WHAT IS HEALTH ASSESSMENT?
Transmission-based precautions
A health assessment is a plan of care that identifies the
specific needs of a person and how those needs will be
addressed by the healthcare system or skilled nursing
facility.
Health assessment is the evaluation of the health status
by performing a physical exam after taking a health
history.
1. Screening of general well-being. The findings will
serve as baseline information for future assessments.
2. Validation of the complaints that brought the patient
to seek health care.
3. Monitoring of current health problems.
4. Formulation of diagnoses and treatments.
5. Assessment uses both subjective and objective data.
✓ Subjective assessment factors are those that are
reported by the patient.
✓ Objective assessment data includes that which is
observable and measurable.
All assessments should consider the patient's privacy
and foster open, honest patient communications!!
Standard Precautions and Transmission-Based
Precautions
Standard precautions, formerly known as universal
precautions, were developed by the Centers for
Disease Control and Prevention (CDC) to protect
health care professionals and patients. The primary
goal of standard precautions is to prevent the exchange
of blood and body fluids. Standard precautions should
be practiced with every patient throughout the entire
encounter.
Always follow these standard precautions
1. Perform hand hygiene before and after every patient
contact.
2. Use personal protective equipment when risk of
body fluid exposure.
3. Use and dispose of sharps safely.
4. Perform routine environmental cleaning.
5. Clean and reprocess shared patient equipment.
6. Follow respiratory hygiene and cough etiquette.
7. Use aseptic technique.
8. Handle and dispose of waste and used linen safely.
These precautions are to be used in conjunction with
standard precautions.
a. Contact transmission - such as in impetigo, scabies,
and varicella zoster virus, are spread directly from person
to person. They can also be spread indirectly from a
contaminated inanimate object to a person.
Everyone must: Clean their hands, including before
entering and when leaving the room.
Providers and staff must also:
 Put on gloves before room entry. Discard
gloves before room exit.
 Put on gown before room entry. Discard gown
before room exit.
Do not wear the same gown and gloves for the care of
more than one person.
 Use dedicated or disposable equipment. Clean and
disinfect reusable equipment before use on another
person.
b. Droplet transmission occurs when microorganisms are
deposited on susceptible body parts via sneezing and
coughing. Suctioning a patient can also transmit
dropletsPertussis and Haemophilus influenzae are
examples of this mode of transmission.
Everyone must:
 Clean their hands, including before entering and
when leaving the room.
 Make sure their eyes, nose, and mouth are fully
covered before room entry.
 Remove face protection before room exit.
b. Airborne transmission spreads microorganisms by air
currents and inhalation. They can also be passed through
ventilation systems. Measles and the varicella virus can
spread in this mode.
Everyone must:
 Clean their hands, including before entering and
when leaving the room.
 Put on a fit-tested N95 or higher level respirator
before room entry.
 Remove respirator after exiting the room and closing
the door.
 Door to room must remain closed.
 ASSESSMENT TECHNIQUES

Inspection - use of one's senses of vision and smell to

consciously observe the patient.

Visual Inspection - Use of sight can reveal many facts

about a patient. The process of visual inspection
necessitates full exposure of the body part being
inspected, adequate overhead lighting, and, when
necessary, tangential lighting (light that is shone at an
angle on the patient to accentuate shadows and
highlight subtle findings).

Smell- olfactory sense provides vital information about

a patient's health status. The patient may have a fruity
breath odor characteristic of diabetic ketoacidosis. The
classic odor that is emitted by a Pseudomonas infection
is another well-recognized smell to the experienced
nurse.

