Health Assessment Transcript

General Survey and Integumentary

Preparation
1. Introduce yourself
- Good afternoon ma’am I’m Nicole Pamularco, your student nurse for today.
Verify the client’s identity
- Before we proceed, Can I ask your name and age ma’am? For verification po.
- What would you like to address ma’am?
Explain to the client what you are going to do
- So, today I’ll be assessing your general appearance and mental health status,
skin, hair, and nails.
Why it is necessary
- We’re doing this assessment to add more information for us to know and to
better assist you with your health concerns.
How the client can cooperate
- And for me to be able to assess you ma’am, can I ask for your consent if it's
okay to touch certain parts of your body?
Confidentiality of data collected
- I rest assured ma'am that all documents and findings will remain confidential
between you, me and the health care teams. Is that okay, ma'am?

2. Perform hand hygiene and observe other appropriate infection control procedures
- I've finished washing my hands so I'm going to put some alcohol before I begin
the assessment.

3. Assemble equipment
- I will be using paper and pens for noting your findings, and gloves as
equipment.
4. Provide for the client privacy
- For your privacy, ma'am, I'll just close the door and the curtains.
General Appearance & Mental Health
So, Ma’am , Let's proceed to the height chart first, to measure your height.
Let's proceed to the weighing scale
- How are you doing today ma’am?
- Did you eat breakfast? Lunch?
- Do you have a companion or are you alone?

5. Observe signs of distress in posture or facial expression.

- I found out that the client has no sign of distress.
6. Observe body build, height, and weight in relation to the client’s age, lifestyle,
and health.
- Her body build is endomorph.
- After weighing the client and checking her height, I found out her BMI is within
the ideal body weight of Filipino standard and for her age.
Height: 5’1 ft
Weight: 60 kg / 132 lbs
7. Observe client’s posture and gait, standing, sitting, and walking.
- The client’s posture is relaxed while standing and while sitting.
- The client has coordinated movement.
8. Observe client’s overall hygiene and grooming.
- The client appears clean and neat.
9. Note body and breath odor.
- There is no unpleasant body or breath odor.
10. Note obvious signs of health or illness.
- The client appears healthy.
11. Assess the client’s attitude.
- The client is cooperative and can follow simple instructions.
12. Note the client’s affect/mood; assess the appropriateness of the client’s
responses.
- The client’s affect is appropriate to the situation and upon asking questions.
13. Listen for quantity, quality, and organization of speech
- The client is logical, makes sense, and the client exhibits thought association.
Skin
- So, ma'am Eloi. I'm going to start with your skin. Can I hold and touch both of
your arms?
- I'll check the right arm first. Okay. The left arm.

14. Inspect skin color.

- The client’s skin is medium color. It varies from light to medium.
15. Inspect uniformity of skin color.
- Her skin is generally uniform except in areas exposed to the sun.
16. Inspect, palpate, and describe skin lesions.
- Do you have any tattoos ma’am?
- Do you have a scar or any other lesions that I cannot see?
- The client’s skin has no abrasion or any lesion. But I observed a raised small
burn on her left arm.
17. Observe and palpate skin moisture.
- The client has moist skin.
18. Palpate skin temperature.
- the client temperature is within normal range.
19. Palpate to assess for presence of edema.
- Can I poked your skin po to check your edema?
- The client’s skin has no presence of edema.
20. Palpate to assess for skin turgor.
- Can I pinch your skin ma’am to check if you have skin turgor?
- Her skin springs back to its previous state after in less than 3 seconds
21. Remove and discard gloves and perform hand hygiene.
Hair
- Let's now move on to your hair
- Now I will inspect your hair ma’am
22. Inspect the evenness of growth over the scalp.
- So the client’s hair is evenly distributed.
23. Inspect hair thickness or thinness.
-The client's hair is thick.
24. Inspect hair texture and oiliness.
- The client’s hair texture and oiliness is silky, resilient hair.
25. Note Presence of infections or infestations.
- There is no infection but there is some dandruff in her scalp.
26. Inspect amount of body hair.
- The amount of her body hair is variable.

Nails
- So ma'am.. the last part of our assessment is the nails.

27. Inspect fingernail plate shape.

- please raise your two thumbs up like this. Okay.
- The client fingernail plate shape shows convex curvature about 160 degrees.
28. Inspect fingernail and toenail bed color.
- The client fingernail and toenail bed color is highly vascular and pinkish in color.
29. Inspect tissues surrounding nails.
- The tissues surrounding her nail are intact.
30. Palpate fingernail and toenail texture.
- The texture of her nails are smooth.
31. Perform blanch test for capillary refill.
- Ma’am can I press your two or more nails between your thumb and index finger.
First in your right. Next on your left.
- The client’s nail bed prompt returned to its usual color in less than two seconds.
32. Document findings.
- Now that I am done with the assessments, I may now document the findings.
- Again I rest assured ma'am that all documents and findings will remain
confidential between you, me and the health care teams.