Must-Knows for Nursing Process and Basic Health Assessment

Week 4-5
System
Integumentary
system

Head and neck

Note

Concepts
Definition, equipment special considerations, assessing dark-skinned
individuals, rationale for ( identification of client, explaining the
procedure, providing privacy, hand hygiene, documentation, etc.)
Variations: cyanosis, pallor, jaundice, erythema, lesions etc.
Palpating for body temperature, texture and moisture
Assessing for skin turgor
Edema, palpating for edema and its gradings
Pitting and dependent edema
Normal and abnormal nail angle ( clubbing)
Normal capillary refill time.
Definition
Equipment
Special considerations such as otoscopic exam for a young child and
an adult.
Application of IPPA
PERRLA, checking for eye response to light accommodation, and
convergence.
Checking the red reflex
Testing for visual acuity using a snellen chart.
Interpretation of snellen chart readings (20/40)
Evaluation of functions of the six extraocular eye muscle.
Whispered voice test
Webers test and Rinnes test.
Checking patency of nostrils.
Cervical lymph nodes
Include other concepts as necessary.