Palpation, which is the act of touching a patient in a

therapeutic manner to elicit specific information

Your hands are the tools used to perform the

palpation process. Different sections of the hands are
best used for assessing certain areas of the body. The
dorsum of the hand is most sensitive to temperature
changes in the body. Thus, it is more accurate to place
the dorsum of the hand on a patient's forehead to
assess the body temperature than it is to use the
palmar surface of the hand. The palmar surface of the
fingers at the metacarpophalangeal joints, the ball of
the hand, and the ulnar surface of the hand best
discriminate vibrations, such as a cardiac thrill and
fremitus. The finger pads are the portion of the hand
used most frequently in palpation. The finger pads are
useful in assessing fine tactile discrimination, skin
moisture, and texture; the presence of masses,
pulsations, edema, and crepitation; and the shape,
position, mobility, and consistency of organs.
Light palpation is superficial, delicate, and gentle. In light
palpation, the finger pads are used to gain information on
the patient's skin surface to a depth of approximately 1
centimeter (cm) below the surface. Light palpation
reveals information on skin texture and moisture; overt,
large, or superficial masses; and fluid, muscle guarding,
and superficial tenderness. To perform light palpation:
1. Keeping the fingers of your dominant hand together,
place the finger pads lightly on the skin over the area that
is to be palpated. The hand and forearm will be on a
plane parallel to the area being assessed.

2. Depress the skin 1 cm in light, gentle, circular motions.

3. Keeping the finger pads on the skin, let the depressed

body surface rebound to its natural position.

4. If the patient is ticklish, lift the hand off the skin before
moving it to another area.

5. Using a systematic approach, move the fingers to an

adjacent area and repeat the process.

6. Continue to move the finger pads until the entire area

being examined has been palpated.

7. If the patient has complained of tenderness in any area,

palpate this area last.
Deep palpation can reveal information about the
position of organs and masses, as well as their size,
shape, mobility, consistency, and areas of discomfort. Sound: DULLNESS
Deep palpation uses the hands to explore the body's Intensity: Moderate
internal structures to a depth of 4 to 5 cm or more. This Duration: Moderate
technique is most often used for the abdominal and Pitch: High
male and female reproductive assessments. Quality: Thud
Normal Location: Organs (liver)
Percussion is the technique of striking one object Abnormal Location: Lungs (atelectasis)
against another to cause vibrations that produce sound. Density:dense
The density of underlying structures produces
characteristic sounds. These sounds are diagnostic of Sound: RESONANCE
normal and abnormal findings. The presence of air, Intensity: Loud
fluid, and solids can be confirmed, as can organ size, Duration: Moderate-long
shape, and position. Any part of the body can be Pitch: Low
percussed, but only limited information can be Quality: Hollow
obtained in specific areas such as the heart. The thorax Normal Location: Normal lungs
and abdomen are the most frequently percussed Abnormal Location: No abnormal location
locations. Density:dense

Intensity refers to the relative loudness or softness of Sound: HYPERRESONANCE

the sound. It is also called the amplitude. Duration of Intensity: Very loud
percussed sound describes the time period over which Duration: Long
a sound is heard when elicited. Frequency describes Pitch: Very low
the concept of pitch. Frequency is caused by the Quality: Boom
sound's vibrations, or the highness or lowness of a Normal Location: No normal location in adults; normal
sound. lungs in children
Abnormal Location: Lungs (emphysema)
The process of percussion can produce five distinct Density:Low dense
sounds in the body: flatness, dullness, resonance,
hyperresonance, and tympany. Specific parts of the Sound: TYMPANY
body elicit distinct percussable sounds. Therefore, Intensity: Loud
when an unexpected sound is heard in a particular part Duration: Long
of the body, the cause must be further investigated. Pitch: High
Quality: Drum
Sound waves are better conducted through a solid Normal Location: Gastric air bubble
medium than through an air-filled medium because of Abnormal Location: Lungs (large pneumothorax)
the increased concentration of molecules. The basic Density:Least dense
premises underlying the sounds that are percussed are:

