NCM 101 Health Assessment - Lecture

Hand out #1

NURSES ROLE IN HEALTH ASSESSMENT: COLLECTING & ANALYZING DATA

NURSING PROCESS
Nursing is the diagnosis and treatment of human responses to actual or potential health problems. Diagnosis and treatment
are achieved through a process, called the nursing process, that guides nursing practice.

The nursing process is a systematic problem-solving method that has five steps:

1. ASSESSMENT - Collecting data (subjective & objective) about a patient’s condition

2. DIAGNOSIS - Analyzing data to make a judgment or statement about the patient’s problem or condition
3. PLANNING - Organizing and individualizing the appropriate care for a patient
4. IMPLEMENTATION - or intervention, providing treatment or education to a patient; carrying out the plan
5. EVALUATION - Appraising the effectiveness and appropriateness of interventions. Assessing whether outcome
criteria have been met.

CHARACTERISTICS OF THE NURSING PROCESS

 Dynamic and cyclic

 Patient centered
 Goal directed
 Flexible
 Problem oriented
 Cognitive
 Action oriented
 Interpersonal
 Holistic
 Systematic

COMMUNICATION
Communication is a process of sharing information and meaning, of sending and receiving messages. The messages we
communicate are both verbal and non-verbal.

Nonverbal behavior
includes vocal cues or paralinguistics, action cues or kinetics, object cues, personal space, and touch.
a. Appearance - ensure appearance is professional

b. Demeanor - display poise

c. Facial Expression - keep expression neutral and friendly

d. Attitude - do not act superior to the client

e. Silence- periods of silence allow you and the client to reflect and organize thoughts

f. Listening - to listen effectively, you need to maintain good eye contact, smile or display an open,
appropriate facial expression, maintain an open body position

CULTURAL CONSIDERATIONS
Culture can influence every aspect of communication,so consider not only the language but also the vocal, action, and
object cues, personal space, and touch.

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PATIENT INTERVIEW COMMUNICATION TECHNIQUES
Affirmation/Facilitation
Acknowledge your patient’s responses through both verbal and nonverbal communication to reassure him that you are
paying attention to what he is saying. Nonverbal gestures: nodding or sitting up and leaning forward. Verbal cues,such
as saying “ah ha,” “go on,”or “tell me more,”

Silence
Periods of silence allow your patient to collect her or his thoughts before responding and help prevent hasty responses that
may be inaccurate. You may feel compelled to fill the silence by asking more questions or even by trying to answer the
question for your patient.Resist the urge.

Restating
Restating the patient’s main idea shows him that you are listening, allows you to acknowledge your patient’s feelings,and
encourages further discussion.
For example, if the patient states,“I take a water pill every day for my blood pressure,” your response might be, “I see—
you take Lasix every morning for your blood pressure.” If the patient replies,“No, I take a water pill every morning,”this
identifies a teaching need.

Active Listening
Pay attention, maintain eye contact, and really listen to what your patient tells you both verbally and non-verbally. Active
listening conveys interest and acceptance.

Broad or General Openings

Use open-ended questions such as,“What would you like to talk about?”

Reflection
Reflection allows you to acknowledge your patient’s feelings,encouraging further discussion. For example, if the patient
states,“I am so afraid of having surgery,”your response would be,“You’re afraid of having surgery?”

Humor
Humor can be very therapeutic when used in the right context. It can reduce anxiety, help patients cope more effectively,
put things into perspective, and
decrease social distance.

Informing
Giving information allows your patient to be involved in his or her healthcare decisions.

Redirecting
Redirecting your patient helps keep the communication goal-directed. To get your patient on track again, you might say,
“Getting back to what brought you to the hospital . . .”

Focusing
Focusing allows you to hone in on a specific area, encouraging further discussion.

Sharing Perceptions
With this technique, you give your interpretation of what has been said in order to clarify things and prevent
misunderstandings. For example, you might say,“You said you weren’t upset, but you’re crying.”

Sequencing Events
Start at the beginning and work through the event until the conclusion. You might say,“What happened before the
problem started?”“Then what happened?”“How did it end?”

Suggesting
Presenting alternative ideas gives your patient options.This is particularly helpful if the patient is having difficulty
verbalizing his or her feelings.

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For example, if the patient says, “I’ve tried so hard to lose weight, but I can’t,” you might say, “Have you tried combining
diet and exercise?”

