BUKIDNON STATE UNIVERSITY

COLLEGE OF NURSING
Health Assessment RLE

Date Performed: Final Grade:

Clinical Instructor:

Assessing the Integumentary system

Definition:

Objectives:
1.

2.

3.
Safety/Security Measures:
1.

2.

3.
Pre-procedural Preparations:
1. Wash hands
2. Introduce yourself to the client and identify client’s identity. Explain what you are going to
do, why it is necessary, and how the client can cooperate.
3. Gather the necessary equipment.
4. Provide Privacy
Equipment:
Millimeter Ruler, Examination gloves, Magnifying glass

Procedure Able to perform Unable to

perform

1. Inquire if client has any history of the following:

 Pain or itching
 Presence and spread of any lesions, bruises, abrasions, or
pigmented spots
 Skin problems
 Associated clinical signs
 Problems in other family members
 Related systemic conditions
 Use of medications, lotions, or home remedies
 Excessively dry or moist feel to the skin
 Tendency to bruise easily
 Any association of the problem to a season of the year
Assessment
2. Inspect skin color.
3. Inspect uniformity of skin color.
4. Assess edema, if present.
 BUKIDNON STATE UNIVERSITY
COLLEGE OF NURSING
Health Assessment RLE
5. Inspect, palpate, and describe skin lesions. Apply gloves if
lesions are open or draining.

6. Describe lesions according to location, distribution, color,

configuration, size, shape, type, or structure.

Assess for Malignant Lesions [2]

A=symmetry
B=Border of irregularity
C=Color variation
D=Diameter> 0.5 cm
7. Observe and palpate skin moisture. [1] Palpate for tenderness
and surface characteristics of any lesions. [2]
8. Palpate skin temperature.
Compare the client’s two feet and the two hands using the dorsal
part of the nurse’s hand [2]
9. Note skin turgor by lifting and pinching the skin on an
extremity.
10. Check for blanching of vascular lesions
11. Document findings in the client record. Draw the location of
skin lesions on body surface diagrams.
12. Ability to Answer questions
13. Definition
14. Objectives
15. Safety/Security Measures
Total Score
Equivalent Grade

Remarks:
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Name and Signature of Instructor:

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