HAND WASHING
Good morning, Ma’am. I’m Kimberly D. Catalan your student nurse for today. Before anything else may I know your
name and birthdate?
For today I’m going to assess your skin hair and nails this is to know patient’s health status. I would just like to tell you
that there are some procedures that it will have skin contact. so, if you fill uncomfortable just tell me, is that okay with
you ma’am?
ASSESSING THE INTEGUMENTARY
SYSTEM
A. Skin
1. Inspects color, odor, and
skin integrity
a. Inspects exposed
area
b. Inspects unexposed
area
c. Inspects oral
mucosa
d. Pulls down eyelids
to examine
conjunctiva
e. Notes for any
unusual odor
chuchu
So, I will now inspect your skin color odor and skin integrity.
May I ask you to open your mouth for me to check your oral mucosa. And
can you pull down your eyelids. (do the pikat thing)
“For the skin color it is fairly the same with the unexposed areas, oral
mucosa is pink and appear moist, the conjunctiva appears pink, and the
sclera is white in color “
Inspect general skin coloration
There are no unusual or prominent discolorations
Odor
Client has no odor of perspiration.
Skin integrity
Skin is intact, and there are no reddened areas.
2. Inspects presence of
lesions.
a. Describes lesions if
primary or
secondary
b. Identifies specific
type of lesion
c. Verbalizes ABCD of
assessing vascular
lesions
Lesion
3. Palpates skin temperature
a. Uses dorsum of the
hand
b. Compares both
sides
Palpate to assess temperature.
4. Palpates for skin turgor.
a. Tests turgor on the
unexposed area of
the skin
b. Tests turgor by
gently pinching a
fold of the skin
5. Palpates skin for texture
and moisture.
a. Uses light palpation
to assess moisture
b. Uses light palpation
to assess moisture
B. Hair
1. Inspects color, quantity,
and hair distribution.
So next I will check if you have presence of lesions both lower and upper
extremities.
Skin is smooth, without lesions
Since there is no presence is lesions, we will not identify the type and the
vascular lesions which are asymmetry, border, color, diameter, and
elevating.
So now Ma’am I will palpate your skin to know if your temperature in both
sides is the same.
Skin is normally a warm temperature same with other side.
Palpate to assess mobility and turgor.
May I ask If I could touch your arm so that I could do test turgor to you?
Is that okay with you Ma’am?
The skin is mobile, with elasticity and returns to original shape quickly.
The skin is moist and smooth.
So, after the skin, I will now inspect your hair for its color, quantity, and
hair distribution.
Is it okay if I can touch your hair Ma’am?
So, your hair color is black/brown. Distribution of hair equally distributed
and it is smooth and silky
2. Inspects scalp for
condition, presence of
lesion or infestations.
So, Ma’am I will now inspect your scalp.
a. Retracts hair while
inspecting the scalp
3. Palpates scalp for texture,
tenderness, mobility.
a. Uses light palpation
to assess hair
b. Uses light palpation
to assess scalp
C. Nails
1. Inspects nails
a. Inspects nails of both
hands for color
b. Inspects nail shape
c. Instructs client to place
fingers together
d. Notes the space
(opening) between two
nails
Scalp is clean and dry. There is no Sparse dandruff. Hair is smooth and
firm, somewhat elastic. No presence of lesions and parasite.
Scalp is shiny, intact, without lesions or masses
After the hair I will now inspect your nails. So, for this can I ask to put
your nails in your lap.
Nails are clean. Nail shape is ____. Pink tones are seen. There is a 160degree angle between the nail base and the skin.
So, Ma’am may I ask to put your fingers together like this.
there is no presence of nail clubbing.
2. Palpates nail for texture
a. Uses light palpation
Nails are hard and basically immobile. Nails are smooth and firm; nail
plate is firmly attached to nail bed.
3. Checks capillary refill
a. Gently presses on
nail
b. Releases the nail
after blanching is
noted
c. Verbalizes the
speed of refill
So now Ma’am I will now check your capillary refill. So, I will just gently
press your nail. Is that okay with you Ma’am?
Pink tone returns immediately to blanched nail beds when pressure is
released.