1. The more solid a structure, the higher its pitch, the
softer its intensity, and the shorter its duration.
2. The more air-filled a structure, the lower its pitch,
the louder its intensity, and the longer its duration.
CHARACTERISTICS OF PERCUSSION SOUNDS
Sound: FLATNESS
Intensity: Soft
Duration: Short
Pitch: High
Quality: Flat
Normal Location: Muscle (thigh) or bone
Abnormal Location: Lungs (severe pneumonia)
Density: Most dense
Auscultation is the act of active listening to body organs
to gather information on a patient’s clinical status.
Auscultation includes listening to sounds that are
voluntarily and involuntarily produced by the body. A
quiet environment is necessary for auscultation.
Auscultated sounds should be analyzed in relation to
their relative intensity,pitch, duration, quality, and
location.
Direct Auscultation
 Direct or immediate auscultation is the process of
listening with the unaided ear. This can include
listening to the patient from some distance away or
placing the ear directly on the patient's skin surface
Indirect or mediate auscultation  Scale (You may need to walk the patient to a central
location if a scale cannot be brought to the patient's
 Describes the process of listening with some room.)
amplification or mechanical device. The nurse  Thermometer
most often performs mediate auscultation with an  Sphygmomanometer
acoustic stethoscope, which does not amplify the  Gooseneck lamp
bodysounds, but instead blocks out environmental  Tongue depressor
sounds. Amplification of body sounds can also be  Stethoscope
achieved with the use of a Doppler ultrasonic  Otoscope
stethoscope.  Nasal speculum
 Ophthalmoscope
STETOSCOPE  Transilluminator
 Visual acuity charts
Parts:  Tuning fork
 Reflex hammer
 Sterile needle
 Cotton balls
 Odors for cranial nerve assessment (coffee, lemon,
flowers, etc.)
 Small objects for neurological assessment (paper clip,
key, cotton ball, pen, etc.)
 Lubricant
 Various sizes of vaginal speculums
 Cervical brush
 Cotton-tip applicator
Diaphragm  Cervical spatula
(High Pitched Sounds)  Slide and fixative
For example: S1 ans S2 Aortic Regurgitation, Mitral  Guaiac material
Regurgitation, Pericardial friction rubs etc.  Specimen cup
 Goniometer
Use of Diaphragm
 The stethoscope can be firmly placed on your HEALTH ASSESSMENT
listening surface.
 Pitch is not affected by the pressure on the Physical Health Assessment
diaphragm.
1. Assessing Appearance and Mental Status
Bell
(Medium Low Pitched Sounds) 2. Assessing the Skin
For example: S3 and S4 Mitral Stenosis
3. Assessing the Hair
Proper use of the Bell
 Placed lightly on auscultation surface 4. Assessing the Nails
 Only enough pressure to produce an air seal
 Pressing the bell firmly makes it function like a 5. Assessing the Skull and Face
diaphragm
 Doing so, may make low pitched sounds disappear 6. Assessing the Eye Structure and Visual Acuity

EQUIPMENT 7. Assessing the Ears and Hearing

The physical assessment will proceed in an
efficient manner if you have gathered all of the 8. Assessing the Nose and Sinuses
necessary equipment beforehand. The equipment
needed to perform a complete physical examination of 8. Assessing the mouth and the Nasopharynx
the adult patient includes:

