NCLHAS1 – Health Assessment Laboratory

RASHES AND SKIN LESIONS o Drug allergy

- Rashes – a widespread lesion
- Lesion – localized abnormalities of the - Pustule
skin o Filled with pus and purulent
Primary Lesion – arise from previously normal o Acne, impetigo, bacterial
skin infections
- Note for: - Cyst
Anatomic location o Semisolid/fluid-filled
Distribution o Encapsulated
Grouping or arrangement (linear, - Plaque
clustered) o Scaly, reddish lesion
- Cause
o Psoriasis
o Allergy
Secondary Lesion – results from changes in
o Insect bite
primary skin lesions / progression
o Wounds/cuts
o Infections and diseases A. Loss of skin surface
- Dermatosis a. Erosion
o Generic term for skin disease i. Loss of superficial
- Macule epidermis, non-bleeding
o Small spot ii. Apthous stomatitis,
o Depressed beneath the skin varicella
o Non-palpable, flat b. Ulcer
o Ex. Freckles, moles i. Loss of epidermis and
- Patch dermis
o Vitiligo, tinea versicolor ii. Bed sores
o Flat, uncircumscribed, more than iii. May bleed and scar
1cm iv. Pressure ulcer, vascular
o Size varies ulcer, neuropathic ulcer
- Papule v. From reddish/shiny skin to
o Less than or equal to 0.5cm complete ulceration
1. Do log rolling
o Elevated mass
vi. Stages:
o Semisolid with fluid
1. Non-blanching
o Molluscum contagiosum – virus erythema with intact
that causes bump, acne epidermis
- Nodule 2. Partial thickness
o Mass ulcer involving
o 0.5 – 2 cm epidermis and
o Firm than papule dermis
o Nevus (mole), skin cancer 3. Full thickness ulcer
- Tumor extending through
o Mass dermis into the
o More than 2cm subcutaneous
o Lipoma – lump under the skin tissue
- Wheal 4. Deep tissue
o Irregular destruction up to
o Superficial area of localized bones and tendons
edema c. Fissure
o Mosquito bites, urticaria i. Deep linear cracks
ii. Extends to dermis
- Vesicle
iii. Athlete’s foot, laceration –
o Filled with serous fluid
puncture wound
o Less than or equal to 0.5cm
B. Material on the skin surface
o Herpes simplex, herpes zoster a. Spider angioma – spider vein –
(chicken pox), cold sore cherry angioma
- Bulla i. Vit B deficiency
o Filled with serous fluid ii. Fiery red, 2cm
o Greater than 0.5cm b. Petechia and purpura
o 2nd degree burn, bullous impetigo i. Bleeding disorder
- Steven Johnson’s disease ii. Deep rep, greater than 1-
o Need immediate management 3mm, rounded, flat
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Turgor – elasticity, used in checking

c. Ecchymosis dehydration
i. “Pasa” , discoloration from ASSESSMENT OF THE HEAD AND FACE
bleeding History
ii. Affects the tissue - Injury
PALLOR - Headache
- Paleness of skin - Seizure
- Albinism - Stiff neck
- Grading - Facial edema
o Mild – conjunctiva is pale - Scalp problem
 Check mucosal membrane P – provoking factor
o Moderate – pale conjunctiva and Q – quality of pain (pulsating)
pale skin R – radiating or referring
o Severe – pale conjunctiva, pale S – severity (pain scale)
skin, pale palm T – time-bound

