Assessment on Skin, Hair & Nails / HEENT

The integument consists of
the skin, nails, hair, and
scalp. First inspect all skin
surfaces or assess the skin
gradually as you examine
other body systems. Use
the assessment skills of
inspection, palpation, and
olfaction to assess the
function and integrity of the
integument

Assessment of the skin reveals changes in
oxygenation, circulation, nutrition, local tissue damage, and
hydration. In a hospital setting the majority of patients are older
adults, debilitated patients, or young but seriously ill patients.
There are significant risks for skin lesions resulting trauma to the
skin while administering care, from exposure to pressure during
immobilization, or from reaction to medications used in
treatment. Patients most at risk are the neurologically
impaired, chronically ill, and orthopedic patients. Others at risk
are patients with diminished mental status, poor tissue
oxygenation, low cardiac output, and in adequate nutrition. In
nursing homes and extended care facilities, patients are often at
risk for many of the same problems, depending on their level of
mobility and presence of chronic illness. Routinely assess the
skin to look for primary or initial lesions that develop. Without
proper care, primary lesions quickly worsen to become
secondary lesions that require more extensive nursing care.

The incident of melanoma, an aggressive form of skin cancer, occurs primarily
in light-pigment people.
To understand the nurse’s role in detection of skin cancer. Cutaneous
malignancies are the most common neoplasms seen in patients. Incorporate a
thorough skin assessment for all patients and educate them about self
examination.

The condition of the patient’s skin reveals the need for nursing
intervention. Use your assessment findings to determined abnormalities and the
type of hygiene measures required to maintain integrity of the integument. To
treat excessively dry skin, tell the patient to avoid hot water, harsh soaps, and
drying agent such as alcohol. Use a super fatted soap, and pat rather than rub
the skin after bathing. Apply skin moisturizes regularly to reduce itching and
drying, and wear cotton clothing. Adequate nutrition and hydration become
goals of therapy if you identify an alteration in the status of the integument.

You will need adequate illumination of the skin for accurate
observations. The recommended choice is natural or
halogen lighting. For defecting skin changes in the dark skinned
patient, sunlight is the best choice. Room temperature also affects
skin assessment. A room that is too warm causes superficial
vasodilatation, resulting in an increased redness of the skin.
A cool environment causes the sensitive patient to develop cyanosis around
the lips and nail beds.

Use disposable gloves for palpation if open, moist, or draining
skin lesions are present. Because you will inspect all skin
surfaces, the patient will assume several positions. The
examination includes inspecting the skin’s
color, moisture, temperature, texture, and turgor. Also note
vascular changes, edema, and lesions. Carefully palpate
abnormalities, and document your findings. Skin odors are
usually noted skin folds such as the axillae or under the female
patient’s breasts.

 Before assessing the skin, ask the patient about the
presence of lesion, rashes, or bruises and determined
whether the alterations are linked to heat, cold, and
stress, exposure to toxic materials or the sun, or new
skin care products. Also determined if there has been
a recent change in skin color or trauma to the skin. If
a patient has been out in the sun, it is useful to know
if the patient wore sunscreen. If not, the patient will
require education on ways to safeguard the skin.
Also assess for history of allergies, use of topical
medications, and a family history of serious skin
disorders.

 Skin color varies from body part to body part and
from person to person. Despite individual
variations, skin color is usually uniform over the
body. Normal skin pigmentation ranges ivory or
light pink to ruddy pink in white skin from light
to deep brown or black in dark skin. Sun-
darkened or darker skin is common around knees
and elbows.

 Is most common in sun-exposed areas and frequently occurs in a
background of sun-damaged skin. In older adults pigmentation
increases unevenly, causing discolored skin. While inspecting
the skin, be aware that cosmetics or tanning agents sometimes
mask color.
 The assessment of color first involves areas of the skin not
exposed to the sun, such as the palms of the hands. Note if the
skin is unusually pale or dark. It is more difficult to note
changes such as pallor or cyanosis in patients with dark skin.
Unusual color hues are best seen in the palms, soles of the
feet, lips, tongue, and nail beds. Areas of increased color and
decrease color are common. Skin creases and folds are darker
than the rest of the body in the dark-skinned patient.

