Assessment skills are one of the most important aspects to prevention of conditions and diseases. The sooner we can find any abnormalities, the quicker we can treat if possible, and the quicker we can treat, the more successful our prognosis will be. In the presented case scenario with patient Mr. Jaramillo, we are to do a focused assessment on his skin. When learning a skin assessment or any assessment for the first time, it is important to practice the correct way to ensure that you continue to do through assessments in your nursing career. I am precepting a student nurse and she is to learn a focused skin assessment for the first time.
At the start of Mr. Jaramillo’s assessment, I would inform the student nurse that you always need to introduce yourself, make sure all equipment is clean, and practice proper hand hygiene. The student nurse should be aware that because of Mr. Jaramillo’s direct complaint, we will be preforming a focused assessment. We are now ready to begin. Always check for patient orientation to person, place, and time, so we can determine if Mr. Jaramillo is capable of answering the questions that are presented to him (Barbarito, & D’Amico, 2012). We would start off by collecting subjective data from the patient.
When obtaining subjective data, always consider the patient’s situation and use the “OLD CART” (onset, location, duration, characteristics, aggravating factors, relieving factors, and treatment) form (Barbarito et al. , 2012). The subjective data that we collected is Mr. Jaramillo is a 41-year-old Hispanic male with a mole on his back that was noticed 6 months ago, which has grown in size. It is dark colored and oddly shaped. He denies any itching but says it does ooze liquid, as evident by fluid noticed on his shirt. There are no aggravating or relieving factors and has not had any prior treatment in regards to this issue.
Mr. Jaramillo has also mentioned that he spends most of his time outdoors, due to his profession and vacationing, but he does not apply sunscreen. When providing directions on performing skin assessments, I would inform the student that we use inspection and palpation techniques (Barbarito et al. , 2012). It is important to know assessment of lesions require the use of the ABCDE tool. The ABCDE acronym stands for asymmetry, border, color, diameter, and evolve (Barbarito et al. , 2012). I would also add the use of the ugly duckling sign. These two tools are helpful to clinicians and patients in evaluation of malignant melanoma.
During the patient’s assessment, we found that the lesion is not round and irregularly shaped, there are no clear borders and it has several notched areas, the lesion is red on half and purplish black on the other half, and the diameter measures 8 mm in size. His partner stated that it enlarged in the past couple of months but we do not have an initial measurement. Normally, benign melanomas are symmetrical, smooth with even borders, carry a monotonous color, small diameters, and remain the same size (American Cancer Society [ACS], 2016).
The subjective information stated by Mr. Jaramillo together with our objective findings, can identify as early warning signs of malignant melanoma. The most important way to lower your risk of melanoma is to protect yourself from exposure to UV rays, which Mr. Jaramillo does not (ASC, 2016). Even though, the ABCDE acronym is a commonly used assessment tool of skin lesions, it is challenging to distinguish the findings of malignant melanoma and atypical nevi because they often display the same criteria. The ugly duckling sign is an added tool that helps differentiate these findings.
This sign was introduced in 1998 and is a comparative view of all other lesions on the skin, after a full head-to-toe inspection is done. The patient may have other lesions that look the same on the skin, but if we find one that seems atypical from the others in the adjacent areas, we can consider it suspicious and refer to a dermatologist (Scope & Marghoob, 2011). After the assessment is done, it is now time for documentation. The two primary purposes for documentation are professional responsibility and accountability. Always remember to document everything.
If it wasn’t documented, it was not done. It is best to use an APIE form for documentation of the skin, hair, nails and even though it was not mentioned, discuss appearance of the patient as well. Documentation should always include date and time. I would inform the student nurse that documentation should follow like this: Mr. Jaramillo is a 41-year-old Hispanic male accompanied with his partner. He presents his self to the clinic today with complaints of a skin lesion on the back which was noted by his partner about 6 months ago, and has changed in appearance.
Mr. Jaramillo is oriented to person, place and time. He denies any itching or irritation to the site but does say oozing occurs as evidenced by fluid noted on his shirt. He denies any aggravating or relieving factors. Patient states he spends much time in the sun but does not protect against it. Upon assessment, the skin lesion is asymmetrical, uneven in border, varies in color, measures 8mm in diameter, and his partner said it has increased in size. This is unable to confirm because there was no initial measurement documented.
He does not have any comparative lesions. I suspect melanoma and suggested that the client be referred to one of our recommended dermatologist. I also requested a copy of the consult report to be sent to the office for our records. In the meantime, client was educated on preventative measures that need to be taken with the diagnosis of melanoma and demonstration will be done for acknowledgement. Patient will follow up with us after consult if necessary. After an assessment is done and documented, you should introduce a plan of care for the patient.
One nursing diagnosis that fits well with Mr. Jaramillo is deficient knowledge (skin cancer) related to lack of information about skin cancer prevention as evidenced by not using preventative measures (Ackley & Ladwig, 2012). An intervention for this would be to teach the client to protect themselves from UV exposure by using the recommended SPF sunscreen (Wheeler, 2010) and teach the client the importance of monthly skin inspection. Ask assistance from partner if needed (Loescher, Harris, Lim, & Su, 2006).
Since this patient decided to undergo surgery, another nursing diagnosis that can be included would be risk of infection related to surgical procedure as evidenced by incision site. An intervention for this would be to assess for signs and symptoms of infection, which includes redness, delayed healing, fever, pain, tenderness, warmth, or swelling, and report to the doctor if found (Ackley et al. , 2012). To make sure this client fully understands the education that I am providing, I would explain and show video/pictorial evidence of how melanoma affects patients. I would teach the client the “Slip! Slop! Slap! …and Wrap” method (ASC, 2016).
This method means to slip on a shirt, slop on the sunscreen in the recommended amounts (Wheeler, 2010), slap on a hat, and wrap on sunglasses to protect your eyes and skin around them (ASC, 2016). According to Wheeler (2010), each adult should apply ? teaspoon to the body part (teaspoon rule) including the face and neck, so I would have Mr. Jaramillo demonstrate the teaspoon rule in order test his understanding. It is also necessary for him to state the signs and symptoms of infection. This will verify that the patient will know what to observe for when assessing the incision site and report to the doctor if necessary.
Melanoma is very much preventable but assessment is the main key. If an early detection and diagnosis of melanoma can be made, we can have a greater survival rates close to 100% (ASC, 2016). Prognosis can become considerably worse if detection of the melanoma is not found until later stages of progression. For this reason, it is useful to encourage monthly accurate assessments of the skin, so if suspected early intervention can take place. Proper documentation of assessments is needed because it can improve safe patient care and provide accurate communication among clinical members so they can collaboratively treat the patient.