Presenting Reality
If your patient seems to be exaggerating or contradicting the facts,help her or him reexamine what has already been said
and be more realistic.

Summarizing
Summarizing is useful at the conclusion of a major section of the interview. It allows the patient to clarify any
misconceptions you may have.
For example, you might say,“Let me see if I have this correct: You came to the hospital with chest pain, which started an
hour ago, after eating lunch.”
THE ASSESSMENT PROCESS
- Systematic and continuous collection, organization, validation,interpretation, and documentation of data.
PURPOSE OF ASSESSMENT
 collect data pertinent to the patient’s health status
 to identify deviations from normal
 to discover the patient’s strengths and coping resources
 to pinpoint actual problems
 to spot factors that place the patient at risk for health problems

SKILLS OF ASSESSMENT
1. Cognitive Skills - “thinking process”; critical thinking,creative thinking,and clinical decision making.

2. Problem-solving Skills
 Reflexive thinking is automatic,without conscious deliberation, and comes with experience.
 Trial-and-error approach is hit-or-miss thinking—random, not systematic and inefficient. This would never be your
primary problem-solving approach, but it may prove helpful at times because it allows you to “think outside of the
box.”
3. Psychomotor Skills
 Assessment is “doing”.
 Four techniques of physical assessment:
a. Inspection
b. Palpation
c. Percussion
d. Auscultation
4. Affective/Interpersonal Skills - Assessment is also a “feeling” process.
5. Ethical Skills - Part of assessment is being responsible and accountable.

NURSE’S ROLE IN HEALTH ASSESSMENT

• Gather information
• Nursing diagnosis and care planning
• Managing problems
• Evaluation
• Discharge teaching
• Advocate

LEVELS OF PREVENTIVE HEALTHCARE

Primary preventive care
- focuses on disease prevention & health promotion
- Examples:
 health fairs
 Immunizations

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  nutritional instruction
Secondary preventive care
- focuses on early detection, prompt intervention, and health maintenance
- Example: in-patient hospitalization
Tertiary preventive care
- deals with rehabilitative or extended care
- Example:
 Skilled nursing care facilities
 rehabilitative hospitals
 long-term care facilities
 home care
 Hospice

TYPES OF ASSESSMENT
TYPE TIME PERFORMED PURPOSE
1. Initial Comprehensive During admission To establish a database
2.Focused / Problem Ongoing process To monitor and/or identify a specific,
Oriented new or overlooked problems
3. Emergency Emergency or crisis situation To identify life threatening
problems
4. Time-lapsed Several months after initial To compare a client’s status over a
assessment period of time

STEPS OF ASSESSMENT
1. Collection of Subjective Data
2. Collection of Objective Data
3. Validation of Data
4. Documentation of Data

TYPES OF DATA
1. Subjective Data
2. Objective Data

SUBJECTIVE DATA
- are referred to as symptoms (e.g., pain, hunger), feelings (e.g., happiness, sadness), perceptions, desires, preferences,
beliefs, ideas, values, and personal information that can be elicited and verified only by the client.
- The major areas of subjective data include:
a. Biographical information (name, age, religion, occupation)
b. Physical symptoms related to each body part or system (e.g., eyes and ears, abdomen)
c. Past health history
d. Family history
e. Health and lifestyle practices (e.g., health practices that put the client at risk, nutrition, activity,
relationships, cultural beliefs or practices, family structure and function, community environment)

OBJECTIVE DATA
- are referred to as signs
- are directly observed by the examiner
- These data include
a. Physical characteristics (e.g., skin color, posture)
b. Body functions (e.g., heart rate, respiratory rate)
c. Appearance (e.g., dress and hygiene)
d. Behavior (e.g., mood, affect)
e. Measurements (e.g., blood pressure, temperature, height, weight)
f. Results of laboratory testing (e.g., platelet count, x-ray findings)
SOURCES OF DATA
1. Primary Source– client

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2. Secondary Source – family members, friends, health professionals, records

METHODS OF DATA COLLECTION

1. Interviews
2. Observation
3. Physical Assessment / Examination

INTERVIEWS
- structured communication intended to obtain subjective data.
- this is known as therapeutic use of self

TYPES OF INTERVIEWS
Directive interviews
- with specific questions and are controlled by the nurse
- require less time and are very effective for obtaining factual data.