Inspect sites where you can more easily identify abnormalities. For
example, you can see pallor more easily in the face, buccal
mucosa, conjunctivae, and nail beds. You observe cyanosis best in the
lips, nail beds, palpebral conjunctivae, and palms.

In recognizing pallor in the dark-skinned patient, you observe that
normal brown skin appears to be yellow-brown and normal black
skin appears to be ashen gray. Also assess the lips, nail beds, and
mucous membranes will be ashen gray. Assessment of cyanosis in
the dark-skinned patient requires that you observe areas where
pigmentation occurs the least. In addition, verify these findings with
clinical manifestation.

The best site to inspect the jaundice is the patient’s
sclera. You see normal reactive hyperemia or
redness, most often in regions exposed to pressure such
as the sacrum, heels, and greater trochanter.

Inspect for any patches or areas of skin color variation. Localized skin changes,
such as pallor or erythema, often indicate circulatory changes. For example,
localized vasodilation resulting from sunburn or fever is a cause for an area of
erythema.In the dark-skinned patient, erythema is not easy to observe, so
palpate the area for heat and warmth to note the presence of skin
inflammation. An area of extremity that appears unusually pale may result from
an arterial occlusion or edema. It is important to ask
if the patient has noticed any changes in skin coloring.

A pattern of findings that is becoming more common is that associated
with patients who are chemically dependent and are intravenous drug abusers.
It is sometimes difficult to recognize signs and symptoms after one
examination. A patient who takes repeated IV injections has
edematous, reddened and warm areas along the arms and legs. This pattern
suggests recent injections. Evidence of old injection sites appears as
hyperpigmented and shinny or scarred areas.

 The hydration of skin and mucous membranes helps to reveal body
fluid imbalances, changes in the skin environment, and regulation of
body temperature. Moisture refers to wetness and oiliness. The skin is
normally smooth and dry. Skinfolds such as the axillae are normally
moist. Minimal perspiration or oiliness is present in normal skin.
Increased perspiration is associated with activity, warm
environments, obesity, anxiety, or excitement. Use ungloved fingertips
to palpate skin surfaces and observe for
dullness, dryness, crusting, and flaking. Flaking is the appearance of
dandrufflike flakes when you lightly rub the skin surface. Scaling
involves fishlike scales that are easily rubbed off the skin’s surface.
Both flaking and scaling are believed to indicate abnormally dry skin.
Excessively dry skin is common in older adults and persons who use
excessive amounts of soap during bathing. Other factors causing dry
skin include lack of humidity, exposure to
sun, smoking, stress, excessive perspiration, and dehydration.
Excessive dryness worsens existing skin conditions.

 The temperature of the skin depends on the amount of blood
circulating through the dermis. Increased or decreased of skin
temperature reflects an increase or decreased of blood flow.
Localized erythema or redness of the skin is often accompanied
by an increased in skin temperature. A reduction in skin
temperature reflects a decreased in blood flow. It is important to
remember that a cold examination room affects the patient’s
skin temperature and color.
 Accurately assess temperature by palpating the skin with
the dorsum, or back, of the hand. Compare symmetrical body
parts. Normally the skin is warm. Skin temperature may be the
same throughout the body or may vary in one area. Always
assess skin temperature in patients at risk for impaired
circulation, such as after a cast application or vascular surgery.
You can identify a stage I pressure ulcer early by nothing
warmth and erythema on an area of the skin.

 The character of the skin’s surface and the feel of deeper
portions are its texture. Determine if the patient’s skin is smooth
or rough, thin or thick, tight or supple, and indurated or soft by
stroking it lightly with the fingertips. The texture of the skin is
normally smooth, soft, and flexible in children and adults.
However, the texture is usually not uniform. The palms of the
hands and soles of the feet tend to be thicker. In older adults the
skin becomes wrinkled and leathery because of a decrease in
collagen, subcutaneous fat, and sweat glands.
 Localized changes result from trauma, surgical wounds, or
lesions. When you find irregularities in texture such as scars or
induration, ask the patient if a recent injury to the skin has
occurred. Deeper palpation sometimes reveals irregularities
such as tenderness of localized areas of induration commonly
caused by repeated injections.

