To check the skin turgor nurse should do?

Appeared in: AIIMS Rishikesh & Jodhpur NO - 2017

Explanation

Skin turgor assessment measures the skin's elasticity, which reflects the body's hydration status.
The standard technique involves gently grasping or pinching a fold of skin with the fingertips, lifting it, and then releasing it.
The nurse then observes the speed at which the skin returns to its normal position. This action directly tests the elastic properties of the skin.

Option B: Pressing the skin is the technique used to assess for pitting edema, where an indentation remains after pressure is applied, indicating fluid excess.
Option C: Palpation is a general assessment term for using touch. It is not specific enough to describe the procedure for testing skin turgor.
Option D: Inspection is the process of visual observation. While the nurse visually observes the skin's return after pinching, inspection alone does not test the skin's elasticity.

Clinical Relevance

Nursing practice connection: Knowing Assessment of Skin Turgor helps nurses interpret findings accurately and avoid errors in routine assessment, medication administration, and patient teaching.
Assessing skin turgor is a quick, non-invasive method to screen for dehydration, a common and potentially serious condition.
It is particularly important in vulnerable populations such as infants, children, and older adults, who are at higher risk for fluid imbalances.
A finding of poor skin turgor (tenting) should prompt the nurse to perform a more thorough hydration assessment, including checking mucous membranes, urine output, and vital signs, and to report the findings.

How to Approach the Question

First, identify the key term in the question: 'skin turgor'.
Recall the definition of skin turgor, which is the skin's elasticity and its relation to hydration.
Consider the physical action required to test elasticity. You need to displace the skin and see if it returns to its original state.
Evaluate the given options: 'Pinching' directly displaces the skin to test its recoil. 'Pressing' is for edema. 'Palpating' is too general. 'Inspecting' is only visual.
Conclude that pinching the skin is the specific and correct procedure for assessing turgor.

Concept Tested & Keywords

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E6 Nursing Fundamentals Potter Perry 12e Part 3 p. 72-74

E6 Nursing Fundamentals Taylor p. 386-388

Practise the full AIIMS Rishikesh & Jodhpur NO - 2017

Attempt every question from this paper in a timed mock, then review the full solution for each one.