Non-directive interviews
- are controlled by the patient
- to identify what is important to the patient

PHASES OF INTERVIEW
1. Pre-interaction phase
2. Orientation phase
3. Working phase
4. Termination phase

PRE-INTERACTION PHASE
- start of therapeutic relationship with a patient
- process, planning, and feeling of a nurse before the first meeting with the patient
NURSES RESPONSIBILITY IN PRE-INTERACTION PHASE
 To become well known about own feelings, fear, and fantasies.
 Analyze professional strengths and weaknesses.
 Collect information about the patient like demographic data, occupational data, etc.
 Prepare a plan based on the data before meeting.

ORIENTATION PHASE
 Essential to develop rapport and gain trust.
 Explain purpose, reason for taking notes and assure client confidentially of the information.
 Nurse initiate effective communication

WORKING PHASE
 Biographical data.
 Reasons for seeking care
 History of present health concern
 Past health history
 Family history
 Review of body systems for current health problems
 Lifestyle
 Health practices and developmental level
 Nurses interpret and validate information
 Collaboration to identify the client’s problems and goals.
TERMINATION PHASE
 Summary and closing phase
 Identifies with client possible plans to resolve the identified problems
INTERVIEWING TECHNIQUE

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  Introduce yourself.
 Don’t rush.
 Avoid interruptions.
 Explain that information from the interview is confidential.
 Actively listen to what your patient is saying.
 Maintain eye contact.
 Work at the same level as your patient.
 Don’t invade your patient’s personal space.
 Explain what you are doing and why.
 If the patient presents with a problem,begin by asking questions about that.
 Begin with non-sensitive issues. Leave more sensitive topics until the end.
 Consider your patient’s cultural background.
 Consider your patient’s developmental level.
 Don’t become preoccupied with writing.
 Be non-judgmental.
 Avoid “why?” questions; they tend to put patients on the defensive.
 Take a good look at your patient’s nonverbal behavior.
 Never pass up an opportunity to teach.
 Present reality.
 Be honest.
 Provide reassurance and encouragement.
 Be respectful.
INTERVIEWING PITFALLS
 Avoid the following traps when interviewing a patient:
 Leading the patient
 Biasing yourself.
 Letting family members answer for patient.
 Asking more than one question at a time.
 Not allowing enough response time.
 Using medical jargon.
 Assuming rather than clarifying and validating.
 Feeling personally uncomfortable.
 Offering false reassurance.
 Asking persistent or probing questions. REMEMBER: The patient has a right to not answer a
 question.
 Changing the subject.
 Taking things literally.Patients who have difficulty expressing feelings directly may use figurative language.
 Giving advice.
 Jumping to conclusions.

OBSERVATION
- the second method of data collection is observation.
- entails deliberate use of your senses of sight,smell,and hearing to collect data.Look at both your patient and his or her
environment to detect anything out of the ordinary.
- Ask yourself:
 Does the patient show signs of physical or psychological stress?
 Does the patient seem comfortable?
 What is the patient doing?
 What position is she or he assuming?
 Are there any abnormal movements?
 What is the patient’s body language telling you?
 Is the patient’s verbal language consistent with his or her nonverbal language?
 Do you notice any unusual odors?
 Do you hear any unusual sounds?
 Is there anything unusual, unsafe, or risky in the patient’s environment?

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- Look for:
 Facial expression, color changes, breathing problems
 Grimacing, guarding, diaphoresis
 Eye contact
 Tone of voice and flow of speech
 Position: orthopnea
 Grooming and dress
 Nervousness, restlessness, voluntary/involuntary movements
 Unusual odors,such as fruity smell associated with diabetic ketoacidosis, or foul odors
 Drainage associated with infection
 Unusual sounds, such as grunting, wheezing, rhonchi, or stridor associated with respiratory problems, or
swishing sounds associated with murmur

NCM 101 Health Assessment - Lecture

Hand out #2

PHYSICAL ASSESSMENT
 Four techniques of physical assessment:
1. Inspection - look at your patient and compare her or his appearance with what you know as normal
2. Palpation - use light touch to assess surface characteristics, to put your patient at ease.Use deep palpation to assess
organs and masses.
3. Percussion - use direct, indirect, and fist percussion to assess organ size and areas of tenderness.
4. Auscultation - listen to your patient directly and indirectly to hear sounds produced by the body.