 Turgor is the skin’s elasticity. Edema and
dehydration diminish turgor. Normally the skin loses
its elasticity with age. To assess skin turgor, grasp a
fold of skin on the back of the forearm or sterna area
with the fingertips and release. Normally the skin
lifts easily and snaps back immediately to its resting
position. The skin stays pinched or tented when
turgor is poor. The patient with poor turgor does not
have resilience to the normal wear and tear on the
skin. A decrease in turgor makes a patient more
susceptible to skin breakdown.

 The circulation of the skin affects color in
localized areas and the appearance of superficial
blood vessels. With aging, capillaries become
fragile. Localized pressure areas, found after a
patient has lain or sat in one position, appear
reddened, pink, or pale. Petechiae are pinpoint-
size, red, or purple spots on the skin caused by
small hemorrhages in the skin layers. Petechiae
indicate serious blood clothing disorders, drug
reactions, or liver disease.

 Areas of the skin become swollen or edematous from
fluid buildup in the tissues. Direct trauma and
impairment of venous return are two common causes of
edema. Inspect edematous areas for location, color, and
shape. The formation of edema separates the skin’s
surface from the pigmented and vascular layers,
masking skin color. Edematous skin also appears
stretched and shiny. Palpate edematous areas to
determine mobility, consistency, and tenderness. When
pressure from your finger leaves an indentation in the
edematous area, it is called pitting edema. To assess
pitting edema, press the edematous area firmly with the
thumb for several seconds and release. The depth of
pitting, recorded in millimeters, determines the degree
of edema. For example, +1 edema equals 2 mm depth,
and +2 edema equals 4 mm.

 The skin is normally free of lesions, except for common
freckles or age-related changes such as skin tags or senile
keratosis, cherry angiomas, and atrophic warts. Lesions
are primary ring as initial spontaneous manifestations of a
pathological, such as a pressure ulcer. When you detect a
lesion, inspect it for color, location. Texture, size, shape.
Observe any exudates for color, odor, amount, and
consistency. Measure the size of the lesions in
height, width, and depth.
 Palpation determines the lesion’s mobility, contour, and
consistency. Palpate gently, covering the entire area of
lesion. If the lesion is moist or has draining fluid, wear
gloves during palpation. Note if the patient complains of
tenderness during palpation. Cancerous lesions frequently
undergo changes in color and size. Report
abnormalities, especially lesions that have changed in
character, to a physician or health care provider for further
examination.

 Good lighting allows you to inspect the
condition and distribution of body hair and
integrity of the scalp. Assessment of the hair
occurs during all portions of the examination.
Assess the
distribution, thickness, texture, and
lubrication of hair. In addition, inspect for
infection or infestation of the scalp.

 Ask a question such as following:
 Has the patient noted change in growth or
loss of hair? Change in texture or color?
What types of hair care products does the
patient use? Has the patient recently been
on chemotherapy or taken vasodilators for
hair growth? Has the patient noted changes
in diet or appetite? If a patient has a
hairpiece, remove it if inspection of the scalp
is essential.

 During inspection explain that it is necessary to separate
parts of the hair to detect abnormalities. First inspect the
distribution, thickness, texture, and lubrication of body hair.
Hair is normally distributed evenly, is neither excessively
dry nor oily, and is pliant or flexible. While separating
sections of scalp hair, observe for characteristics of color
and coarseness. Normal terminal hair is
black, brown, red, yellow, or variations in shades of these
colors. The hair is coarse of fine and shinny. Normal
variation exists in the shape of hair fibers. Patient’s hair
may be straight, curly, spiral, or wavy. The hair of black
persons is unusually thicker and drier than the hair of
whites.
 In older adults the hair becomes dull gray, white, or
yellow. The hair also thins over the scalp, axillae, and
public areas. Older men lose facial hair, whereas older
women sometimes develop hair on the chin and upper lip.

