Marquez, Marice Abigail J.

BSN 1-A
April 15, 2016
7:00 am-11:00am
Nursing Skills Laboratory
Ms. Floribel San Luis
ASSIGNMENT:

Assessment
Skin Examination
Inspect skin color
(best assessed
under natural
light and on areas
not exposed to
the sun).
Inspect uniformity
of skin color.

Assess edema, if
present (i.e.,
location, color,
temperature,
shape, and the
degree to which
the skin remains
indented or pitted
when pressed by
a finger).
Inspect, palpate,
and describe skin
lesions.

Normal

Abnormal

Varies from light to

deep brown; from
ruddy pink to light
pink; from yellow
overtones to olive

Pallor, cyanosis,
jaundice, erythema

Inspect uniformity of
skin color. Generally
uniform except in
areas exposed to the
sun; areas of lighter
pigmentation (palms,
lips, nail beds) in darkskinned people

Areas of either
hyperpigmentation or
hypopigmentation

No edema

Presence of Edema (See

scale of Edema)

Freckles, some
birthmarks that have
not changed since
childhood, and some
longstanding vascular
birthmarks such as
strawberry or portwine hemangiomas,
some flat and raised
nevi; no abrasions or
other lesions.

Various interruptions in
skin integrity; irregular,
multicolored, or raised
nevi, some pigmented
birthmarks such as
melanocystic nevi, and
some vascular
birthmarks such as
cavernous
hemangiomas. Even
these deviations from

Observe and
palpate skin
moisture.

Palpate skin
temperature.
Compare the two
feet and the two
hands, using the
backs of your
fingers.

Note skin turgor

(fullness or
elasticity)

Hair Examination
Inspect the
evenness of
growth over the
scalp.
Inspect hair
(thickness or
thinness).
Inspect hair
(texture and
oiliness).

Note presence of
infections or
infestations by
parting the hair in
several areas,
checking behind

Moisture in skin folds

and the axillae (varies
with environmental
temperature and
humidity, body
temperature, and
activity)
Uniform; within normal
range

normal may not be

dangerous or require
treatment. Assessment
by an advanced-level
practitioner is required.
Excessive moisture
(e.g., in hyperthermia);
excessive dryness (e.g.,
in dehydration)

Generalized
hyperthermia (e.g., in
fever); generalized
hypothermia (e.g., in
shock); localized
hyperthermia (e.g., in
infection); localized
hypothermia (e.g., in
arteriosclerosis
When pinched, skin
Skin stays pinched or
springs back to
tented or moves back
previous state (is
slowly (e.g., in
elastic); may be slower dehydration). Count in
in older adults.
seconds how long the
skin remains tented.
Evenly distributed hair.

Patches of hair loss (i.e.,

alopecia)

Thick hair

Very thin hair (e.g., in

hypothyroidism)

Silky, resilient hair

Brittle hair (e.g.,

hypothyroidism);
excessively oily or dry
hair
Flaking, sores, lice, nits
(lice eggs), and
ringworm

No infection or
infestation

the ears and

along the hairline
at the neck.
Inspect amount of
body hair.

Nails Examination
Inspect fingernail
plate shape to
determine its
curvature and
angle.
Inspect fingernail
and toenail
texture.

Inspect fingernail
and toenail bed
color.

Inspect tissues
surrounding nails.
Perform blanch
test of capillary
refill. Press the
nails between
your thumb and
index finger; look
for blanching and
return of pink
color to nail bed.
Perform on at
least one nail on
each hand and
foot.
Assessing the
Nose

Variable

Hirsutism (abnormal
hairiness) in women;
naturally absent or
sparse leg hair (poor
circulation)

Convex curvature;
angle of nail plate
about 160

Spoon nail: clubbing

(180 or greater)

Smooth texture

Excessive thickness or
thinness or presence of
grooves or furrows;
Beaus lines; discolored
or detached nail
Bluish or purplish tint
(may reflect cyanosis);
pallor (may reflect poor
arterial circulation.

Inspect fingernail and

toenail bed color.
Highly vascular and
pink in light-skinned
clients; dark-skinned
clients may have
brown or black
pigmentation in
longitudinal streaks
Intact epidermis
Prompt return of pink
or usual color
(generally less than 2
seconds)

Hangnails; paronychia
(inflammation)
Delayed return of pink
or usual color (may
indicate circulatory
impairment)

Inspect the
external nose for
any deviations in
shape, size, or
color and flaring
or discharge from
the nares.
Lightly palpate
the external nose
to determine any
areas of
tenderness,
masses, and
displacements of
bone and
cartilage.
Determine
patency of both
nasal cavities.

Observe for the

presence of
redness, swelling,
growths, and
discharge.
Inspect the nasal
septum between
the nasal
chambers.
Assessing the
Mouth and Throat
Lips

Teeth

Symmetric and
straight
No discharge or flaring
Uniform color

Asymmetric
Discharge from nares
Localized areas of
redness or presence of
skin lesions

Not tender; no lesions

Tenderness on
palpation; presence of
lesions

Air moves freely as the

client breathes
through the nares

Air movement is
restricted in one or both
nares

Mucosa pink
Clear, watery
discharge
No lesions

Mucosa red, edematous

Abnormal discharge
(e.g., pus)
Presence of lesions
(e.g., polyps)
Septum deviated to the
right or to the left

Nasal septum intact

and in midline

The lips should be

symmetrical, pink,
smooth, and moist.
There should be no
growths, lumps, or
discoloration of the
tissue.
The patient's teeth
should be clean with
no decay, appear
white and shiny
enamel with smooth
surfaces and edges.
Adults should have a

If the lips are

asymmetrical, cyanotic,
cherry red, pale, or dry.

Missing teeth, loose or

broken teeth and
misaligned teeth

 Gums

Buccal Mucosa

Hard Palate

Soft Palate/Uvula

Tongue

total of 32 teeth with

16 teeth in each arch.
Children by the age of
2 1/2 have a total of
20 deciduous teeth
with 10 in each arch.
The gums should
appear symmetrical,
moist, pink/coral with
tight well defined
margins.
Tissues are inspected
by shining a penlight
on the inside surface
of the cheek. Healthy
tissue appears to be
moist, smooth,
glistening and pink.
Healthy palates
appearing whitish in
color with a firm
texture and irregular
transverse rugae.
Should be light pink,
smooth and upwardly
movable, if healthy.

Include swelling,
cyanotic, pale, dry,
spongy texture,
bleeding, or discolored
gums.
If the buccal mucosa is
dry, cyanotic, or pale.

Includes the palate

looking yellow or
showing extreme pallor.

Includes the uvula

deviates from the
midline, asymmetrical
rise of the soft palate
and/or uvula and
reddening of the soft
palate and/or uvula.
A healthy dorsal side
Includes markedly
of the tongue is a
reddened, cyanotic or
symmetrical protrusion extreme pallor
of the tongue, with a
healthy tongue being
pink, moist, with a
slightly rough surface
from the papillae,
possibly with a thin,
whitish coating on the
tongue.