VALIDATING, ORGANIZING, & PRIORITIZING DATA

Validating Data
- process of confirming or verifying that the subjective and objective data you have collected are reliable and accurate.
- Methods of Validation
 Recheck your own data through a repeat assessment.
 Clarify data with the client by asking additional questions.
 Verify the data with another health care professional.

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  Compare your objective findings with your subjective findings to uncover discrepancies.

Organizing Data
- framework that address the physical, psychosocial, and spiritual needs of a patient in a holistic approach.
- common frameworks include the following:

Maslow’s Hierarchy of Human Needs: Organizes data according to the patient’s basic human needs: physiological,
safety and security, love and belonging, selfesteem, and self-actualization.

Roy’s Adaptation Theory: Organizes data according to the patient’s adaptation to physiological, self-concept, social
role, and interdependence demands.

Gordon’s Functional Health Patterns: Organizes data into 11 functional groups that contribute to a person’s overall
health and well-being, quality of life, and attainment of human potential.

Prioritizing Data
Top-priority or primary problems—such as airway problems—are life-threatening.

Secondary problems— such as pain—require prompt attention to prevent further

progression or deterioration in your patient’s condition.

Third-level problems—such as teaching needs—do not require immediate attention and can be
addressed once your patient’s condition has stabilized.
DOCUMENTING FINDINGS
a. Computerized documentation (checklist format)
b. Narrative format
c. Methods of problem-oriented documentation are
 SOAPIE
 PIE
 FDAR
DOCUMENTATION TIPS
 Be brief and to the point.
 Use acceptable abbreviations.
 If documentation is handwritten, make sure writing is legible.
 No need to write in complete sentences.
 State the facts. Avoid interpretations.

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  Avoid terms such as “normal,” “good,” “usual,” and “average.”
 Avoid generalizations.
 Document sequentially, in chronological order.
 Do not leave blanks or skip lines.
 Use correct spelling and grammar.
 No erasures or whiting out.
 Record date and time and sign your full signature.
NURSING HEALTH HISTORY
The purpose of the health history is to:
 Provide the subjective database.
 Identify patient strengths.
 Identify patient health problems, both actual and potential.
 Identify supports.
 Identify teaching needs.
 Identify discharge needs.
 Identify referral needs.
TYPES OF HEALTH HISTORY
COMPLETE HEALTH HISTORY includes biographical data, reason for seeking care, current health status, past health
status, family history, a detailed review of systems, and a
psychosocial profile.

FOCUSED HEALTH HISTORY focuses on an acute problem, so all of your questions will relate
to that problem.

COMPONENTS OF HEALTH HISTORY

 biographical data
 reason for seeking care
 current health status
 past health status
 family history
 a detailed review of systems
 psychosocial profile (developmental considerationl)
CURRENT HEALTH STATUS
-PQRST
-COLDSPA

■ Precipitating/Palliative Factors
Ask:What were you doing when the problem started? Does anything make it better,such as medications or certain
positions? Does anything make it worse,such as movement
or breathing?

■ Quality/Quantity
Ask: Can you describe the symptom? What does it feel like,look like,or sound like? How often are you experiencing it?
To what degree does this problem affect your ability to perform your usual daily activities?

■ Region/Radiation/Related Symptoms
Ask: Can you point to where the problem is? Does it occur or spread anywhere else? (Take care not to lead your patient.)
Do you have any other symptoms? (Depending on the chief complaint, ask about related symptoms. For example, if the
patient has chest pain, ask if she or he has breathing problems or nausea.)

■ Severity
Ask: Is the symptom mild, moderate, or severe? Grade it on a scale of 0 to 10, with 0 being no symptom and 10 being the
most severe. (Grading on a scale helps objectify the symptom.)

■ Timing
Ask: When did the symptom start? How often does it occur? How long does it last?

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DEVELOPMENTAL CONSIDERATIONS
- The last part of your health history is taking a psychosocial profile, but before you do this, consider the developmental
stage of your patient.

