpate the hair and scalp for cleanliness, dryness parasites and lesions
Hair color
Fundamentals of Nursing
1/22/2013
Submitted to: Ms. Azenith Lupig RN., MAN.
Submitted by: Apryll Rose Mayo
SKIN
Assessment Procedure
Normal Findings
Actual Finding
Significance
Inspection
Inspect general skin coloration
Inspect for color variations
Check for skin integrity
Inspect for lesions
Palpation
Assess texture
Assess thickness
Assess moisture
Assess mobility and turgor
Detect edema
Evenly colored skin tones without usual or prominent discoloration.
Some clients have suntanned areas, freckles, or white patches known as vitiligo. Variation is due to different amount of melanin.
Skin is intact, and there is no reddened areas
Without lesions
Skin is smooth and even
Skin is normally thin but calluses are common on the areas exposed to pressure.
Skin moisture may vary from moist to dry depending on the area.
Skin pinches easily and returns to its position.
Skin rebounds and does not remain indented when pressure is released.
Skin is pale in appearance
Skin is rough
Poor skin turgor
Edema in the lower extremeties
Pallor is seen in arterial insufficiency, decreased blood supply and anemia.
Erythema is seen in inflammation or trauma
Skin breakdown may progress to ulcer
Lesions may indicate local or systemic problem
Roughening of the skin may be a sign of dehydration
Very thin skin may seen in client with arterial insufficiency
Diaphoresis may occur with fever or hypothyroidism
Seen in dehydration
Decreased mobility may be seen in edema
Due to renal failure
SCALP AND HAIR
Assessment Procedure
Normal Findings
Actual Finding
Significance
Inspection and Palpation
Inspect for general color or condition
Palpate the hair and scalp for cleanliness, dryness parasites and lesions
Hair color