Changes occur in the thickness, texture, and lubrication of scalp
hair. Disturbances such as a febrile illness or scalp disease alter
the condition of the hair making it fine and brittle. Baldness or
thinning of the hair is usually related to genetic tendencies and
endocrine disorders such as diabetes and even menopause.
Poor nutrition causes stringy, dull, dry, and thin hair. The hair is
lubricated from the oil of sebaceous glands. Excessively oily hair
is associated with androgen hormone stimulation. Dry, brittle hair
occurs with aging and excessive use of chemical agents.

The amount of hair covering the extremities may be reduced as
a result of aging and arterial insufficiency and is most commonly
seen over the lower extremities. In women do not confuse a loss
of hair with shaven legs.

Inspect the scalp for lesions, which are not easily noticed in thick
hair. The scalp is normally smooth and inelastic, with even
coloration. By carefully separating strands of hair, thoroughly
examine the scalp for lesion. Note the characteristics of any
scalp lesions. If lumps and bruises are found, ask if the patient
has experience recent head trauma. Moles on the scalp are
common. You should warn the patient that combing or brushing
sometimes causes mole to bleed. Scaliness or dryness of the
scalp is frequently caused by dandruff or psoriasis.

Careful inspection of hair follicles on the scalp and pubic areas may
reveal lice or other parasites. Lice attach their eggs to hair. The head and
body lice are tiny and have grayish white bodies. Crab lice have red legs.
Lice eggs look like oval particles of dandruff. The lice themselves are difficult
to see. Observe for bites or pustular eruptions in the follicles and in areas
where skin surfaces meet, such as behind the ears and in the groin. The
discovery of lice requires immediate treatment.

 The condition of the nails reflects general
health, state of nutrition, a person’s
occupation, and level of self-care. The most
visible portion of the nails is the nail
plate, transparent layer of epithelial cells
covering the nail bed. The vascularity of the
nail bed creates the nail’s underlying color.
The semilunar, whitish area at the base of
the nail bed from which the nail plate
develops is the lunula.

 Before assessing the nails ask if the patient has
had any recent trauma. A blow to the nail changes
the shape and growth of the nail, as well as loss of
all or parts of the nail plate. Have the patient also
describe nail care practices. Improper care
damages nails and cuticles. It is also important to
find out if patients have acrylic nails or silk
wraps, because these are areas for fungal growth.
Question whether the patient has noticed changes
in nail appearance or growth. Alterations occur
slowly over time. Knowing if the patient has risks for
nail or foot problems will influence the level of
hygienic care recommended.

 Inspect the nail bed color, the thickness and shape of the nail, the
texture of the nail, and the condition of tissue around the nail. The
nails are normally transparent, smooth and convex, with
surrounding cuticles smooth, intact, and without inflammation. In
whites, nail beds are pink with translucent white tips. In the dark-
skinned patients, nail beds are darkly pigmented with a blue or
reddish hue. A brown or black pigmentation is normal with
longitudinal streaks. Trauma, cirrhosis, diabetes mellitus, and
hypertension cause splinter hemorrhages. Vitamin, protein, and
electrolyte changes can cause various lines or bands to form on
nail beds.
 Nails normally grow at a constant rate, but direct injury or
generalized disease slows growth, with aging, the nails of the finger
and toes become harder and thicker. Longitudinal striations
develop, and the rate of nail growth slows. Nails become more
brittle, dull, and opaque and turn yellow in older adults because of
insufficient calcium. Also with age the cuticle becomes less thick
and wide.

Inspection of the angle between the nail and the nail bed
normally reveals an angle of 160 degrees. A larger angle and
softening of the nail bed indicate chronic oxygenation
problems. Palpate the nail base is normally firm. To
palpate, gently grasp the patient’s finger and observe the color
of the nail bed. Next, apply gentle, firm, quick pressure with the
thumb of the nail bed and release. As you apply pressure, the
nail bed appears white or blanched; however, the pink color
should return immediately on release of pressure. Failure of the
pinkness to return promptly indicates circulatory insufficiency.
An ongoing bluish or purplish cast to the nail bed occurs with
cyanosis. A white cast pallor results from anemia.

Calluses and corns often occur on the toes or fingers. A callus
is flat and painless, resulting from thickening of the epidermis.
Friction and pressure from shoes causes corns, usually over bony
prominences. During the examination in struct the patient in
proper nail care.