SUMMARY OF DEVELOPMENTAL THEORIES

Theorist Theory Focus
Sigmund Freud Psychosexual: Biological drives influence a person’s psychological and personality
development.
Erik Erikson Psychosocial: The human life cycle is composed of eight developmental stages, each
containing a developmental crisis to be resolved. Psychosocial strengths emerge with
resolution of the crisis.
Abraham Maslow Self-actualization: People are innately motivated toward psychological growth, self-
awareness,
and personal freedom. Basic needs must be met before a person can advance to higher needs
Jean Piaget Cognitive development: An individual’s knowledge comes from the interaction between
genetic
potential and culturally influenced environmental experiences.
Lawrence Kohlberg Moral development: Cognitive development and emotional growth affect the individual’s
ability to
make autonomous decisions.
Carol Gilligan Moral development from a female perspective: Women have moral concern for others based
on
their innate nurturing instincts. They maintain social rules and the expectations of families,
social groups, or culture
Evelyn Duvall Family development: Family goes through identifiable stages with tasks to be mastered.

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SAMPLE HEALTH HISTORY FORM

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 SAMPLE 1 SAMPLE 2

APPROACH TO PHYSICAL ASSESSMENT

PHYSICAL EXAMINATION
-is a process during which you use your senses
to collect objective data.

PURPOSE OF PHYSICAL EXAMINATION

 identify actual or potential health problems

TYPES OF PHYSICAL EXAMINATION

Complete physical assessment
 general survey
 vital sign measurements
 assessment of height and weight
 physical examination of all structures, organs,
 and body systems.

Focused physical assessment

 assess only the parts of the body that relate to that problem
 It is usually performed when your patient’s condition
 is unstable,as a follow-up to
a complete assessment,or when you are pressed for time.

TECHNIQUES OF PHYSICAL ASSESSMENT

INSPECTION

1. Direct inspection involves directly looking at your patient.

2. Indirect inspection involves using equipment to enhance visualization.
For example, the oto/ophthalmoscope allows better
visualization of the ears and eyes; and specula,
such as the nasal speculum and vaginal speculum,
open and illuminate,allowing for better visualization.
Guidelines:
 adequate lighting and sufficiently expose the area being assessed.
 be systematic in approach (head to toe)
 be comparative when possible. Ask yourself, “Does it look the same on the left side as the right?”
 look for surface characteristics such as color, size, and shape.
 look for gross abnormalities or signs of distress.
 notice any unusual odors or hear any unusual sounds
 view your findings in light of the patient’s growth and developmental stage and cultural background,which may
influence your interpretation

PALPATION
- using the sense of touch
- assess surface characteristics, such as texture, consistency, and
temperature, and allows you to assess for masses,
organs, pulsations, muscle rigidity, and chest excursion.

1. Light palpation

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- is best for assessing surface characteristics, such as temperature, texture,mobility,shape,and size.It is also useful in
assessing pulses, areas of edema, and areas of tenderness.

2. Deep palpation
a. Single-handed - is applying harder pressure with your fingertips or pads over an area
b. Bimanual - is used to assess organ size, detect masses, and further assess areas of tenderness.

To assess for rebound tenderness, press down firmly with your dominant hand and then lift it up quickly. An increase in
the patient’s pain when you release the pressure signals
rebound tenderness.

Parts of Hands Used in Palpation

PERCUSSION
- is used to assess density of underlying structures, areas of tenderness, and deep tendon reflexes (DTRs). It entails
striking a body surface with quick, light blows and eliciting vibrations and sounds.
1. Direct percussion - tapping your hand or fingertip over a body surface
2. Indirect percussion - using a percussion hammer to test reflexes
3. Fist or blunt percussion - is used to assess for organ tenderness

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AUSCULTATION
- involves using your sense of hearing to collect data
- listen to sounds produced by the body, such as heart sounds,lung sounds,bowel sounds,and vascular sounds.
1. Direct auscultation- is listening for sounds without a stethoscope
2. Indirect auscultation- with a stethoscope
Guidelines:
 Always have earpieces pointing forward to seal the ear canal. Warm your stethoscope.
 Work on the patient’s right side. This stretches your stethoscope across the patient’s chest and minimizes
interference.
 Never listen through clothes.
 Make sure that the environment is quiet.
 If hair is a problem, wet it to minimize artifact.
 Use light pressure to detect low-pitched sounds
 Use firm pressure to detect high-pitched sounds.
 Close your eyes to help you focus.
 Learn to become a selective listener.
 Most of all—practice!

