College of Nursing Document Code CON- CODE

EVALUATION TOOL Revision No. 1 Page

Effectivity Date January 2020

Name: ______________________________________ Date Performed: __________________

Year Level & Section: _________________________
ASSESSMENT OF THE SKIN, HAIR, AND NAILS

ASSESSMENT SKILL RATING

1. Perform hand- washing [ before the beginning of examination, to
prevent the microorganisms from spreading to one patient to another
and also to protect the nurse]]
2. Gather equipment/assemble materials needed. [to save time]
3. Explain procedure to patient.
4. Ask client to wear gown.
SKIN
1.Note for any distinctive odor emanating from the skin.
2. Inspect for generalized color variations (brownness, yellow, redness,
pallor, cyanosis, jaundice, erythema and vitiligo).
3. Check for skin integrity noting for skin breakdown by paying attention
to the pressure areas.
4. Inspect the primary, secondary, or vascular lesions. (Note: size, shape,
location, distribution and configuration)
5. Palpate lesions (glove hand palpate skin lesions between the thumb
and index finger for size, mobility, consistency and tenderness).
6. Palpate texture (rough, smooth) of skin, using palmar surface of three
middle fingers.
7. Palpate temperature (cool, warm, hot) and moisture (dry, sweaty, oily)
of skin over sternum.
8. Palpate thickness of skin with finger pads.
9. Palpate mobility and turgor by pinching up skin over sternum.
10. Palpate for edema, pressing thumb over feet of ankles.
TOTAL
SCALP AND HAIR
1.Inspect for color.
2. Inspect for amount and distribution.
3. Inspect and palpate for thickness, texture, oiliness, lesions and
parasites.
TOTAL
NAILS
1.Inspect for grooming and cleanliness.
2. Inspect for amount and markings.
3. Inspect shape.
4. Palpate texture and consistency, noting whether nail plate is attached
to nail bed.
5. Test for capillary refill (press the nail tip briefly and watch for color
change)
 College of Nursing Document Code CON- CODE
EVALUATION TOOL Revision No. 1 Page
Effectivity Date January 2020

TOTAL
Grand TOTAL

SCORE Equivalent Description Score Equivalent

66 1.0 37-39 3.25
63-65 1.25 Very 33-36 3.5 RATING SCALE:
60-62 1.5 Satisfactory 30-32 3.75
57-59 1.75 27-29 4.0 1- Not Observed
53-56 2.0 Satisfactory 24-26 4.25 2- Needs
50-52 2.25 20-23 4.5 Improvement
47-49 2.5 17-19 4.75 3- Satisfactory
43-46 2.75 Needs 16 and 5.0 4- Very Satisfactory
40-42 3.0 Improvement below
_______________________
Clinical Instructor
 College of Nursing Document Code CON- CODE
EVALUATION TOOL Revision No. 1 Page
Effectivity Date January 2020

Name: ______________________________________ Date Performed: __________________

Year Level & Section: _________________________
ASSESSMENT OF THE HEAD AND NECK

ASSESSMENT SKILL RATING

1. Perform hand- washing
2. Gather equipment/assemble materials needed (gloves, penlight, small
glass of water, stethoscope)
3. Explain procedure to patient.
HEAD AND FACE
1.Inspect head for size, shape, and configuration.
2. Palpate head for consistency while wearing gloves.
3. Inspect face symmetry, features, movement, expression and skin
condition.
4. Palpate temporal artery for tenderness and elasticity
5. Palpate temporomandibular joint range of motion, swelling,
tenderness, or crepitation by placing index finger over the front of each
and asking client to open mouth. Ask client if he/she has history of
frequent headaches.
TOTAL
NECK
1.Inspect neck while it is in slightly extended position (and using a light)
for position, symmetry and presence of lumps and masses.
2. Inspect movement of thyroid and cricoid cartilages and thyroid gland by
having the client to swallow a small sip of water.
3. Inspect the cervical vertebrae by having client flex neck.
4. Inspect neck for range of motion by having client turn chin to right and
left shoulder, touch each ear to the shoulder, touch chin to chest and lift
chin to ceiling.
5. Palpate trachea by placing your finger in the sternal notch, feeling to
each side, and palpating the tracheal rings.
6. Palpate the thyroid gland.
7. Auscultate thyroid gland for bruits if the gland is enlarged (use the bell
of stethoscope)
8. Palpate lymph nodes for size/ shape, delimitation, mobility,
consistency, and tenderness.
a. Preauricular nodes (front of ears)

b. Postauricular nodes (behind the ears)

c. Occipital nodes (posterior base of skull)

 College of Nursing Document Code CON- CODE
EVALUATION TOOL Revision No. 1 Page
Effectivity Date January 2020

d. Tonsillar nodes (angle of the mandible, on the anterior edge of the

sternocleidomastoid muscle)
e. Submandibular nodes (medial border of the mandible) do not confuse
with the lobulated submandibular gland.