 Normal nail: approximately 160 degree angle between nail plate and
nail.
 Clubbing: change in angle between nail and nail base (eventually
larger than 180 degrees); nail bed softening, with nail flattening;
often, enlargement of fingertips
 Causes: chronic lack of oxygen: heart or pulmonary disease.
 Beau’s lines: transverse depressions in nails indicating temporary
disturbance of nail growth (nail grows out over several months)
 Causes: systematic illness such as severe infection, nail injury.
 Koilonychia (spoon nail): concave curves.
 Causes: iron deficiency anemia, syphilis, use of strong detergents.
 Splinter hemorrhage: red or brown linear streaks in nail bed.
 Causes: minor trauma, subacute bacterial endocarditis, trichinosis.
 Paronychia: inflammation of skin at base of nail.
 Causes: local infection, trauma.

 Nail care
 ⦁ Instruction the patient to cut nails only after soaking them about
10 minutes in warm water. (Exception: Diabetic patients are warned
against soaking nails.)
 ⦁ Instruct the patient to avoid using over the –counter preparations
-
to treat corns, calluses, or ingrown toenails.
 ⦁ Tell the patient to cut nails straight across and even with the tops
of the fingers or toes. If the patient has diabetes, tell the patient to
file rather than cut the nails.
 ⦁Instruct the patient to shape nails with a file or emery board.
 ⦁ if patient is diabetic:
 Wash feet daily in warm water. Inspect feet each day in good
light, looking for dry places and cracks in the skin. Soften dry feet
by applying a cream or lotion such as nivea, eucerin, or alpha keri.
 Do not put lotion between the toes.
 Caution patient against using sharp objects to poke or dig under
toenail or around the cuticle.
 Have patient see a podiatrist for treatment of ingrown toenails and
nails that are thick or tend to split.

 An examination of the head and neck
includes the
head, eyes, ears, nose, mouth, pharynx, and
neck. During the assessment of peripheral
arteries, also assess the carotid arteries. You
need to understand each anatomical area
and its normal function. Assessment of the
head and neck uses
inspection, palpation, and auscultation.

 The history allows you to screen for possible
intracranial injury if necessary. Ask whether the
patient experience recent trauma to the head or
if neurological symptoms such as
headache, dizziness, seizures, poor vision, or
loss of consciousness have occurred. The
history also includes a review of the patient’s
occupation, focusing on those patients who
wear safety helmets. In addition, ask if the
patient participates in contact
sports, cycling, roller blading, or skate boarding.

 Inspect the patient’s head, nothing the position, size, shape, and
contour. The head is normally held upright and midline to the trunk.
A horizontal jerking or bobbing indicates a tremor. Holding the head
titled to one side is an indication of unilateral hearing or visual loss.
The skull is generally round with prominences in the frontal area
anteriorly and the occipital area posteriorly. Trauma typically
causes local skull deformities. In an fants a large head results from
congenital anomalies or the accumulation of cerebrospinal fluid in
the ventricles. Adults sometimes have enlarged jaws and facial
bones resulting from acromegaly. Palpate the skull or nodules or
masses. Gentle rotation of the fingertips down the midline of the
scalp and then along the sides of the head reveals abnormalities.
Also note the patient’s facial features, looking the eyelids,
eyebrows, nasolabial folds, and mouth for shape and symmetry. It
is normal for slight asymmetry to exist. If there is facial asymmetry,
note if all features on one side of the face are affected or if only a
portion of the face is involved. Various neurological disorders such
as a facial nerve paralysis affect different nerves that innervate
muscles of the face.

 Examination of the eye includes assessment
of visual acuity, visual fields, and external
and internal eye structures. The assessment
detects visual alteration and determines the
level of assistance patients require when
ambulating or performing self-care-activities.
Patients with visual problems need special
aids for reading teaching materials or
instruction.