EDEMA Inspect the head for size and shape,

- Swelling local or generalized symmetry and movement
- Preorbital edema
- Grading pitting edema Normal – variable, symmetrical, upright, still
o 1+ - barely detectable, immediate Abnormal – very small or large, asymmetric,
rebound time tilted to one side (torticollis), tremors
o 2+ - 2-4mm, 15sec or less
rebound time Head for Size
o 3+ - 5-7mm, 10-20sec rebound - Anencephaly – absent parts of brain and
skull
time
- Microcephaly – smaller and deformed
o 4+ - 7mm and up, 20sec rebound
- Hydrocephalus – CSF production
time
- Elephantiasis
Shape and Symmetry
- Synostotic trigonocephaly – triangular
Check the color of the nail beds and palpate
- Synostotic scaphocephaly – round, alien
for capillary refill.
head
- Beau lines
- Synostotic brachycephaly – short and
- Onycholysis
wide
o Separation of nail plate from
- Synostotic anterior plagiocephaly –
nailbed anteriorly aligned
o Fungal - Synostotic posterior plagiocephaly –
- Onychomycosis posteriorly alighned
o Fungal infection - Normocephaly – spherical
- Clubbing
o Clubbed fingers Inspect the scalp by parting hair on several
o Straighten in clubbing of fingers places and observing for lesions, nits,
- Splinter hemorrhage dandruffs or infections
o Microembolism
- Dark longitudinal streaks Normal – smooth, intact, moves freely over
- Half-and-half nails skull
o Pinkish white Abnormal – scaliness, lumps, redness, soft
o Due to chronic renal failure areas
o Yellow nails
o Koilonychia – spoon nails Health teaching for scalp
o Pitted nails - Eat foods rich in Vit B
Palpate for capillary refill
- 5 secs pinch, 2 secs rebound time Abnormalities
- Seborrheic dermatitis
Palpate client’s temperature on the - Lice
forehead with the dorsum of the hand. - Dandruff
- Scaliness
Palpate the skin for moisture, texture and - Psoriasis
turgor. - HPV
NCLHAS1 – Health Assessment Laboratory
Ask client to close eyes; nurse introduces
different objects (dry, dull, soft, sharp)
Inspect the hair, noting the quality and ASSESSMENT OF THE EYES
distribution. Sclera
Palpebral fissure
Coarse hair, thick hair, equally distributed, free Globe / eyeball
from infestation, silky Iris
Pupil
Palpate the skull’s contour and symmetry Muscles of eye
noting for masses, depression or
tenderness. History taking
- Use corrective lenses
Note for shape - Vision
Tenderness - Problems or changes in the vision
For depression, is there indentation - Double vision (Diplopia)
History taking - Blurred vision
- Visual loss
Inspect for facial symmetry and expression. Check for
Check the function of the - Pain
temporomandibular joint. - External eye problem
- Lifestyle factor
There is facial symmetry - Eye disorders, surgery, trauma
Facial expression is appropriate for the - Glaucoma exam
situation - Systemic disorders
- Family history
Abnormalities
- Moon face – Cushing’s Syndrome Abnormalities
o Buffalo hump - Preorbital edema
o Caused by cortisol o Allergies
overproduction o Local inflammation
- Paralysis – asymmetrical – CNVII o Myxedema – severe
o Bell’s palsy – temporary hypothyroidism related
o Stroke o Fluid retaining states
- Masked face o Nephrotic syndrome
o Abnormal facial expression - Ptosis
o Parkinson’s face o Drooping of eyelids
o Myasthenia gravis – oculomotor
TMJ nerve damage
- Crepitus – clicking or popping sound - Acute hordeolum (sty)
- Movement – restricted or deviated o Painful, redness infection in the
- Tenderness – is there pain eyelashes
o Cased by Staphylococcus aureus
Test Cranial Nerve VII o Do warm compress for
(Motor) vasodilation
Ask client to smile - Chalazion
- Shows upper and lower teeth o Inflammatory lesion in the
Ask client to frown meibomian gland
Ask client to raise brows o Blockage, cyst
Ask client to keep eyes tightly closed; nurse will
- Dacryocystitis
pry it
o Lacrimal sac inflammation,
Ask client to purse lips
excessive tear
Ask client to puff out cheeks
o Blockage and infection
Test CN V - Blepharitis
o Bleph inflammation
Ask client to clench teeth; nurse pulls the jaw  Bleph – margin of eyelids
down - Entropion
o Inward of lower eyelid
Test CNVII - Ectropion
(Sensory) o Outward sagging of eyelid
o Skin excoriation
NCLHAS1 – Health Assessment Laboratory
o Corneal ulceration - 10mm opening

- Racoon’s eyes
o Purplish discoloration in the Test visual acuity using Snellen’s chart.
periorbital Herman Snellen
o Skull fracture
o Skull/brain injury Numerator – distance of patient away from
- Nystagmus chart
o Repetitive uncontrolled Denominator – distance of which a normal eye
movements can read
o Reduced vision, inner ear
Abnormalities
problems, multiple sclerosis,
- Presbyopia – developmental eye visual
brain lesion, narcotics
acuity loss
- Strabismus
- Hyperopia – far sightedness
o Eye is not aligned
- Myopia – near sightedness
- Diplopia
o Double vision
Examine the pupils for size, shape, and
reaction to light.
Inspect eye structures.
Pupil
Eyebrows for hair quality and distribution. - 3-5mm
- Round
PERRLA – Pupil should be Equal, Round,
Reactive to Light and Accommodation. Consensual reflex
*Documentation
Conjunctiva Right = 3 (normal) / 1 (illuminated)
- Pale, glistening, pink ***should be equal to Left
- Clear
- Visible blood vessels Abnormalities
- Abnormalities - Excessively dilated/constricted
o Conjunctivitis o Injury especially brain
o Scleritis - Mydriasis
o Icterus o Fixed dilated pupils
o Angled glaucoma, CNS disease
Eyelids position to eyeballs, adequate closure. - Miosis
- Abnormalities o Fixed constricted pupils
o Epicanthus – vertical fold of the
- Anisocoria
skin o Unequal pupil size
o Distichiasis – additional row of
lashes Check for accommodation and
o Coloboma – congenital disease, convergence.
no eyelids
o Exopthalmus – Grave’s disease, Accommodation – action of eye
protruding eyeball Convergence – inward movement
o Pinguecula – yellowish nodule of
the bulbar conjunctiva Test ocular muscle function through the
o Cataracts – clouding cardinal fields of gaze.
o Glaucoma – build-up
o Hyphema – blood accumulation Superior rectus
o Blue sclera – osteogenesis Superior oblique
imperfecta, transparency of Medial rectus
collagen fibers of the sclera Lateral rectus
Inferior oblique
Iris has same color. Inferior rectus
- Heterochromia – different color of iris
Confrontation test for gross check of visual
Adequacy of closure fields.
- Adequate closure
- 2mm covering iris Delayed or absent perception of patient
NCLHAS1 – Health Assessment Laboratory
- Tophus
o Uric acid crystals

