SKIN inspection
Color:
N-evenly colored skin tones without unusual
or prominent discoloration
A-pallor- pale-ashen, cyanosis-blue tinged or
mottled, jaundice-yellow pale-pumpkin.
Color variation:
N-freckles, moles, suntanned areas
A-rashes-red or dark, albinism-general loss of
pigmentation
Integrity​:
N-skin intact and no reddened areas
A-skin breakdown evident –reddened
area-pressure ulcer
Lesions:
N-smooth without lesions, scattered moles
and freckles, birthmarks
A-primary, secondary or vascular lesions,
note distribution: diffuse or localised and
Configuration:
discrete, grouped, confluent, linear, annular,
zosteriform.
SCALP/HAIR inspection
Color and condition:
N-natural vs chemical color e.g. pale blond to
black, smooth and firm, sparse dandruff
visible,
course, short, long or medium length, style
Amount and distribution:
N-fine hair covers entire body except soles,
palms, lips and nipples, balding is
symmetricA-excessive generalised hair loss,
patchy hair loss
Lesions and infestations:
SCALP/HAIR palpation
Tenderness:
N-nil tenderness
A: tenderness noted
Hair texture:
N-smooth and firm
A-dull, dry, excessive scaly
NAIL palpation
Texture and consistency:
N-hard and immobile, nail plate attached to
nail bed
A-thickened nails, yellow, brittle
Capillary Refill:
N-pink tone returns immediately to blanched
nail beds when pressure is released i.e. cap
refill<2secs
A-slow >2secs capillary nail bed refill
HEAD/ FACE inspection
Symmetry, expression:
N-face is symmetric with a round, elongated
or square appearance, erect and in midline
A-asymmetry, acorn shaped, enlarged,
drooping of left/right side of face-one sided
facial paralysis
Movement, lesions, oedema:
N- no abnormal movements noted, held still
and upright, nil lesions noted, nil oedema
A -oro-facial movements noted, tremors
noted, lesions noted, and oedema
present-localise
NECK inspection
Symmetry, position, lesions:
N-Neck is symmetric with head cantered and
without bulging masses
A-Swelling, enlarged masses, nodules noted
N-hard and smooth without lesions or Movement of neck:
infestations N-thyroid cartilage, cricoid cartilage and
A-lesions or lumps/ infestations noted thyroid gland move upward symmetrically as
the client
NAIL inspection swallows
Color and markings: A-Asymmetric movement or generalised
N-pink tones noted, no markings enlargement of the thyroid gland
A-pale or cyanotic nails, Beau's lines, yellow
discoloration ROM​:
N- neck movement smooth and controlled, 45
Cleanliness: degree flexion, 55 degree extension, 40
N-nails clean and manicured degree lateral
A-nails dirty, broken and jagged abduction and 70 degree rotation,
A-stiffness, rigidity and limited mobility of
Shape​: the neck
N-convex in shape, 160 degree angle between
nail base and skin AXILLAE inspection
A-early clubbing noted, late clubbing noted, Rash​:
spoon nails N-no rash or infection noted
A-redness, inflammation, dark, velvety
SKIN palpation pigmentation of the axillae
Texture:
N-skin is smooth and even Lesions:
A-skin is rough,flaky,dry N-nil lesions noted
A-lesions present
Moisture:
N-skin moist to dry FACE palpation
A-diaphoresis in fever, clammy, reduced Temporomandibular joint:
moisture or dry in dehydration N-no swelling, tenderness with movement,
mouth opens and closes fully, lower jaw
Mobility and Turgor: moves laterally 1-
N-skin pinches easily and returns to original 2cm in each direction
position immediately A-limited ROM, swelling,tenderness
A-decreased turgor in dehydration or
decreased mobility seen in oedema NECK palpation
Trachea:
Oedema: N-trachea is midline
N-skin rebounds, nil oedema A-trachea pulled to one side
A- slight to great indentations on skin noted
on palpation ROM​:
as in inspection