GENERAL SURVEY AND ASSESSMENT OF INTEGUMENTARY
ASSESSMENT PROCEDURES
PREPARATION
1. Introduce yourself and verify
the client’s identity. Explain
to the client what you are
going to do, why it is
necessary, and how the client
can cooperate.
2. Perform hand hygiene and
observe other appropriate
infection control procedures.
3. Assemble equipment
4. Provide client privacy
GENERAL APPEARANCE & MENTAL STATUS
5. Observe for signs of distress
in posture or facial
expression.
WHAT TO DO FINDINGS
Hi Good Day, I am Luzel, your
student-nurse for today. Could you
please verify your first and last name
as well as your DOB just to make sure
that I am speaking with the right
person.
I don’t want to take much of your
time, so I’ll go ahead and explain why
we are conducting this assessment.
We will be doing some palpation of
certain parts of your body to assess
your skin, hair and nails and other
procedures and the reason why we
are conducting this assessment is
because it will provide important
information about your physical and
emotional health. You can cooperate
by following me on what to do. Will
that be fine with you.
I am now washing my hands as a
preventative measure that helps both
the patient and I, a healthcare
provider from potential infections.
I am now preparing the equipment to
be used in this assessment
• Paper and pen to document
all of the data that will be
collected
• Examination Gloves to
prevent potential
transmission of infection
• Weighing scale to get the
height and weight
• Tape measure to measure or
assess wound size, skin
lesions, and body
circumference
• Ruler to measure or assess
• Close the curtains to provide
privacy
• Close windows if open
• Check the room if it is well
lighted
How’s your day going Ma’am? No distress noted
By asking these types of questions, I DEVIATION: Bending over because of
am already observing for any signs of

6. Observe body build, height,
and weight in relation to the
client’s age, lifestyle, and
health.
7. Observe client’s posture and
gait, standing, sitting, and
walking.
8. Observe client’s overall
hygiene and grooming.
9. Note for body and breath
odor
10. Note obvious signs of health
or illness.
11. . Assess the client’s attitude.
12. Note the client’s
affect/mood; assess the
appropriateness of the
client’s responses.
13. Listen for quantity, quality,
and organization of speech
distress this can provide important abdominal pain, wincing, frowning,
clues about the patient’s emotional or labored
state and well-being and we can also breathing
better understand how someone is
feeling and if they are responding
appropriately.
Assess this along with observation of The patient’s body build, height, and
patient’s posture and gait by weight are proportionate and varies
instructing the patient to stand up, with lifestyle
walk, and sit.
DEVIATION: Excessively thin or obese
The patient is relaxed, has erect
posture and coordinated movement
DEVIATION: Tense, slouched,
bent posture, uncoordinated
movement, tremors, dirty,
unkempt
Look at the client's overall The patient’s overall appearance is
appearance; Look for any obvious clean and neat
signs of poor hygiene or grooming,
such as unkempt hair, body odor, or DEVIATION: Dirty, unkempt
dirty clothes.
Stand a few feet away from them and No body/breath odor or minor body
take a deep breath to detect any odor relative to work or exercise
body odor; Observe clothing.
DEVIATION: Foul body odor,
Observe their oral hygiene: Poor oral ammonia odor, acetone breath odor,
hygiene can lead to bad breath. foul breath
Observe the person's teeth and gums
for any signs of plaque or other oral
health issues.
Observe the patient’s appearance Healthy appearance
DEVIATION: Pallor, weakness,
obvious illness
“Ask the patient if they’re okay to Cooperative
proceed”
DEVIATION: Negative, hostile,
By asking questions to the patient, I withdrawn
am already able to assess if they are
being cooperative
Just mention that patient’s mood was The patient’s mood and responses
already assessed at the beginning of are appropriate to the situation
the interview
DEVIATION: Inappropriate to
situation
The patient is understandable,
speaking in a moderate pace, and
exhibits thought association.

SKIN
14. Inspect skin color.
15. Inspect uniformity of skin
color.
16. Inspect, palpate, and
describe skin lesions.
17. Observe and palpate skin
moisture.
18. Palpate skin temperature.
Look at the client's skin closely and
observe the color. Be sure to look at
different areas of the body, including
the face, arms, hands, legs, and feet.
By using natural light, I was able to
assess the skin color accurately.
Do the same procedure as inspecting
skin color
Ask the patient to roll up their
sleeves to check the uniformity of
skin color
Use your fingers to feel the skin and
note its texture, firmness, and any
tenderness or pain
• Start by observing the skin's
appearance.
• Touch the skin: Use your
fingertips to gently touch the
skin
• Palpate the skin to feel for
moisture
Common areas to assess skin
moisture include the forehead,
cheeks, back of the hands, arms, legs,
and feet
• Use the back of your hand:
The back of the hand is a
sensitive area that can detect
temperature changes more
accurately than the
fingertips.
• Start at the extremities.
• Move towards the center.
assess the temperature of
other areas, such as the
arms, legs, and torso.
DEVIATION: Rapid or slow
pace, overly loud or soft, uses
generalizations,
lacks association
The patient’s skin color varies from
light to deep brown, from ruddy
pink to light
Pink
DEVATION: Pallor, Cyanosis,
Jaundice, Erythema
The patient’s skin color is generally
uniform except
in areas exposed to sun; areas of
lighter pigmentation.
in dark skinned
DEVIATION: Areas of either
Hyperpigmentation
or Hypopigmentation
The patient has no
abrasion or other lesion; Freckles,
some birth marks,
some flat nevi.
DEVIATION: Various interruption
in skin integrity; irregular,
multicolored, or raised nevi
Moisture in skin folds
and the axillae, affected by different
factors. The patient has no signs of
flakey skin or rough texture. There’s
also not much of moisture given the
setting.
DEVIATION: Excessive moisture or
dryness
The patient’s temperature is
uniformed based on the parts of the
body that I have palpated; Within
normal range (36.5 C to 37.0C)
DEVIATION: Generalized/ Localized
hyperthermia/hypothermia