APPROACH TO THE PHYSICAL ASSESSMENT ( PATIENTS WITH SPECIAL NEEDS)

Children
 Infants: Allow parents to be present and to help, if appropriate.
 Children 1 to 2 years old: May be fearful,so use games or toys during examination. Leave eye, ear, and mouth
 assessment until last.
 Children 2 to 3 years old: Most difficult to examine.May cling to parents, so let parents help.Allow child to see
 and touch equipment. Demonstrate use of equipment on doll or parent.
 Children 4 to 5 years old: More cooperative; respond well when play is incorporated into examination.
 School-age children: Usually cooperative;can converse and follow instructions.
 Adolescents: May be sensitive and modest.May not want parent present during examination. Let patient know that it
is okay to ask questions.

Pregnant Patients
 Assess both the mother-to-be and the fetus.
 Include fundal heights and fetal heart tones in the examination.
 Assess for normal changes that occur during pregnancy.
 Pay special attention to nutritional assessment.
 Remember that patient may have difficulty changing or assuming positions during last trimester.
 Be aware that hormonal swings may exaggerate patient’s responses.

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Elderly Patients
 Do not rush.
 Look for developmental changes.
 Do not assume.For example,your patient may be elderly, but that does not mean he or she is hard of hearing.
 Conserve your patient’s energy by minimizing position
 changes and helping her or him change positions as needed.
 Allow enough time for patient to respond to questions or instructions.

Disabled Patients
 Identify the disability.
 Focus on the patient’s functional ability and mental capacity
 Modify your assessment based on the patient’s assets and needs. For example, if he or she is deaf, you may need to
write instructions or have someone available who can sign.
 Be alert and sensitive to your patient’s needs,especially if she or he is unable to communicate verbally

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TOOLS OF PHYSICAL ASSESSMENT

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 ASSESSMENT OF SKIN, HAIR, AND NAILS

SKIN

The Skin is the largest organ of the body, with a total area of about 20 square feet.
The skin protects us from microbes and the elements,
helps regulate body temperature, and permits the sensations of touch, heat, and cold.
Skin has three layers:
1. The epidermis, the outermost layer of skin,
provides a waterproof barrier and creates our skin tone.
2. The dermis, beneath the epidermis, contains tough connective tissue,
hair follicles, and sweat glands.
3. The deeper subcutaneous tissue (hypodermis) is made of fate and connective
tissue

The skin’s color is created by special cells called melanocytes, which produce the pigment melanin. Melanocytes are
located in the epidermis.

Skin conditions
• Rash: Nearly any change in the skin's appearance can be called a rash. Most rashes are from simple skin irritation; others
result from medical conditions.
• Dermatitis: A general term for inflammation of the skin. Atopic dermatitis (a type of eczema) is the most common form.
• Eczema: Skin inflammation (dermatitis) causing an itchy rash. Most often, it's due to an overactive immune system.
• Psoriasis: An autoimmune condition that can cause a variety of skin rashes. Silver, scaly plaques on the skin are the most
common form.
• Dandruff: A scaly condition of the scalp ray be caused by seborrheic dermatitis, psoriasis, or eczema.
• Acne: The most common skin condition, acne affects over 85% of people at some time in life. Cellulitis: Inflammation
of the dermis and subcutaneous tissues, usually due to an infection. A red, warm, often painful skin rash generally results.
• Skin abscess (boil or furuncle): A localized skin infection creates a collection of pus under the skin. Some abscesses
must be opened and drained by a doctor in order to be cured.
• Rosacea: A chronic skin condition causing a red rash on the face. Rosacea may look like acne, and is poorly understood.
• Warts: A virus infects the skin and causes the skin to grow excessively, creating a wart. Warts may be treated at home
with chemicals, duct tape, or freezing, or removed by a physician.
• Melanoma: The most dangerous type of skin cancer, melanoma results from sun damage and other causes. A skin biopsy
can identify melanoma.
• Basal cell carcinoma: The most common type of skin cancer. Basal cell carcinoma is less dangerous than melanoma
because it grows and spreads more slowly.

HAIR

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Hair is simple in structure, but has important functions in social functioning. Hair is made of a tough protein called keratin. A hair
follicle anchors each hair into the skin. The hair bulb forms the base of the hair follicle. In the hair bulb, living cells divide and grow
to build the hair shaft. Blood vessels nourish the cells in the hair bulb, and deliver hormones that modify hair growth and structure at
different times of life.