 Determine if the patient is at risk for partial or complete visual loss by
reviewing history of eye disease, eye
trauma, diabetes, hypertension, or eye surgery. Assessment for
common symptoms of eye disease is critical. Some symptoms of eye
disease are:
 Eye pain
 Photophobia (sensitivity to light)
 Burning or itching
 Excess tearing or crusting
 Diplopia (double vision) or blurred vision
 Awareness of a “film” or “curtain” over the field of vision
 Floaters, flashing lights, or halos around lights
 Review the patient’s occupational history, use of glasses or contact
lenses, use of safety glasses at work and for hobbies, and regularity of
visits to an ophthalmologist or optometrist. Question the patient about
current medications, including eye drops or ointments. Also determine
whether there is a family history of eye disorder or disease.

 The assessment of visual acuity, the ability to see small
details, test central vision. The easiest way to assess
visual acuity is to ask the patient to read printed material
under adequate lighting. If the patients use glasses or
contact lenses, they should wear them. Know the
language your patient speak and whether your patient is
literate. Asking the patient to read aloud tests literacy. A
patient who has difficulty reading related to vision needs to
consult of an ophthalmologist or optometrist for further
evaluation. If you are caring for a patient who is unable to
read clearly, assess if he or she is able to distinguish
objects or light. Hold your hand 30 cm from the patient’s
face, and instruct the patient to count upraised fingers. To
check light perception, shine a penlight into the eye and
then turn the light off. If the patient notes when the light is
turned on or off, light perception is intact.

 As a person looks a straight head, he or she can
normally see all objects in the periphery. To assess
visual fields, have the patient stand or sit 60 cm
away, facing you at eye level. The patient gently
closes or covers one eye and looks at you directly
opposite. You close the opposite eye so that the
field of vision is superimposed on that of the
patient. Move a finger equidistant at arm’s length
from you and the patient outside the field of
vision, and then slowly bring it back into the visual
field. Ask the patient to tell you when he or she is
able to see your finger. If you see the finger before
the patient does, this reveals that a portion of the
patient’s visual field is reduced.

 To inspect external eye structures, stand
directly in front of the patient at eye level and
ask the patient to look at your face.
 POSITION AND ALIGNMENT
 Assess the position of the eye in relation to one
another. Normally they are parallel to each
other. Bulging eyes usually indicate
hyperthyroidism. The crossing of eyes results
from neuromuscular injury or inherited
abnormalities. Tumors or inflammation of the
orbit causes abnormal eye protrusion.

 For the remainder of the examination the
patient removes contact lenses. Inspect the
eyebrows for size, extension, texture of
hair, alignment, and movement. Coarseness of
hair and failure to extend beyond the temporal
canthus may reveal hypothyroidism. If the
brows are thinned, this may indicate that the
patient plucks or waxes the hair. Aging causes
loss of the lateral third of the eyebrows. Have
the patient raise and lower the eyebrows. The
brows normally raise and lower symmetrically.
An inability to move the eyebrows indicates a
facial nerve paralysis.

 Inspect the eyelids for position; color; condition; and direction of
lashes; and the patient’s ability to open, close, and blink. When the
eyes are open in a normal position, the lids do not cover the pupil, and
you cannot see the sclera above the iris. The lids are also close to the
eyeball. An abnormal drooping of the lid over the pupil is called
ptosis, caused by edema or impairment of the third cranial nerve. In
the older adult, ptosis results from a loss of elasticity that accompanies
aging. You will possibly observe defects in the position of the lid
margins. An older adult frequently has lid margins that turn out or in.
An entroption sometimes lead s to the lashes of the lid irritating the
conjunctiva and cornea, increasing risk infection. The eyelashes are
normally distributed evenly and curved outward away from the eye.
 The lids normally close symmetrically. Failure of lids to close
exposes the cornea to drying. This condition is common in
unconscious patient or those with facial nerve paralysis. Ask the
patient to open the eyes and observe the blink reflex. Normally the
patient blinks involuntarily and bilaterally as many as 20 times a
minute. The blink reflex lubricates the cornea report absent or
infrequent, rapid, or monocular blinking.

 The lacrimal gland located in the upper, outer wall
of the anterior part of the orbit, is responsible for
tear production. Tears flow from the gland across
the eye’s surface to the lacrimal duct, which is in
the nasal corner or inner canthus of the eye. The
lacrimal gland can be the site of tumors or
infection, and you will inspect it for edema and
redness. Palpate the gland area gently to detect
tenderness. Normally the gland cannot be felt. The
nasolacrimal duct may become
onbstructed, blocking the flow of tears. Observe for
evidence of excess tearing or edema in the inner
canthus. Gentle palpation of the duct at the lower
eyelid just inside the orbital rim causes a
regurgitation of tears.