19. Palpate to assess for
presence of edema.
• Common areas to assess skin
temperature include the
forehead, cheeks, back of the
hands, chest, abdomen, back,
arms, legs, and feet
• Palpate for edema over the No presence of edema;
tibia (shin bone) as shown
here and behind the medial DEVIATION: Edema
malleolus (inner side of the
ankle), and over the dorsum
of each foot
• Push and hold on the said
parts for approximately 5
seconds.

20. Palpate to assess for skin
turgor.
• Assessing skin turgor is a
quick and easy way to
determine a person's level of
hydration.
• Pinch the skin: use thumb
and forefinger to pinch (back
of the hand or antecubital
fossa)
• skin over sternum, inner
aspects of thigh or forehead
The patient’s skin sprang back to its
previous state ( Turgor is considered
normal if the time for the skin to
return to the hand is less than 2
seconds and considered decreased if
> 2 seconds).
DEVIATION: Skins stays pinched or
tented or moves back slowly

21. Remove and discard gloves

and perform hand hygiene.
HAIR
22. Inspect the evenness of
growth over the scalp.
23. Inspect hair thickness or
thinness.
24. Inspect hair texture and
oiliness.
• Instruct the patient to The patient’s hair is evenly
remove hair tie if applicable distributed
• Look at the scalp
• Part the Hair: Look for any DEVIATION: Patches of hair loss
irregularities in hair growth (alopecia)
such as patches of thin hair
• Feel the scalp for any bumps,
lumps or irregularities in the
scalp skin or underlying
tissues
• Check the hairline: Examine Thick hair
the hairline for any changes
in hair density or thinning of DEVIATION: Very thin hair (in
hair around the temples or hypothyroidism)
crown of the head.
• Feel the hair: Run your Silky and has resilient hair (it can
fingers through the hair to bounce back from the constant
feel for any changes in hair challenges it undergoes on a daily
texture or oiliness. Note if basis).
the hair feels dry or oily

25. Note presence of infections
or infestations.
26. Inspect the amount of body
hair.
NAILS
27. Inspect fingernail plate shape
28. Inspect fingernail and toenail
bed color.
29. Inspect tissues surrounding
nails
30. Palpate fingernail and toenail
texture.
• Observe the scalp for any
signs of dandruff, itching, or
redness, which may indicate
an underlying scalp condition
Part the hair in several areas
and checking behind the ears and
along the hairline at the neck
Men typically have more hair growth
on the face, chest, and back, while
women typically have less hair
growth on these areas but may have
more hair on the legs, pubic area,
and underarms
to determine its curvature and angle
• The Schamroth window test:
used to identify or confirm
clubbing
Gently press on the skin around the
nail to check for tenderness or pain,
which can also indicate infection or
inflammation
Check for softness or brittleness:
Look for any signs of softness or
brittleness in the nails, which can
indicate a vitamin deficiency or other
health condition. (A deficiency in B-
complex vitamins, especially biotin)
• A lack of folic acid and
vitamin C can lead to
hangnails
DEVIATION: Brittle hair; excessively
oily or dry hair
No infection or infestation
DEVIATION: Flaking, sores, lice,
nits, and ringworms
Variable
DEVIATION: Hirsutism in women
excessive growth of darkhair in a
male-like pattern such as the face,
chest, and back; naturally absent or
sparse leg hair (poor circulation)
There is no clubbing. There is also no
tenderness in the nailbed which may
indicate infection or injury.
Convex curvature; angle between
nail and nail bed usually 160 degrees
DEVIATION:
Less: spoon shaped
More: clubbing
Highly vascular and
pink in light skinned; dark skinned
may be brown or black
DEVIATION: Bluish or purplish tint;
pallor
The tissues surrounding the nails are
smooth in texture, the cuticles are
intact, pink or flesh-colored in color,
and no signs of inflammation
DEVIATION: Excessive thickness or
thinness or presence of grooves or
furrows; Beau’s line
Smooth texture, no ridges which
may indicate vitamin deficiency.
There is also no hangnails
There is also no tenderness in the
nailbed which may indicate infection
or injury.
DEVIATION: Excessive thickness or
thinness or presence of grooves or
furrows; Beau’s line
31. Perform blanch test of
capillary refill.
• Press two or more nails
• Capillary refill test: pressing The blood returned within 2-3
on the nail to temporarily seconds, indicating good blood flow
restrict blood flow and then and oxygenation.
releasing the pressure to
observe how quickly blood DEVIATION: Delayed return of pink
returns to the nail bed or usual color
between your thumb and
index finger; look for
blanching and return of pink
color to nail bed.

32. Document findings CLOSING REMARKS: Now that we’re

done with the assessment, I would
like to thank you for your
participation. You we’re cool with all
of the things I asked you to do.

RECAP OF THE FINDINGS:

Before we end this assessment, do

you have any concerns that I might
assist you with or any questions for
me?