SKIN ASSESSMENT
Steps Notes or comments
1. Greet the patient
2. Introduce yourself
3. Explain the procedure to the Skin is examined to check for any
patient changes in color, tone or
hyperpigmentation that occur to know
any unexpected or sudden changes on
the skin that may lead to disease or
infection, etc. so checking the skin can
warn us in the initial stage.
4. Provide privacy
5. Perform hand hygiene
6. Make sure the patient is wearing
a hospital gown
7. Inspect general appearance of
the skin
8. Examine hair and scalp by Note for distribution, texture, quantity
parting hair using a cotton of hair
applicator or tongue depressor
9. Inspect the head and neck Including the eyes, eyelids,
including forehead conjunctiva, sclerae, eyelash,
eyebrows, nose, cheeks, lips, oral
cavity
10. Ask permission to expose back
by moving the gown
11. Inspect the shoulders, arms,
hands
12. Inspect and palpate fingernails. Note color, shape, any lesions
13. Inspect chest and abdomen
14. Inspect thigh and lower legs
15. Inspect and palpate toenails and Note color, shape, any lesions
insoles
16. Ask the patient to stand to check
lower back and posterior legs
17. To assess for mobility, lift a fold a. Note the ease with which it is
of skin move
b. Then note for the speed with
which it returns into place to
assess for turgor
18. Examine the breasts and Saved for last; ask permission first
genitalia from the patient and if possible, have a
female/male clinician when doing this
depending on the gender of the
patient.
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HEENT ASSESSMENT
Steps Notes/Comments
1. Greet the patient
2. Introduce yourself
3. Explain the procedure to the patient
4. Provide privacy
5. Perform hand hygiene
6. HEAD Observe for facial drooping, ptosis, goiter,
a. General Inspection: etc.
Assess patient’s:
- General appearance
- Facial symmetry
- Any abnormalities noted
7. Sinus palpation
- Apply pressure to the patients’
sinuses in order to assess for
any pain. Pain can suggest a
possible underlying infection.
Technique to test for sinus tenderness:
1. Using the thumb of both
hands, press up on the frontal
sinuses (at the roof of the
nose, below the eyebrows),
avoiding pressure on the
eyes
2. Then press up on the
maxillary sinuses
8. Eyes
a. External inspection:
-Assess for jaundice,
bleeding, infection,
inflammation, etc.
b. Red reflex:
-Using an ophthalmoscope,
you can shine the light in a
patient’s eyes and visualize
the “red reflex” in both eyes.
The wrong color in this reflex
can indicate serious
conditions.
9. EARS Some basic tips for using the otoscope:
a. External inspection: hold the scope near the head, pull back
on the ear you are examining with the
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- Do general inspection hand that is not holding the otoscope (in
without using an otoscope order to straighten the ear canal), and
first. brace your pinky against the patient’s
b. Otoscopic examination: skull (to avoid rapid movements that will
- Using an otoscope, assess cause the scope to go too deep into the
the internal structures of the canal). Note for presence of cerumen,
ear. intact tympanic membrane, etc.
c. Hearing tests
1. Weber test:
o Place the base of ® The sound is heard in the midline
the lightly vibrating or equally on both ears
tuning fork firmly
on top of the
patient’s head or
midforehead
o Ask where the
patient hears it-on
one or both ears
2. Rinne Test:
o Place the base of
the lightly vibrating
tuning fork on the
mastoid bone
(behind the ear
and level with the
canal) and ask if
the patient hears a
vibration
o When the patient
can no longer hear ® The U of the fork should face
the sound, quickly forward, which maximizes the
place the fork close sound transmission for the patient.
to the ear canal ® Normally, the sound is heard
and ask if the longer through air than through
patient hears a bone (AC>BC)
vibration.
10. NOSE
a. Sense of smell:
- Ask the patient if they have
observed any issues with
their sense of smell.
b. External inspection Note for any abnormalities present.
c. Internal inspection:
- Using the otoscope, assess
both nasal openings/canals
for any abnormal findings.
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11. THROAT
a. External inspection of mouth:
- are the lips cracked? Any
external findings?
b. Inspection of oral cavity:
- visually we can look for any
abnormal findings within the
oral cavity.
• Make sure to look -if you find anything that is out of the
behind the lips and ordinary, ask the patient about it,
under the tongue as characterize it (any pain, what does it look
well! like, where is it, etc.) and follow up!
• You can also, use this
as an opportunity to
ask the patient if they
have access to routine
dental care!
c. Palpation of the oral cavity: if
time allows, or unusual
findings suggest the need to
do so, gloving up
and palpating within the oral
cavity (under the tongue as
well).
d. Oropharynx: looking in the
back of the throat with help of
a tongue depressor.
12. NECK
a. Inspection Note for any lumps or lesions
b. Palpate
• Lymph nodes are one We are looking to find any unusual
example of structures manifestations (enlarged size, abnormal
we want to palpate for feel/rigidity, pain).
(even if nothing is
seen visibly).
Technique of lymph node palpation of the
neck:
1. Use the pad of the 2nd and 3rd
fingers to palpate the different lymph
nodes with a gentle rotary motion
moving the skin over the underlying
tissues in each area:
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a. Pre-auricular nodes (in front
of the ear)
b. Posterior auricular (behind
the ear)
c. Occipital (base of the skull)
d. Tonsillar (angle of the
mandible)
e. Submandibular (below the
mandible)
f. Submental (below the chin)
g. Superficial cervical (top of
proximal 3rd of SCM)
h. Posterior cervical (posterior
triangle and anterior to the
trapezius)
i. Supraclavicular
(supraclavicular area)
Technique for thyroid test:
a. Stand behind the patient (this can While realistically an ultrasound (and
make the maneuver less awkward) further imaging) will be more informative
b. Ask the patient to flex the neck if we suspect abnormalities with the
slightly forward to relax the SCM thyroid, in the absence of a clear goiter,
c. Feel for the adman’s apple we can palpate the thyroid in the following
(laryngeal prominence) with both manner.
fingers.
d. Place the fingers of both hands on
the patient’s neck so that your index
fingers are just below the cricoid
cartilage
e. Ask the patient to sip and swallow
water as before. Feel for the thyroid
isthmus moving up under your finger
pads. It is often but not always
palpable.
f. Displace the trachea to the right with
the fingers of the left hand; with the Not the size, shape, and consistency of
right-hand fingers, palpate laterally the gland and identify any nodules or
for the right lobe of the thyroid in the tenderness
space between the displace trachea
and the relaxed SCM. Find the Feeling/not feeling the thyroid can both
lateral margin. In similar fashion, be normal findings.
examine the left lobe
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Technique for palpation for tracheal
deviation:
1. Place your finger along the right side
of the trachea and note the space
between it and the SCM
2. Do the same maneuver along the
left side or the trachea and compare
both sides if symmetrical
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