Our Lady of the Pillar College-Cauayan

Cauayan City, Isabela

College of Nursing and Midwifery

HEALTH ASSESSMENT

INTEGUMENTARY SYSTEM PHYSICAL ASSESSMENT

Name of Patient: Patient K Age: 19 Gender: Female Birthday: November 9, 2003

Address: Sillawit Cauayan City, Isabela Occupation: Student Status: Middle Class Civil Status: Single
Chief Complaints: _____________________________________________________________________________________________________________

Assessment Technique Actual Findings Analysis/ Interpretation

SKIN Inspection ● There is no unusual odor
● No presence of unusual odor, odors from NORMAL
● Odor
hyperhidrosis, odors from night sweat, urine
odor, mousy odor

Inspection ● The color of the patient’s skin is light brown. NORMAL

● Color ● No presence of bluish, jaundice, pallor, ● Given that Patient K is of Asian
erythema and brownness. descent and has dark skin. As an
outcome, her skin has a shade
that is typical for their race,
which is light brown.

● The patient has no presence of skin breakdown

in her upper and lower extremities.
NORMAL
Inspection ● since the patient has no
 presence of dryness in her skin.
● Presence of skin breakdown

 The patient has a keloid which is 1.5 cm in her right ABNORMAL

arm. ● The keloid of the patient is due
● She has a five 0.5 mole in her face which is a to her vaccine when she was a
Inspection macule. child, her scars are due to
● Presence of lesions ● Presence of callus in her left feet.. wound healing and callus due to
● And a 0.5 scar and 1 cm scar in her right knees. pressure in her slippers. As
verbalized by the patient she
doesn’t try any surgery yet like
plastic surgery.

NORMAL
● The patient’s skin is smooth and fine. ● There is no presence of dryness
and crack in her skin and feet.

Palpation

● Texture NORMAL
● The patient’s skin temperature
is in normal range.
● The patient’s skin temperature is warm.

Palpation NORMAL
● Since there is no presence of
● Temperature thinness in the patient’s skin.

● The patient’s skin is thick.

NORMAL
Palpation ● There is no presence of tenting
in the patient's skin.
 ● Thickness
● I checked in her clavicle and sternum for
elasticity.
● Within 1-2 seconds the patient’s skin is returned
Palpation immediately from its place after I release the
skin. NORMAL
● The patient’s skin is returned
● Skin turgor immediately after palpation.

● The patient’s ankle and feet are not shiny and

are not fluid filled.
● There is no [presence of edema
Palpation

● Presence of Edema

SCALP AND HAIR

Inspection ● The patient’s color of hair is black. NORMAL
● COLOR
● There is no artificial color. ● There is no presence of gray
and white color of hair.
● And given that the patient is of
Asian descent. As a result, her
hair typically seems to be black
in color.

Inspection and Palpation ● The patient’s hair is distributed well and NORMAL
● Amount and distribution equally. ● There are no signs of alopecia
● No presence of patchy or hair loss. in the patient’s head.

 Normal
Palpation  Since there were no presence of
 The patient’s hair is thick. thinness in patient’s scalp and hair.
 NORMAL
● Thickness
Palpation
● The patient’s hair is smooth and fine to touch.

NORMAL
● The patient's scalp produces just
● Texture the right amount of oil, which
Inspection ● The patient’s hair is not oily and dry. contributes to the brilliance of
her hair.

NORMAL
● There is no presence of dandruff
● Oiliness in her scalp.
Inspection ● There is no presence of lesion in her scalp and
her scalp is healthy.

Inspection ● There is no presence of parasites in the patient’s NORMAL

● Presence of Lesions scalp and her scalp is clean.

● Presence of Parasites

NAILS
Inspection ● The patient has not used any artificial color such
● Grooming
as nail polish. NORMAL
● The nails are properly trimmed.
 Inspection ● The color of the patient’s nail is light pink. NORMAL
● There is no sign of yellowish,
● Color and markings
half-half nails, bluish, black and
white nails.

Inspection ● The patient's nail shape is convex. NORMAL

● Has no presence of spooning
● Shape and clubbing.

Inspection and Palpation ● The patient’s nails are fine and smooth to touch. NORMAL

● Texture and consistency

Palpation ● When the patient's fingers are pinched and then
released after one second, the color returns to its
normal state. NORMAL

● Capillary refill test