 Pen and paper

 Marking peg
 Tape measure
 Clean gloves
 Penlight or flashlight
General Survey (Assessing Appearance and Mental
Status)
Health assessment begins with a general survey
involving observation of the client's general appearance,
level of comfort, mental status, measurement of vital
signs, height and weight.
Assessing General Appearance
1. Stature or Posture
Normal standing posture shows an upright
stance with parallel alignment of the hips and shoulders.
Normal sitting posture involves some degree of
rounding of the shoulders. Observe whether the
patient has a slumped, erect, or bent posture, which
reflects mood or pain. Changes in older adult
physiology often result in a stooped, forward bent
posture, with the hips and knees somewhat flexed and
the arms bent at the elbows.
2. Health Status
3. Height and Weight
Height and weight reflect a person's general
health status.Assess every patient to identify if he or
she is at a healthy weight, overweight, or obese.
Weight is routinely measured during health screenings,
visits to physicians' offices or clinics, and on admission
to the hospital. Infants and children are measured for
both height and weight at each health care visit to
assess for healthy growth and development. If older
adults are underweight, difficulty with feeding and
other functional activities is a possibility. Measuring
height and weight of older adults, along with obtaining
a dietary history, shows risk factors for chronic diseases.
Nursing History for Weight Assessment
ASSESSMENT
 Ask about total weight lost or gained; compare with
usual weight: note time period for loss (e.g., gradual,
sudden, desired, or undesired).
 If weight loss desired, ask about eating habits, diet
plan followed, food preparation, calorie intake,
appetite, exercise pattern, support group
participation, weight goal. If weight loss undesired,
ask about anorexia, vomiting; diarrhea, thirst;
frequent urination, and change in lifestyle, activity,
and stress levels.
 Assess if patient has noted changes in social aspects
of eating: more meals in restaurants, rushing to eat
meals, stress at work, or skipping meals.
 Assess if patient takes chemotherapy, diuretics,
insulin, fluoxetine, prescription and nonprescription
appetite suppressants, laxatives, oral hypoglycemics,
or herbal supplements (weight loss); steroids, oral
contraceptives, antidepressants, insulin tweight gain).
 Assess for preoccupation with body weight or body
shape such as fasting, never feeling thin enough,
unusually strict caloric intake or restrictions, laxative
abuse, induced vomiting, amenorrhea, excessive
exercise, alcohol intake.
RATIONALE
 Assessment determines severity of problem and
reveals if weight change is related to disease process,
change in eating pattern, or pregnancy. Assessment
helps to determine appropriateness of diet plan
followed.
 Assessment focuses on problems that cause weight
loss (e.g., gastrointestinal problems).
 Lifestyle changes sometimes contribute to weight
changes.
 Weight gain or loss is a side effect of these
medications.
 Excesses indicate an eating disorder.
4. Personal Hygiene
Hygiene and grooming: Note the patient's level
of cleanliness by observing the appearance of the hair,
skin, and fingernails. Determine if his or her clothes are
clean. Grooming depends on the patient's cognitive and
emotional function, daily or social activities, and
occupation. Observe for excessive use of cosmetics or
colognes that could indicate a change in self-perception.
Dress: Culture, lifestyle, socioeconomic level, and
personal preference affect the selection and wearing of
clothing. However, you should assess whether or not
the clothing is appropriate for the temperature,
weather conditions, or setting. Depressed or mentally
ill people may not be able to select proper clothing, and
an older adult might tend to wear extra clothing
because of sensitivity to cold.
5. SKIN COLOR /LESIONS
Physical examination begins with an inspection
of all visible skin surfaces; the less visible surfaces are
assessed when you examine other body systems. Use
the senses of sight, smell, and touch while performing
inspection and palpation of the skin.
 Assessment of the skin reveals the patient's health
status related to oxygenation, circulation, nutrition,
local tissue damage, and hydration. Check the
condition of the patient's integument to determine
the need for nursing care. For example,
assessment findings can help determine the type
of hygiene measures required to maintain integrity
of the integument. Adequate nutrition and
hydration become goals of therapy if there is an
alteration in the integumentary status.
Nursing History for Skin
Assessment
 Ask patient about history of changes in skin;
dryness, pruritus, sores, rashes, lumps, color,
texture, odor, and lesion that does not heal.
Consider if patient has the following history: fair,
freckled, ruddy complexion: light-colored hair or
eyes; tendency to burn easily.
 Determine whether patient works or spends
excessive time outside. If so, ask whether patient
wears sunscreen and the level of protection.
 Determine whether patient has noted lesions,
rashes, or bruises. Question patient about
frequency of bathing and type of soap used.
 Ask if patient has had recent trauma to skin.
 Determine whether patient has history of allergies.
 Ask if patient uses topical medications or home
remedies on skin.
 Ask if patient goes to tanning parlors, uses sunlamps,
or takes tanning pills.
 Ask if patient has family history of serious skin
disorders such as skin cancer or psoriasis. Determine
if patient works with creosote, coal, tar, petroleum
products, arsenic compounds, or radium
RATIONALE
 Patient is best source to recognize change. Usually