Hair growth occurs in cycles consisting of three phases:

• Anagen (growth phase): Most hair is growing at any given time. Each hair spends in this phase.
• Catagen (transitional phase): Over a few weeks, hair growth slows and the hair follicle shrinks.
• Telogen (resting phase): Over months, hair growth stops and the old hair detaches hair follicle. A new hair begins the
growth phase, pushing the old hair out.

Hair grows at different rates in different people; the average rate is around one-half inch per month. Hair color is created by pigment
cells producing melanin in the hair follicle. With aging, pigment cells die, and hair turns gray.

NAILS

The nail organ is an integral component of the digital tip. It is a highly versatile tool that protects the fingertip,
contributes to tactile sensation by acting as a counterforce to the fingertip pad, and aids in peripheral thermoregulation via
glomus bodies in the nail bed and matrix. Because of its form and functionality, abnormalities of the nail unit
result in functional and cosmetic issues. The structures that define and produce the nail (nail plate) include the matrix
(sterile and germinal), the proximal nail fold, the eponychium, the paronychium, and the hyponychium
(see the image). Collectively, the nail bed (sterile matrix),nail fold, eponychium, paronychium, and
hyponychium are referred to as the perionychium.All nail growth occurs at the nail's base, where the specialized cells that
make up the nail's plate are produced; these cells are pushed forward as new cells form behind them. The nail plate is also
attached to the underlying, richly vascularized nail bed, which supplies the plate with necessary nutrients.

CALAMBA DOCTORS’ COLLEGE

Virborough Subdivision, Parian, Calamba City, Laguna

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 Performance Evaluation Checklist

Name: ________________________ Date:_______________

Year and Section: _______________

PERFORMING ASSESSING SKIN, HAIR AND NAILS

INSTRUCTION: Rate the nursing skill performance of the student based as follows:
5 = Perfect (91-100) 4 = Very Satisfactory (85-90) 3 = Satisfactory (80-84) 2 = Poor (79-75) 1 = Need Improvement (74 and below)

ASSESSMENT SKILL 5 4 3 2 1 Comments

1.Gather equipment ( gloves, exam light, penlight,
magnifying glass, centimeter ruler ).
2.Explain procedure to client
3.Ask client to gown
SKIN
Note any distinctive odor.
Inspect for generalized color variations (brownness yellow,
redness, pallor, cyanosis, jaundice, erythema, vitiligo)
Inspect for skin breakdown.
Inspect for primary, secondary, or vascular lesions, ( Note
size, shape, location, distribution, and configuration).
Palpate lesions.
Palpate texture (rough, smooth) of skin, using palmar
surface of three middle fingers.
Palpate temperature (cool, warm, hot) and moisture (dry,
sweaty, oily) of skin, using dorsal side of hand.
Palpate thickness of skin with fingerpads.
Palpate mobility and turgor by pinching up skin over
sternum
Palpate for edema, pressing thumbs over feet or ankles.
SCALP AND HAIR
Inspect color
Inspect amount and distribution.
Inspect and palpate for thickness, texture, oiliness, lesions,
and parasites.
NAILS
Inspect for grooming and cleanliness
Inspect for color and markings.
Inspect shape.
Palpate texture and consistency.
Test for capillary refill.
TOTAL RATING

STUDENT SIGNATURE: __________________________

CLINICAL INSTRUCTORS SIGNATURE: ____________

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 ASSESSMENT OF HEAD, FACE AND NECK

SKULL & FACE ASSESSMENT

There is a large range of normal shapes of skulls. A normal head size is referred to as normocephalic. If head size appears
to be outside of the normal range, the circumference can be compared to standard size tables. Measurements more than
two standard deviations from the norm for the age, sex and race of the client are abnormal should be reported to the
primary care provider. Names of areas of the head are derived from names of the underlying bones: frontal, parietal,
occipital, mastoid process, mandible, maxilla and zygomatic

Many disorders cause a change in facial shape or condition. Kidney or cardiac disease can cause edema of the eyelids.
Hyperthyroidism can cause exophthalmos, a protrusion of the eyeballs with elevation of the upper eyelids resulting in a
startled or staring expression. Hypothyroidism or myxedema, can cause a dry, puffy face with dry skin and coarse features
and thinning of scalp hair and eyebrows.