 The bulbar conjunctiva covers the exposed surface of the eyeball up to the
outer edge of the cornea. You see the sclera under the bulbar
conjunctiva, and it normally has the color of white porcelain in whites and
light yellow in black-skinned patients. To view both structures, gently retract
both lids simultaneously with thumb and index finger pressed against the
lower and upper bony orbits. Wear gloves if there is crusty drainage on
eyelid margins. Wear a pair of new gloves to examine each eye to prevent
cross contamination. For adequate exposure retract the eyelids without
placing pressure directly on the eyeball. Ask the patient to look
up, down, and side to side. Inspect for color, texture, and lesions.
 The palpebral conjunctiva is the delicate membrane lining the eyelids.
Normally the conjunctiva is transparent, enabling you to view the tiny
underlying blood vessels that give it a pink color. To inspect the palpebral
conjunctiva, gently depress the lower lid. Often the patient is able to
depress the eyelid to facilitate examination. Note the conjunctiva’s color
and the presence of edema or lesions. A pale conjunctiva results from
anemia, whereas a fiery red appearance is the result of inflammation.
Conjunctivitis is highly contagious, and the crusty drainage that collects
on eyelid margins easily spreads from one eye to the other.

 The cornea is the transparent, colorless portion of the eye
covering the pupil and iris. From a side view, it looks like
the crystal of a wristwatch. While the patient looks straight
ahead, inspect the cornea for a clarity and texture while
shining a penlight obliquely across the surface of the
cornea. In older adults the cornea loses its luster. Any
irregularity in the surface indicates an abrasion or tear that
requires further examination by a physician or health care
provider. Both conditions are quite painful. Note the color
and details of underlying iris. In an older adult the iris
becomes faded. A thin, white ring along the margin of the
iris, called an arcus senilis, is common with aging but is
abnormal in anyone under age 40.

 Observe the pupils for size, shape, equality, accommodation, and reaction
to light. The pupils are normally black, round, regular, and equal in size.
Cloudy pupils indicate cataracts. Dilated or constricted pupils result from
neurological disorders or the effect of ophthalmic or certain systemic drugs.
Pinpoint pupils are a common sign of opioid intoxication. When you shine a
beam of light through the pupil and onto the retina, you stimulate the third
cranial nerve and cause the muscles of the iris to constrict. Any
abnormality along the nerve pathways from the retina to the iris alters the
ability of the pupils to react to light. Changes in intracranial
pressure, lesions along the nerve pathways locally applied eye drugs, and
direct trauma to the eye alter pupillary reaction.
 Test pupillary reflexes in a dimly lit room. While the patient looks
straight ahead, bring a penlight from the side of the patient’s face, directing
the light onto the pupil. If the patient looks at the light, there will be a false
reaction to accommodation. A directly illuminated pupil constricts, and the
opposite pupil constricts consensually. Observe the quickness and equality
of the reflex. Repeat the examination for the opposite eye.
 To test accommodation, ask the patient to gaze at a distant object and then
at a test object held by you approximately 10 cm from the bridge of the
patient’s nose. The pupils normally converge and accommodate by
constricting when looking at close objects. The pupil responses are equal.
If assessment of pupillary reaction is normal in all tests, record the
abbreviation PERRLA.

 The examination of internal eye structures
through the use of an ophthalmoscope is
beyond the scope of a new graduate nurse’s
practice. Patients in a greatest need of the
examination are those with
diabetes, hypertension, and intracranial
disorders.

 There are assessment determines the
integrity of ears structures and hearing
acuity. You will inspect and palpate external
ear structures, inspect middle ear structures
with the otoscope, and test the inner ear by
measuring the patient’s hearing acuity.
Assessment of patients with hearing
impairment provides useful data for you in
planning effective communication
techniques.