skin cancer is first noticed as a localized change in
skin color.
 Characteristics are risk factors for skin cancer.
Exposed areas such as face and arms are more
pigmented than rest of body. The American Cancer
Society (2011) recommends use of sunscreen.
 Mast skin changes do not develop suddenly. Change
in character of lesion possibly indicates cancer.
Bruising indicates trauma or bleeding disorder.
 Excessive bathing and use of harsh soaps cause dry
skin.
 Some injuries cause bruising and changes in skin
texture.
 Skin rashes commonly occur from allergies.
 Incorrect use of topical agents causes inflammation
or irritation.
 Overexposure of skin to these irritants can cause skin
cancer.
 family history can reveal information about patient's
condition.
 Exposure to these agents creates risk for skin cancer.
6. Breath/Odor
Body odor: An unpleasant body odor can result
from physical exercise, poor hygiene, or certain disease
states. Validate any odors that might indicate a health
problem.
7. Mood/Affect
Affect is a person's feelings as he or she
appears to others. Patients express mood or emotional
state verbally and nonverbally. Determine whether or
not verbal expressions match nonverbal behavior and if
the mood is appropriate for the situation. By
maintaining eye contact you can observe facial
expressions while asking questions.
Assessing Mental Status
 Language (Quantity and quality of speech)
Normal speech is understandable and
moderately paced and shows an association with the
person's thoughts. However, emotions or neurological
impairment sometimes causes rapid or slowed speech.
Observe whether the patient speaks in a normal tone
with clear inflection of words.
 Orientation - person, place, time and situation
Orientation is something healthcare providers
check when screening for dementia and evaluating
cognitive abilities. It refers to a person's level of
awareness of self, place, time, and situation.
When testing a person's orientation, a doctor asks
standard questions that may seem like small talk. But
these questions are useful for testing recent and
longer-term memories.
What is your name? - Orientation to person Where are
you? - Orientation to place
What is the date? - Orientation to time
What time is it?
What just happened to you? - Orientation to situation
 Level of Consciousness
Consciousness is defined as the state of being
aware of physical events or mental concepts. Conscious
patients are awake and responsive to their
surroundings.
The level of consciousness has been described as the
degree of arousal and awareness. A manifestation of
altered consciousness implies an underlying brain
dysfunction. Its onset may be sudden, for example
following an acute head injury, or it may occur more
gradually, such as in hypoglycaemia.
A range of situations can lead to altered consciousness.
These include: profound hypoxaemia; hypercapnia;
cerebral hypoperfusion; stroke; convulsions;
hypoglycaemia; recent administration of sedatives or
analgesic drugs; drug overdose; subarachnoid
haemorrhage; and alcohol intoxication. It is not possible
to directly assess the level of consciousness - it can only
be assessed by observing the patient's behavioural
response to different stimuli.
 Memory
a. Immediate recall (information presented seconds
previously)
b.Recent(events or information earlier in the day, or few
days)
c. Remote or long-term (knowledge recalled from
months or years ago)
An important concept in memory assessment includes
the examination of delayed recall for newly learned
information. The simple assessment of the ability to
immediately recall newly presented information, for
example, may not be significantly impaired in individuals
with even gross memory disorders.
MEMORY-ability to record, retain, and reproduce
information constitutes memory functioning.
Semantic memory represents the ability to learn
information about the world in general. Episodic memory
represents memories that are tied to specific episodes.
For example, the knowledge that a bicycle has two
wheels, pedals, a seat, and handlebars represents
semantic memory; it is not possible to identify when this
information was acquired. The memory of the first time
one rode a bicycle is an example of episodic memory; the
events surrounding that first ride are part of the memory
trace.
Sensory Memory
 Shortest Memory System
 Stimulus
 Sensation Based Perception
Short Term Memory
 30 Seconds Timeline
 A weak chain system
 Auxiliary System
Long Term Memory Assessment of Hair
 Explicit and Conscious
 Implicit and Unconscious  INSPECT THE SCALP
 Long Processing  Cleanliness, color, dryness, Lump, lesions, Lice
(pediculus humanus capitus)
Under the long term memory  Dandruff etc
Explicit Memory
 Declarative
 Episodic Memory  Inspect and palpate the head for the following:
 Semantic Memory  Shape & symmetry
 Hair & scalp
Implicit Memory  Masses
 Procedural Memory  Tenderness
 Muscle Memory
 Highest Stage of Learning
Normal findings:
 Attention span
 Evenly distributed hair
Attention span refers to an individual's ability  Thick hair
to attend to a stimulus or object over a period of time.  Silky, resilient hair
This ability is also known as sustained attention or  No infection nor infestation
vigilance.
Abnormal findings:
Assessment of Skin, Hair and Nails (Integument)
 Alopecia Areata
Assessment of Hair An autoimmune disorder that results in non
Factors to consider in assessment of hair inflammatory loss of hair in a circumscribed distribution
 Developmental changes
 Ethnic differences  Traction alopecia
 Individual’s hair care practices and factors Tight hair braiding practices exert traction force
influencing them on the hair bulb with subsequent hair loss.