f. Submental nodes (a few centimeters behind the tip of the mandible);

use one hand.

g. Superficial Cervical nodes (superficial to the sternomastoid muscle)

h. Posterior cervical nodes (posterior to the sternocleidomastoid and

anterior to the trapezius on the posterior triangle)

i. Deep cervical chain nodes (deep within and around the sternomastoid
muscle)

j. Supraclavicular nodes (hook fingers over clavicles and feel deeply

between the clavicles and the sternomastoid muscles)

TOTAL
Grand TOTAL

SCORE Equivalent Description Score Equivalent

66 1.0 37-39 3.25 RATING SCALE:
63-65 1.25 Very 33-36 3.5
60-62 1.5 Satisfactory 30-32 3.75 1- Not Observed
57-59 1.75 27-29 4.0 2- Needs
53-56 2.0 Satisfactory 24-26 4.25 Improvement
50-52 2.25 20-23 4.5 3- Satisfactory
47-49 2.5 17-19 4.75 4- Very Satisfactory
43-46 2.75 Needs 16 and 5.0
40-42 3.0 Improvement below _______________________
Clinical Instructor

Name: ______________________________________ Date Performed: __________________

Year Level & Section: _________________________
ASSESSMENT OF THE EYES

ASSESSMENT SKILL RATING

 College of Nursing Document Code CON- CODE
EVALUATION TOOL Revision No. 1 Page
Effectivity Date January 2020

1. Perform hand- washing

2. Gather equipment/assemble materials needed (Snellen’s chart,
Rosenbaum card, eye occlude, penlight, Ishihara test plate,
ophthalmoscope, and penlight)
3. Explain procedure to patient.
4. Ask the client to wear gown.
Vision Test
1.Assess the distant visual acuity (Snellen’s chart at a distance of 20 feet,
with and without corrective lenses; one eye at a time.)
2. Assess the visual acuity (with Rosenbaum card at a distance of 14
inches from the eye, one eye at a time)
3. Perform color vision test (with Ishihara test plate, one eye at a time)
4. Test visual fields for gross peripheral vision by performing the
confrontation test.
 Position the client two feet away from the nurse at eye level. The
client covers the left eye while the nurse covers her right eye, then
look directly with each other with their uncovered eyes. Slowly
move one finger upward from below of inferiorly, then superior,
temporal, nasal direction. Repeat the test to the other eye.

TOTAL
Extra- ocular Muscle Function Test
1.Assess corneal light reflex (using a penlight to observe parallel
alignment of light reflection on corneas)
2. Perform the cover- uncover test (using a card to cover one eye at a
time to observe eye movement)
3. Perform position test.
 Hold an object 12 inches from the client’s face. Move the object
through the six cardinal positions of gaze observing eye
movement)
TOTAL
External Eye Structure
1.Inspect eyelids, lashes.
2. Inspect position of eyeballs.
3. Inspect bulbar conjunctiva and sclera.
4. Inspect the palpebral conjunctiva.
5. Inspect the lacrimal apparatus over the lacrimal glands.
6. Inspect the iris pupilk for shape and color; size and shape of the pupil.
7. Inspect the cornea and lens.
8. Palpate the lacrimal apparatus over the lacrimal glands and the puncta.
9. Test the pupillary reaction to light.
 Darken the room. Shine a light obliquely to the pupil then observe
the pupils reaction to the light.
10. Test accommodation of pupils by shifting gaze from far to near.
 College of Nursing Document Code CON- CODE
EVALUATION TOOL Revision No. 1 Page
Effectivity Date January 2020

TOTAL
Internal Eye structure
1.Inspect the red reflex by using an ophthalmoscope (shine the light beam
towards the client’s pupil).
2. Inspect the optic disc by using ophthalmoscope.
3. Inspect the retinal vessels, retinal background for color and presence of
lesions by using ophthalmoscope.
4. Inspect the fovea and macula for lesions by using ophthalmoscope.
5. Inspect anterior chamber for transparency using ophthalmoscope.
TOTAL
Grand TOTAL

RATING SCALE:

1- Not Observed
2- Needs
Improvement
3- Satisfactory
SCORE Equivalent Description Score Equivalent 4- Very Satisfactory
66 1.0 37-39 3.25
63-65 1.25 Very 33-36 3.5 _______________________
60-62 1.5 Satisfactory 30-32 3.75 Clinical Instructor
57-59 1.75 27-29 4.0
53-56 2.0 Satisfactory 24-26 4.25
50-52 2.25 20-23 4.5
47-49 2.5 17-19 4.75
43-46 2.75 Needs 16 and 5.0
40-42 3.0 Improvement below