NOTRE DAME OF TACURONG COLLEGE

COLLEGE OF NURSING
Lapu-Lapu Street, Tacurong City, Sultan Kudarat, Philippines
Telephone No.: (064) 200-3631 Fax No.: (064) – 200-4131

ASSESSMENT OF THE HEAD, FACE AND NECK, EYES AND EARS

Student Name: _______________________________Year Level: __________

Inclusive Date: _____________________

Direction: In using the checklist, please use the following rating scale in evaluating the
performance of the student.

5 Excellent
Student performs the procedure correctly, and perfectly.
Student states the rationale correctly and completely.
Student is able to answer questions accurately.
4 Very Satisfactory
Student performs the procedure correctly.
Student states the rationale correctly but incompletely.
Student is able to answer questions.
3 Satisfactory
Student performs the procedure correctly but failed to states
the rationale.
Student is able to answer questions when cued.
2 Fair
Student performs the procedure when cued.
Student fail to states the rationale.
Student is able to answer questions when cued.
1 Poor
Student fails to perform the procedure correctly even when
cued. Student does not know the rationale.

Note: An average score of 2.4 and below will require student to repeat the RD.
 PROCEDURE
1. Assemble all equipment needed for the examination of
the integumentary system. 1 2 3 4 5
2. Properly position the patient for the examination. 1 2 3 4 5
3. Perform the assessment in a systematic manner. 1 2 3 4 5
4. Perform the assessment in an organized and timely 1 2 3 4 5
fashion
5. Provide the patient with explanations throughout the
assessment 1 2 3 4 5
ASSESSMENT PROCESS
Health History
This involves identifying symptoms and risk factors
associated with integumentary disorders. Students should
use appropriate communication and interviewing skills
during the interview process.
Discuss the different Integumentary Symptoms
a. Changes in moles or other lesions 1 2 3 4 5
b. Nonhealing sore or chronic ulceration 1 2 3 4 5
c. Pruritus/itching 1 2 3 4 5
d. Rashes 1 2 3 4 5
e. Hair changes 1 2 3 4 5
f. Nail changes 1 2 3 4 5
Past Health History 1 2 3 4 5
a. Childhood illnesses
b. Hospitalizations 1 2 3 4 5
c. Surgeries 1 2 3 4 5
d. Serious injuries/chronic illnesses 1 2 3 4 5
e. Immunizations 1 2 3 4 5
f. Allergies (food, drug, environmental) 1 2 3 4 5
g. Medications (prescribed and OTC) 1 2 3 4 5
h. Recent travel 1 2 3 4 5
Assess Family History 1 2 3 4 5
Review of Systems 1 2 3 4 5
a. General health status
b. HEENT 1 2 3 4 5
c. Respiratory 1 2 3 4 5
d. Cardiovascular 1 2 3 4 5
e. Gastrointestinal 1 2 3 4 5
f. Genitourinary 1 2 3 4 5
g. Musculoskeletal 1 2 3 4 5
h. Neurological 1 2 3 4 5
i. Endocrine 1 2 3 4 5
j. Lymphatic/hematologic 1 2 3 4 5
Psychosocial Profile
 a. Health practices and beliefs/self-care activities 1 2 3 4 5
b. Typical day 1 2 3 4 5
c. Nutritional pattern (24-hour recall) 1 2 3 4 5
d. Activity/exercise patterns 1 2 3 4 5
e. Recreation, pets, hobbies 1 2 3 4 5
f. Sleep/rest patterns 1 2 3 4 5
g. Personal habits(tobacco, alcohol, caffeine, drugs) 1 2 3 4 5
Physical Assessment
This involves the application of knowledge
and skill. Besides demonstrating assessment skills,
students should show knowledge of normal anatomy and
physiology. 1 2 3 4 5
This allows them to identify integumentary system
landmarks and differentiate normal from abnormal findings,
considering
developmental and cultural variations.
General Survey: Vital signs, height, weight
Head-to-toe scan as related to other systems
a. HEENT
b. Respiratory
c. Cardiovascular
d. Abdomen 1 2 3 4 5
e. Genitourinary
f. Musculoskeletal
g. Neurological
h. Lymphatic/hematological
FOCUSED ASSESSMENT
Skin:
a. Color 1 2 3 4 5
b. Odor 1 2 3 4 5
c. Integrity 1 2 3 4 5
d. Vascular lesions 1 2 3 4 5
Describe:
a. Morphology 1 2 3 4 5
b. Distribution 1 2 3 4 5
c. Pattern and configuration 1 2 3 4 5
d. Location of lesions 1 2 3 4 5
Hair:
a. Color 1 2 3 4 5
b. Quantity 1 2 3 4 5
c. Distribution of hair 1 2 3 4 5
d. Condition of scalp 1 2 3 4 5
e. Presence of lesions 1 2 3 4 5
Nails:
a. Color 1 2 3 4 5
 b. Condition 1 2 3 4 5
c. Angle of attachment 1 2 3 4 5
d. Presence of focal or generalized abnormalities 1 2 3 4 5
Palpation
Skin:
a. Temperature 1 2 3 4 5
b. Texture 1 2 3 4 5
c. Turgor 1 2 3 4 5
d. Hydration 1 2 3 4 5
e. Surface characteristics and tenderness of lesions 1 2 3 4 5
f. Pulsations and blanching of vascular lesions 1 2 3 4 5
Hair: 1 2 3 4 5
a. Texture
b. Scalp tenderness, masses, and mobility 1 2 3 4 5
DOCUMENTATION 1 2 3 4 5
a. This entails written communication skills.
Critical thinking is reflected in student’s ability to cluster 1 2 3 4 5
the data, formulate nursing diagnoses, and plan
therapeutic nursing interventions.
b. Accurately and succinctly document subjective 1 2 3 4 5
findings from the health history.
c. Accurately and succinctly document objective 1 2 3 4 5
findings from the physical examination
d. Formulate actual and potential nursing diagnoses 1 2 3 4 5
with supporting data

Total Points: ______________

Average: ______________
RD Grade: _____________

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Signature over Printed Name (Faculty)
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Signature over Printed Name (Student)
 NOTRE DAME OF TACURONG COLLEGE
COLLEGE OF NURSING
Lapu-Lapu Street, Tacurong City, Sultan Kudarat, Philippines
Telephone No.: (064) 200-3631 Fax No.: (064) – 200-4131

Return Demonstration Additional Questions

Skin
Question
What is a primary lesion?
What is skin turgor?
What is an unexposed area?
What is tenting?
What is the epidermis?
What is vitamin D?
What is the stratum basale?
What is the eccrine gland?
What is vitiligo?
Hair
What is alopecia?
What is hirsutism?
What is alopecia areata?
What are head lice (pediculosis)?
What is tinea capitis?
What is vellus?
What is less than 3 seconds?
What is 160 degrees?
What is clubbing?
Answer
An initial change in the skin
Evaluates skin elasticity
The best area to assess skin turgor
Reflects dehydration
The outer, protective layer of the skin
The vitamin from the sun that is
synthesized by the skin
The layer of skin that contains melanin
and is the site for basal cell carcinoma
The gland that responds to external
temperature and stress by secreting
sweat
A patchy loss of skin pigmentation
Loss of hair
Increased growth of facial hair in
women
Patchy hair loss associated with stress
Common infestation among school-age
children
A fungal infection of the scalp
Fine body hair
Normal capillary refill time
Normal angle of nail attachment
Angle of nail attachment greater than
180 degrees