• First inspect the color, distribution, quantity,  Hirsutism

thickness, texture, and lubrication of body hair. Scalp
hair is coarse or fine and curly or straight; and it should
be shiny, smooth, and pliant. While separating sections
of scalp hair, observe characteristics of color and
coarseness.
• Color varies from very light blond to black to gray and
is sometimes altered by rinses or dyes. In older adults
the hair becomes dull gray, white, or yellow.
Excessive androgenic hormones in a female
patient can cause masculine changes including hair in
male distribution patterns(beard, chest, back, upper
thighs).
 Trichotillomania
Compulsive hair pulling cause breakage of hair
and thinned or balding of areas on scalp, although some
hair remains present and visible in the affected area.

• Be aware of the normal distribution of hair growth in Symptoms:

a man and a woman. At puberty an increase in the  Compulsively pulling out hair
amount and distribution of hair occurs for both genders.  Chewing pulled out hair
During the aging process the hair may thin over the  Bald patches
scalp, axillae, and pubic areas. For older men, facial hair  Noticeable hair loss
decreases.  Daily life affected by hair-pulling

• Assess for causes of changes in the thickness, texture, Assessment of Nails

and lubrication of scalp hair. At times these are a result ASSESSING NAILS
of febrile illnesses or scalp diseases that result in hair  Shape; convex
loss.  Angle between nail and its base is 160 degrees
 Texture: smooth, nail base should be firm and non
tender
 Color: pinkish nail bed with translucent white tips
 Capillary refill
The Nail Blanch Test, also called the capillary nail refill 16-Red nail: polycythemia- systemic lupus
test, is performed on the nail beds as an indicator of
tissue perfusion (the amount of blood flow to tissue) 17-Horizontal white and pink bands:Nephrotic syndrome
and dehydration.
18-Brittle Nail: detergents and water- hypothyrodism
Assessment of Nails
1. Inspect fingernail plate shape, curvature & angle
Normal
 Colorless and a convex curve.
 Angle between nail and nail bed: usually 160°

Deviations from Normal

 Concave
 Clubbed fingernails (≥180°) due to chronic tissue
hypoxia

2. Inspect and palpate finger & toenail bed color

Normal
 Highly vascular and pink in light skinned; dark
skinned may be brown or black

Deviations from Nails

 Bluish or purplish tinges;
 Pale

Nails disorders Longitudinal ridging

1-Absent part: anonychia congenita
2-Pitting: Psoriasis
3-Cuticle invasion: lichen planus
4-Dark brown pigmentation,ridging :monilia
5-Distal onycholysis: Tinea
6-Spoon nails: Iron deficiency
7-Discoloured nails with inverted edges : Ectodermal
dysplasia
8-Clubbing: toxins-malignancy-hypoxia
9-Short and overcut nails( biting) : anxiety
10-Splinter haemorrhage: infective endocarditis
 Normal variations, especially in elderly. Common
cause is normal aging
Abnormal findings:
 Onycholysis is a common nail disorder. It is the
loosening or separation of a fingernail or toenail
from its nail bed. It usually starts at the tip of the
nail and progresses back.
Causes: trauma, fungal infection, topical irritants,
psoriasis, warts.
 Koilonychia (spoon nails)
Transverse and longitudinal concavity of the nail
appeared to be like a spoon. Causes: iron-deficiency
anemia, trauma

