Republic of the Philippines

President Ramon Magsaysay State University

(formerly Ramon Magsaysay Technological University)
Iba, Zambales, Philippines
Tel/Fax No.: (047) 811-1683

COLLEGE OF NURSING
Name:________________________________Section/Group:_______________Date:____________

Rating

5 Correctly and independently performs procedure and states complete rationale

4 Performs procedure and states rationale with minimal guidance
3 Satisfactorily performs procedure with moderate guidance
2 Procedure incorrectly done without rationale
1 Procedure not performed

Assessing the Skin

Procedure Steps 5 4 3 2 1
Assemble Equipment:
 Millimeter Ruler
 Examination gloves
 Magnifying glass
Procedure
1. Introduce yourself and verify the client’s identity. Explain
to the client what you are going to do, why it is necessary,
and how the client can cooperate.
2. Perform hand hygiene and observe other appropriate
infection control procedures.
3. Provide client privacy.
4. Inquire if the client has any History of the following:
 Pain or Itching
 Presence and spread of any lesions, bruises,
abrasions, or pigmentation spots
 Skin problem
 Associated clinical signs
 Problems in other family members
 Related systemic conditions
 Use of medications, Lotions, or Home remedies
 Excessively dry or moist feel to the skin
 Tendency to bruise easily
 Any association of the problem to a season of the
year
Assessment
5. Inspect skin color
6. Inspect uniformity of skin color
7. Assess edema, if present
Inspect, Palpate, and describe skin lesions. Apply gloves if
lesions are open or draining.
 Describe lesions according to location,
distribution, color, configuration, size, shape,
type, or structure.
Observe and palpate skin moisture
Palpate skin temperature
 Compare the two feet and the two hands, using
the backs of your fingers.
 Republic of the Philippines
President Ramon Magsaysay State University
(formerly Ramon Magsaysay Technological University)
Iba, Zambales, Philippines
Tel/Fax No.: (047) 811-1683

COLLEGE OF NURSING
Note skin turgor by lifting and pinching the skin on an
extremity.
Document findings in the client record. Draw the location
of skin lesions on body surface diagrams.

Actual Score Actual Score

Computation: ×60+ 40= ×60+ 40=Grade
Total Score ❑

Grade:_______________

Remarks:__________________________________________________________________________
__________________________________________________________________________________
____________________________________________________

Evaluated by:

___________________

Clinical Instructor

Conforme:

___________________

Signature of Student