INTEGUMENTARY
moisture
1) assess clients history (lesions, rashes, trauma)
❖ Identify any symptom related to the
integumentary system, risk factors for skin
problems, presence of diseases in other
systems that could contribute to skin
problems.
❖ RISK FACTORS FOR SKIN PROBLEMS
- Nutritional deficiencies
- Genetic predisposition
- Repeated injury/irritation
- Race and age
- Excessive sun exposure
- Harsh soaps or other harsh cleaning
products
- radiation/chemicals/environmental
pollutions
- Medication
- Infection
- Systemic illness (HIV/AIDS)
- stress
2) EXAMINE THE PATIENT;S SKIN, NOTING
COLOR, ODOR, AND THE PRESENCE OF
LESIONS (DESCRIBING MORPHOLOGY,
DISTRIBUTION, PATTERN, AND LOCATION)
❖ The client’s skin is uniform in color,
unblemished and no presence of any foul
odor.
❖ No edema
Papules - a papule is a raised area of skin tissue
that’s less than 1 centimeter around. A papule can
have distinct or indistinct borders. It can appear in a
variety of shapes, colors, and sizes. It’s not a
diagnosis or disease.
Macule - a macule is a flat, distinct, discoloured
area of skin less than 1 centimeter wide. It doesn’t
involve any change in the thickness or texture of
the skin.
Pustule - pustules are small bumps on the skin
that contain fluid or pus. They usually appear as
white bumps surrounded by red skin. Theme
bumps look very similar to pimples, but they can
grow quite big. Pustules may develop on any part
of the body, but they most commonly form on the
back, chest, and face.
3) PALPATE FOR SKIN:
❖ TEMPERATURE = warm, cold
❖ TURGOR = good skin turgor, poor skin
turgor
❖ MOISTURE = increased or decreased
❖ LESIONS = to determine whether a lesion
is raised, indented, and to determine its
surface characteristics.
❖ TEXTURE = soft and fine, coarse and thick
❖ TENDERNESS
❖ PULSATIONS
❖ BLANCHING = blanching of the skin occurs
when the skin becomes white or pale in
appearance.
4) INSPECT NAILS FOR COLOR, AND SHAPE
❖ Nail Beds = pinkish
❖ Cyanosis = hypoxia
❖ Shape = convex
5) PALPATE FOR NAIL TEXTURE AND
CAPILLARY REFILL
❖ CAPILLARY REFILL = determines the
dehydration and the amount of blood flow to
tissues.
❖ Texture = firm; clubbing = soft , boggy;
brittle
Nails are smooth and intact with the epidermis.
When nails are pressed between the fingers
(blanch test), the nails return to their usual color in
less than 2 seconds.
HEAD AND FACE
1) ASSESS THE CLIENT’S HISTORY (HEAD
TRAUMA, HEADACHES)
2) INSPECT HEAD FOR:
❖ Size
❖ Shape
❖ Symmetry of the facial features = check the
palpebral fissures and nasolabial folds.
❖ lesions
❖ Hair/hair distribution
❖ Conditions of the scalp
HAIR: The hair of the client is thick, silky hair is
evenly evenly distributed and has a variable
amount of body hair. There are also no signs of
infection and infestation observed.
❖ Can be black, brown, or burgundy
depending on the race.
❖ Evenly distributed covers the whole scalp
❖ No evidence of alopecia
❖ Maybe thick or thin, coarse or smooth.
❖ Neither brittle nor dry.

❖ HEAD: the head of the client is rounded,
normocephalic and symmetrical.
❖ SKULL
❖ Generally round, with prominences in the
frontal and occipital area. (normocephalic)
A. GENERAL APPEARANCE = no redness
and swelling; no secretions
B. EYELIDS = no swelling; no lesions
C. EYELASHES = equally distributed
D. EYEBALLS = no protrusion
E. LACRIMAL GLANDS = no swelling; no
redness; no drainage
F. CONJUNCTIVA = pinkish in color
G. PUPILS = equal size; PERRLA

3. Assess extra ocular muscle movement - 6

Cardinal Gaze Test

4. Assess the client’s visual field (peripheral vision)

and acuity (Snellen Chart)

❖ SKULL: there are no nodules or masses 5. Palpate eyeballs - consistency, symmetry.

and depressions when palpated. Palpate the lacrimal glands and ducts - no
❖ FACE: the face of the client appeared tenderness upon palpation.
smooth and has uniform consistency and
with no presence of nodules or masses. 6. Determine upper lid strength - no weakness; no
❖ FACE ptosis
❖ Observe the face for shape.
❖ Inspect for symmetry 7. Assess for blinking reflex - positive blinking
➢ Inspect for the palpebral fissure reflex.
(distance between the eyelids);
should be equal in both eyes.
➢ Ask the patient to smile. There
should be bilateral nasolabial folds
(creases extending from the angle of
the corner of the mouth). Slight
asymmetry in the fold is normal.
➢ If both are met, then the face is
symmetrical.

3) PALPATE FOR TENDERNESS, MASSES, AND

TEMPORAL PULSE
❖ SKULL
➢ No tenderness noted upon palpation

❖ SCALP
➢ No tenderness or masses on
palpation

1. ASSESS HISTORY OF VISUAL PROBLEMS,

PAIN, AND DRAINAGE
❖ Example: history of conjunctivitis, cataract,
glaucoma, diabetes mellitus.

2. INSPECT EXTERNAL STRUCTURE OF THE

EYE’S