11-yellow nail : lymphoedema-bronchiectasis-  Paronychia

lymphoma
Inflammation of the nail folds - red, swollen, often
12-Half and half: hepatic cirrhosis tender.Frequent immersion in water is a risk factor
for chronic paronychia.
13-Ridging: Rheumatoid arthritis
 Pitted nails
14-Longitudinal Brown Lines: Addison's disease-Breast
cancer-Melanoma
- Lesions from psoriasis; arise from nail matrix that
15-White nails: anemia cause pitting on the nail plate as it grows.

 Beau's lines
- Results from slowed or halted nail growth in
response to illness, physical trauma, or poisoning.
Hypotension, MI, malnutrition, hypocalcemia
 Clubbing
- Results from chronic hypoxia to distal fingers,
such as emphysema or congestive heart failure.
Angle between nail plate and proximal nail fold
greater than 180 degrees.
The nail curves downward so it looks like the
round part of an upside-down spoon.
 Half-and-half nails (Lindsay's nails)
Color changes associated with chronic renal failure;
proximal portion of nails are white, distal portion
are pink or brown.
 Splinter hemorrhages
Brownish red longitudinal lines in the direction of
nail growth results from damage of capillaries.
Nonspecific finding associated with trauma most
commonly but also seen in subacute bacterial
endocarditis and scleroderma
Assessment of the Skin
 Assessment of the skin involves inspection and
palpation
 The entire skin surface maybe assessed at one
time or as each specific area of the body is
assessed
 The nurse may also use the olfactory sense to
detect unusual skin odors which are mostly
evident in the skinfolds or in the axillae
 Pungent body skin odor is frequently related
to poor hygiene, hyperhidrosis (excessive
perspiration), or bromhidrosis (foul – smelling
perspiration).
The skin is assessed for the following:
 Skin color
 Uniformity of color
 Edema (location, color, temperature, shape, and
the degree to which the skin remains indented
or pitted when pressed by a finger)
 Circumference of the extremity with edema
 Lesions (described according to location,
distribution, color, configuration, size, shape,
type or structure)
 Skin moisture
 Skin temperature
 Skin turgor
 Before assessing the skin, the nurse should
review the characteristics of primary and
secondary skin lesions if necessary
 Ensure that adequate lighting is available
Equipment needed:
 Ruler
 Hand Gloves
 Magnifying Glass
Lesions -is an area of tissue that has
been damaged through injury or
disease.
Bruising - forms when a blow breaks
blood vessels near skin's surface,
allowing a small amount of blood to
leak into the tissues under the skin.
Erythema - skin redness & warmth; seen
in inflammation, allergic reactions, or
trauma.
Vitiligo - is a chronic skin disease
characterized by portions of the skin
losing their pigment . It occurs when skin
pigment cells die or are unable to
function
Most common skin lesions
Benign skin lesions, Growth and Conditions (non-
cancerous)
 Acne
 Skin tags
 Cherry angioma
 Freckle
 Mole
 Seborrheic keratosis
Cancerous (malignant)
 Melanoma
 Squamous cell
 keratocanthoma
Pallor - loss of color (pale to ashen without
underlying pink)
Cyanosis - skin appeared to be blue-tinged or blue,
dull.
Jaundice – yellow skin tones, from pale to
pumpkin, particularly in the sclera, oral mucosa,
palms, and soles.
Primary Skin Lesions
 Macule. A small, circular, flat spot less than
2/5 in (1 cm) in diameter. Macules come in a
variety of shapes and are usually brown, white,
or red.
Examples : freckles , flat moles, tattoo, stork bite
 Vesicle. A raised lesion less than 1 cm across
and filled with a clear fluid.
Example: herpes simplex, chicken pox
 Pustule. A raised lesion of any size filled with
pus.
Example: pustular acne, folliculitis
 Bulla. Fluid-filled, greater than 1cm diameter