Increased adrenal hormone production or administration of steroids can cause a round face with reddened cheeks, referred
to as moon face, and excessive hair growth on the upper lips, chin and sideburn areas. Prolonged illness, starvation and
dehydration can result in sunken eyes, cheeks and temples

INFANTS

• Newborns delivered vaginally can have elongated, molded heads, which take on more rounded shapes after a week or
two. Infants born by cesarean section tend to have smooth, rounded heads.

• The posterior fontanel (soft spot) is about 1 cm (0.4 in.) in size and usually closes by 8 weeks. The anterior fontanel is
larger, about 2 to 3 cm (0.8 to 1.2 in.) in size. It closes by 18 months.

• Newborns can lift their heads slightly and turn them from side to side. Voluntary head control is well established by 4 to
6 months.

NECK

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Neck, in land vertebrates, the portion of the body joining the head to the shoulders and chest. Some important structures
contained in or passing through the neck include the seven cervical vertebrae and enclosed spinal cord, the jugular veins
and carotid arteries, part of the esophagus, the larynx and vocal cords, and the sternocleidomastoid and hyoid muscles in
front and the trapezius and other nuchal muscles behind. Among the primates, humans are characterized by having a
relatively long neck.
The neck is a complex anatomic region between the head and the body. In the front, the neck extends from the bottom part
of the mandible (lower jaw bone) to the bones of the upper chest and shoulders (including the sternum and collar bones).
The back of the neck is mostly comprised of muscles, as well as the spine.

CALAMBA DOCTORS’ COLLEGE

Virborough Subdivision, Parian, Calamba City, Laguna

29
 Performance Evaluation Checklist

Name: ________________________ Date:_______________

Year and Section: _______________

PERFORMING ASSESSMENT OF THE HEAD, FACE, AND NECK

INSTRUCTION: Rate the nursing skill performance of the student based as follows:
5 = Perfect (91-100) 4 = Very Satisfactory (85-90) 3 = Satisfactory (80-84) 2 = Poor (79-75) 1 = Need Improvement (74 and below)

ASSESSMENT SKILL 5 4 3 2 1 Comments

1. Gather equipment (gloves, penlight or flashlight, small
glass of water, stethoscope)
2. Explain procedure to client.
HEAD AND FACE
1. Inspect head for size, shape and configuration
2. Palpate head for consistency while wearing gloves.
3. Inspect face for symmetry, features, movement,
expression and skin condition.
4. Palpate temporal artery for tenderness and elasticity.
5. Palpate temporo-mandibular joint for range of motion,
swelling tenderness, or crepitation by placing index
finger over the front of each and asking client to open
mouth. Ask if client has history of frequent headaches
NECK
1. Inspect neck while it is in a slightly extended position
(and using a light) for position, symmetry, and
presence of lumps and masses.
2. Inspect movement of thyroid and cricoid cartilage and
thyroid gland by having client swallow a small sip of
water.
3. Insect cervical vertebrate by having client flex neck
4. Inspect neck range of motion by having client turn
chin to right and left shoulder, touch each ear to the
shoulder, touch chin to chest, and lift chin to ceiling.
5. Palpate trachea by placing your finger in the sternal
notch, feeling to each side, and palpating the tracheal
rings.
6. Palpate the thyroid gland.
7. Auscultate thyroid gland for bruits if the gland is
enlarged (use bell of stethoscope).
8. Palpate lymph nodes for size/shape, delimination,
mobility, consistency, and tenderness (refer to display
to display on characteristics of lymph nodes).
a. Preauricular nodes (front of ears)
b. Postauricular nodes (behind the ears)
c. Occipital nodes (posterior base of skull)
d. Tonsillar nodes (angle of the mandible, on the anterior
edge of the sternocleidomastoid muscle).
e. Submandibular nodes (medial border of the mandible;
don't confuse with the lobulated submandibular gland.
f. Submental nodes ( a few centimeters behind the tip of

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 the mandible); use one hand.
g. Superficial cervical nodes ( superficial the
sternomastoid muscle).
h. Posterior cervical nodes (posterior to the
sternocleidomastoid and anterior to the trapezius in the
posterior traingle).
i. Deep cervical chain nodes (deep within and around the
sternomastoid muscle).
j. Supraclavicular nodes (hook fingers over clavicles and
feel deeply between the clavicles and the
sternomastoid muscles)
TOTAL RATING

STUDENT SIGNATURE: __________________________

CLINICAL INSTRUCTORS SIGNATURE: _____________

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