Test for color blindness - External otitis media

o Infection discharge from middle
Deuteranopes – green color blind ear infection
Protanopes – red color blind - Mastoiditis
o Inflammation of the mastoid gland
Corneal reflex
- Amaurotic Cat’s eye Outer ear soft tissues
o Light reflection - Scaphoid fossa
- Retinoglastoma - Helix
o Chalky - Concha
- Asthenopia - Anti-helix
- Astigmatism - Tragus
- Color blind - Anti-tragus
- Blindness - Lobule

ASSESSMENT OF THE EAR Examine the internal auditory canal and

eardrums with the otoscope.
External Ear
Inner Ear Abnormalities
Note for - Perforated ear drum (if reversible, they
- Changes in hearing use Tympanostomy Tube)
- Otorrhea – ear drainage - Acute Otitis Media
- Ear pain - Chronic Otitis
- Tinnitus – ear ringing - Otitis Media Effusion – bacterial
- Roaring or crackling infection
- Vertigo – spinning - Scarred tympanic membrane
- Past treatments (surgeries) - Foreign body
- History of hearing loss in the family
- Ear care Test CNVII for hearing acuity.
- Hearing aid
- Presbycusis – developmental hearing Voice Test
loss - 25 – 80 dB
Weber Test
Inspect the external ear for color, shape, - Tuning fork on occiput
size, including position/alignment of ear Rinne Test
lobes. - Bone and air conduction
- Air conduction is 2x the bone conduction
Color – same as face
Size – symmetrical 10mm Types of Hearing loss
Symmetry - Conductive hearing loss (Weber
Alignment – lateral canthus positive)
Contour/shape – no lumps or lesion - Sensory neural

Abnormalities If equal or longer it is conductive hearing loss

- Microtia If air conduction is longer but not twice the
o Small/deformed auricle bone conduction it is sensory neural hearing
- Macrotia loss
o Excessive enlargement
- Anotia ASSESSMENT OF THE NOSE AND SINUSES
o Absence of ear auricle
- Edematous ear Patency of the Nare
o Cartilaginous swollen
inflammation Test Cranial Nerve I
- Cysts Four familiar odors
o Fluid sac
- Carcinoma on auricle Abnormalities
o Sun exposure tumor - Anosomia
NCLHAS1 – Health Assessment Laboratory
o Loss of smell - Diptheira
o Central pantosomia – brain - Uvulitis
o Peripheral pantosomia – disease-
related
- Epistaxis
o Nasal bleeding Test CN IX and X
- Rhinitis Use tongue depressor
- Rhinosinusitis Ask client to say “aah”
- Nasal polyps Check for gag reflex
- Deviated septum
- Perforated septum - Valsalva maneuver
- Foreign body obstruction
Test CNXII
ASSESSMENT OF THE MOUTH AND THE Motor innervations of the tongue
THROAT Taste test
Bitter
Oral Cavity Sour
Lips Salty
Buccal mucosa Sweet
Gums
Teeth ASESSMENT OF THE NECK
Palate Trachea
Tongue Range of Motion (flexion, extension, lateral,
Tonsils abduction, rotation)
Uvula Palpate the trachea
Palpate the lymph nodes
Abnormalities - Pre-auricular
- Kopik’s spots - Posterior auricular
o Pathognomonic sign for measles - Occipital
- Apthous ulcers - Tonsillar
o Vesicular oral lesions - Submandibular
- Submental
o “singaw”
- Superficial cervical
- Oral candidiasis
- Posterior cervical
- Gingivitis
- Deep cervical chain
- Gingival hyperplasia
- supraclavicular
- Ankyloglossia
Palpate the thyroid gland
o Short lingual frenulum
Auscultate if there is enlargement
 Frenectomy
- “Black Hairy” tongue
- Strawberry tongue
o Kawasaki disease
- Red “Beefy” tongue
o Pernicious anemia
- Scrotal tongue
o Fissured tongue
Tonsils
1+ - 0-25 obstructed
2+ - 25-50 obstructed
3+ - 50-75 obstructed
4+ - 75-100 obstructed (kissing tonsils)

Palate
- Cleft palate
- Kaposi sarcoma
- Forscheimer Spots
- Torus palatinus

Uvula
- Bifid uvula
o Diptheria portusis