Example: second-degree burn
 Nodule. A solid lesion that has distinct edges,
greater 1cm diameter often with depth.
Example: basal cell carcinoma
 Papule. A solid, raised lesion less than 1cm
diameter. Papules and plaques can be rough
in texture and red, pink, or brown in color.
Example: wart, insect bite
 Wheal. Raised, flesh-colored or red
edematous papules or plaques, vary in size &
shape.
Example: urticaria
 Plaque - Raised, defined, any color greater
than 1cm diameter.
Example: Psoriasis
 Cyst - Distinct and walled-off,
containing fluid/semi-solid material,
varied in size
Example: epidermal cyst, cystic acne
Secondary Skin Lesions
 Scale. A dry build-up of dead skin cells that
often flakes off the surface of the skin. Diseases
that promote scale include fungal infections,
psoriasis, and seborrheic dermatitis
 Crust. A dried collection of blood, serum, or pus.
Also called a scab, a crust is often part of the
normal healing process of many infectious
lesions.
 Erosion. Lesion that involves loss of the
epidermis.
 Lichenification - Rough, thick epidermis with
exaggerated skin lines; often a characteristic of
scratch dermatitis and atopic dermatitis.
 Atrophy. An area of skin that has become very
thin and wrinkled. Normally seen in older
individuals and people who are using very strong
topical corticosteroid medication
 Ulcer. Lesion that involves loss of the upper
portion of the skin (epidermis) and part of the
lower portion (dermis), extending to
subcutaneous, fascia, muscle, bone or all.
Example: pressure ulcers, vascular ulcers,
neuropathic ulcers
Pressure Ulcer Staging Chart
Stage 1: Intact skin with non-blanchable redness of a
localised area usually over a bony prominence.
Darkly pigmented skin may not have visible
blanching, its colour may differ from the surrounding
area. The area may be painful, firm, soft, warmer or
cooler as compared to adjacent tissue.
Stage II: Partial thickness loss of dermis presenting
as a shallow open ulcer with a red pink wound bed,
without slough. May also present as an intact or
open/ruptured serum-filled or scro-sanguineous
filled blister. Presents as a shiny or dry shallow
ulcer without slough or bruising.
Stage III: Full thickness tissue loss. Subcutaneous
fat may be visible but bone, tendon or muscle are
not exposed. Slough may be present but does not
obscure the depth of tissue loss. This stage may
include undermining and tunneling.
OBJECTIVE:
 skin uniform in colour,
 no redness, lesions or ulcerations noted.
 warm and dry to touch, no tenting hair long
with course texture, evenly distributed scalp
free of redness/lesions nails pink, no clubbing,
cuticles smooth, capillary refill 1 second

Stage IV: Full thickness tissue loss with exposed

bone, tendon or muscle. Slough or eschar may be
present. This stage often includes undermining and
tunneling. Exposed bone/muscle is visible or
directly palpable.

Assessment of the Skin

 Palpate skin temperature, texture, moisture
and turgor
 Skin with decreased turgor remains elevated
after being pulled up and released

Assessing Edema
 Take thumb and press on top of ankle, foot
and/or shin for 5 seconds

O No pitting edema

1+Mild pitting edema. 2 mm depression that

disappears rapidly.

2+Moderate pitting edema. 4 mm depression that

disappears in 10-15 seconds.

3+Moderately severe pitting edema. 6 mm

depression that may last more than 1 minute.

4+Severe pitting edema. 8 mm depression that can

last more than 2 minutes.

SUBJECTIVE:
 no past history of skin disease,
 no changes in color/texture denies rashes,
lesions,or pruritus.
 washes hands frequently with mild soap
denies changes to texture/patterns of hair
growth patient colours hair with chemical,
 no problems reported reports no problems
with nail growth/ contour