PREPARATION:

Good morning/afternoon Ma’am, I am (NAME), a student nurse and I will be assisting you for
today. For verification lang po can I ask your full name po? How about your birth date po? May I
check your name tag lang po maam.

So today po I will be assessing your skin, nails, and hair po. This will go on for about 20 to 30
minutes po noh and I will take down notes of the data we get po. We are doing this to get more
information for us to create a care plan for you po. Rest assured po that this assessment will be
strictly confidential and will only be shared with those with the legal right to know. Okay lang po
ba yun?

Alright po maam, before we start may I ask consent lang po to touch certain parts of your body?
I ask for your cooperation and participation po maam throughout the assessment. If there are any
concerns or feelings of uncomfort please feel free to say so, okay po ba yun?

Alright po ma’am is the lighting and ventilation in the room okay naman po? Give me a few
minutes lang po to prepare for this assessment. Okay po ma’am close ko lang po yung curtains.

(the room is well ventilated and lighted, the room is free from noise and distraction, the patient is
provided with privacy. All equipment are provided in a table near the client)

*magalcohol/magwash ng hands*
*magprep ng gloves*

GENERAL APPEARANCE AND MENTAL STATUS:

Alright po ma’am. First time niyo po ba dito sa ospital? Kamusta naman po staff dito so far?
That’s good naman po noh.

So ma’am start na po tayo sa assessment. Proceed lang po muna tayo sa height chart. (take note
of height). Alright po ma’am sa weighing scale naman po tayo. (take note of weight)

Okay po ma’am upo na lang po tayo ulet. Madalas po ba sila nag eexercise ma’am? Alright po
ma’am may I ask na lang po kung anong petsa po ngayon?

FINDINGS:
Upon general survey and mental assessment. There were no deviations found. Patient showed
no signs of distress. The patient weighs 45 and is 4’9 tall with a mesomorph body build. Her
BMI is within normal range and the client’s posture is relaxed while standing and sitting.
Body movement was coordinated and the client looked neat and clean. There was no presence
of foul odors and the patient looks healthy. Client is cooperative and can follow simple
instructions. The client gave appropriate and understandable answers. Answers were logical,
made sense and exhibited thought association.

SKIN:
So ma’am I will start assessing your skin na po. Pwede po ba mahawakan ang both arms and legs
po? Alright ma’am may I ask na lang po na patanggal po ang socks and shoes. Start na po ako.

Okay po ma’am check ko lang po right arm niyo (palpate right arm, check skin color). Okay po
ma’am left arm naman po (palpate left arm, check skin color). Can you hold out both arms na
lang po (check temp of both at the same time). Kukurutin ko lang po yung part na toh ma’am
pasabi na lang po if masakit *kurutin yung back ng hand*.

I’ll proceed to the right leg pataas na lang po ng pantalon ma’am (palpate right leg, check skin
color). Okay po ma’am left leg naman po (palpate left leg ,check skin color) (palpate both at the
same time for temp). Medyo didiinan ko lang po yung part na toh *sundutin ang tibia saka
yung paa*.

*discard gloves, magalcohol*

FINDINGS:
So, the client’s skin is a light color and I observe quite a few moles on her face and arms as
well as a birthmark on her left leg . Her skin is generally uniform except in areas exposed to
sun. The client’s skin has no abrasion or any lesion. The client has moist skin and her
temperature is warm and uniform. The client’s skin has no presence of edema and her skin
springs back to its previous state after less than 3 seconds.

HAIR:
Okay po ma’am I will be assessing your hair naman po. Tatanggalin ko lang po bun niyo okay
lang po ba yun?
*WEAR GLOVES*
Okay po, I will start touching your hair na po. (kapain ang ponytail, check several areas dun sa
ulo part, check behind the ear and hairline sa neck)
*discard gloves, magalcohol*

FINDINGS:
So, the client’s hair is evenly distributed. She has thick, silky, and resilient hair. There are no
signs of infection or infestation, and the amount of her body hair is variable.
NAILS:
I’ll proceed po sa last part ng assessment which is your nails po noh. I’ll start po with your
fingernails. Pwede po pa thumbs up po ang dalawang kamay (inspect curvature). Alright po
pagaya na lang po ng kamay ko (naka flat both hands) (inspect color and tissue). Alright po
check ko na lang din po toenails niyo, patanggal na lang po ulit ng sapatos (inspect color and
tissue). Ma’am pahawak po ng right hand niyo po (texture ng nails, perform blanch test). Left
hand naman po ma’am (texture, perform blanch test sa index saka thumb).

FINDINGS:
The client’s fingernail plate shape shows convex curvature about 160 degrees. The client’s
fingernail and toenail bed color is highly vascular and pinkish in color. The tissues
surrounding her nails are intact and the texture of her nails are smooth. The client’s nail bed
returned to its usual color in less than two seconds. Now that I am done with the assessment I
may now document the findings.

CLOSING:

Well, that concludes the assessment po ma’am. I will forward all the data to your physician and
we will update you na lang po on the results. Thank you po for your cooperation and
participation po ma’am, I will leave you be na po.