Saint Paul University Philippines

Tuguegarao City, Cagayan 3500

School of Nursing and Allied Health Sciences

College of Nursing

HEAD-TO-TO PHYSICAL ASSESSMENT

STUDENT’S COPY

ASSESSMENT OF THE SKIN, HAIR AND NAILS

A. Learning Objectives
Students will:
 Evaluate the client’s current physical condition
 Detect early signs of developing health problems
 Establish a baseline for future comparison
 Evaluate the client’s responses to medical or nursing interventions

B. Equipment/Supplies
 examination light
 penlight
 mirror (self-assessment of skin)
 magnifying glass
 centimeter ruler
 gloves
 woods light/UV light
 Examination gown or drape

C. Procedure

Evidence to be produced Rationale

1. Introduce self to patient To establish rapport, and gain trust of patient.
2. Identify the client using the 2 identifiers. Ensures correct patient to be examined.
3. Explain the procedure. Discuss what it is, why it is Enhances comfort and cooperation.
necessary and how can s/he cooperate.
4. Gather supplies/equipment necessary for the Facilitate convenience in performing the examination.
procedure.
5. Provide comfortable examination area. Well-lighted Promotes comfort.
and at room temperature.
6. Observe infection control measures - hand washing, Prevents/Limits transmission of microorganisms.
hand hygiene. Wear clean gloves as necessary.
7. Provide client privacy. Promotes comfort and respect.
8. Prepare the client for examination. Facilitate convenience in performing the examination.
a. Assess for toileting needs.
b. Ask patient to wear examination gown/drape.
c. Ask patient to remove nail enamel, artificial
nails, wigs, toupees, or hair pieces as
appropriate.
d. Place the patient in sitting or lying position.
Position may vary depending on the site and
area of examination
General Skin Condition
9. Inspect the patient’s exposed skin surfaces for To detect unusual skin condition that may indicate
color, integrity, hair distribution, scars, wounds, etc... medical problems.
10. Assess the skin for warmth and moisture with the To detect changes in body temperature and skin
dorsum of the dominant hand. moisture.
Hair
11. Inspect the patient’s hair for color, moisture and To detect unusual hair condition that may indicate
texture. medical problems.
12. Note for any hair loss, presence and absence of
nits, lice and dandruff.
Skin Turgor
13. Explain the procedure. Enhances comfort and cooperation.
14. Expose the area to be assessed (anterior chest or Promotes comfort and ensures privacy.
arm).
15. Lift and pinch the skin for 2 seconds. To assess skin turgor.
16. Observe the skin’s response.
Nails
17. Explain the procedure. Enhances comfort and cooperation.
18. Inspect nail grooming, cleanliness, color, To detect unusual nail condition that may indicate
markings and shape medical problems.
19. Palpate nail texture
Test for Capillary Refill
20. Explain the procedure. Enhances comfort and cooperation.
21. Depress the nail edge to blanch and release To detect adequacy of circulation.
22. Note the change in color of the nails. To detect unusual nail color that may indicate medical
problems.
Presence of Edema (on the feet)
23. Explain the procedure. Enhances comfort and cooperation.
24. Expose the feet. To detect presence of edema that may indicate
medical problems related to the heart, kidneys, etc.
25. Depress the ankle malleolus, tibia or other bony
prominence's with 2 finger pads.
26. Repeat procedure on the other foot.
Thank patient.
Ensure patient’s safety and comfort. Provide safety and comfort after the procedure.
Remove gloves (as necessary). Prevents transmission of microorganisms.
Perform medical asepsis. Cleanses soiled hands and prevents transmission of
microorganisms.
Document over-all finding, report for any unusual Record purposes and retrieval of data in the
findings. management of care.

References:

Jarvis, Carolyn. (2004). Pocket Companion for Physical Examination and Health Assessment. 4th Ed. St.
Louis, Missouri, Saunders

Weber, J. et al. (2014). Health Assessment in Nursing. 5th. Ed. Philadelphia, Lippincott