 The Patient’s health history includes a review of
risks for hearing problems, a history of ear
surgery or trauma, and the patient’s current
exposure to high noise levels. Determine if the
patient has ear
pain, itching, discharge, tinnitus, vertigo, or
change in hearing. Note behaviors indicative of
hearing loss, such as failure to respond when
spoken to, request to repeat comments, leaning
forward to hear, and a child’s inattentiveness. If
the patient has had recent hearing
problems, determine the onset, contributing
factors, and effect on ADLs. Also assess if the
patient wears a hearing aid and how the patient
normally cleans the ears.

 With the patient sitting, inspect the position, color, size, shape, and
symmetry of the auricle. Be sure to examine lateral and medial
surfaces and surrounding tissue. The auricles are normally of equal
size and level with each other. The upper point of attachment to the
head is normally in a straight line with the other canthus, or corner
of the eye. Ears that are low set or at unusual angle are sign of
chromosome abnormality. The color is the same as the face without
moles, cysts, deformities, or nodules. Redness is sign of
inflammation or fever. Extreme palor indicates frostbite. Palpate the
auricles for texture, tenderness, swelling, and skin lesions. Auricles
are normally smooth, firm, mobile, and without lesions. If the patient
complains of pain, gently pull the auricle and press on the tragus
and palpate behind the ear over the mastoid process. If palpating
the external ear increases the pain, an external ear infection is
likely. If palpation of the auricle and tragus does not influence the
pain, the patient may have a middle ear infection. Tenderness in the
mastoid area indicates mastoiditis.


Inspect the opening of the ear
canal for size and presence of
discharge. If discharge is
present, wear gloves during the
examination. A swollen or
occluded meatus is not normal.
A yellow, waxy substance called
cerumen is common. Yellow or
green foul-smelling discharge
indicates infection or a foreign
body.

 Observe the deeper structures of the external and middle
eat with the use of an otoscope. A special ear speculum
attaches to the battery tube of the ophthalmoscope. For
best visualization select the largest speculum that fits
comfortably in the patient’s ear. Before inserting the
speculum, check for foreign bodies in the opening of the
auditory canal.
 Make sure the patient avoids moving the head during the
examination to avoid damage to the canal and tympanic
membrane. Infants and young children often need to be
restrained. Lie infants supine with their heads turned to
one side and their arms held securely at their sides. Have
young children sit on their parent’s laps with their legs held
between the parent’s knees.

Turn on the otoscope by rotating the dial at the top of the battery
tube. To insert the speculum properly, ask the patient to tip the
head slightly to the opposite shoulder. Hold the handle of the
otoscope in the space between the thumb and index
finger, supported
on your middle finger. This leaves the ulnar side of your hand to
rest against the patient’s head, stabilizing the otoscope as it is
inserted into the canal. There are two types of grips for the
otoscope. In one, you hold the battery tube along the patient’s
neck with
your fingers against the neck. In the other grip, lightly brace the
inverted otoscope against the side of the patient’s head or check.
Insert the scope while pulling the auricle upward and backward in
the adult and older child. This maneuver straightens the ear canal.
In infants pull the auricle back and down. Insert the speculum
slightly down and forward, 1.0 or 1.5 cm into the ear canal.

Take care not to scrape the sensitive lining of the ear
canal, which is painful. The ear canal normally has little
cerumen and is uniformly pink with tiny hairs in the outer
third of the canal. Observe for
color, discharge, scaling, lesions, foreign bodies, and
cerumen. Normally cerumen is dry or moist and sticky. Dry
cerumen occurs in Asians and Native Americans about
85A% of the time. A reddened canal with discharge is a sign
of inflammation or infection. In older adults, accumulated
cerumen creates a mild hearing loss. During the
examination ask the patient or how he or she normally
cleans the ear canal. Caution the patient on the danger of
inserting pointed objects into the canal. Avoid the use of
cotton-tipped applicators to clean the ears because this
causes impaction of cerumen deep in the ear canal.

The light from the otoscope allows visualization of the eardrum. Know the
common anatomical landmarks and their appearance.
Move the auricle to see the entire drum and its periphery. Because the
eardrum is angled away from the ear canal, the light from
the otoscope appears as a cone shape rather than a circle. The umbo is
near the center of the drum, behind which is the attachment
of the malleus. The underlying short process of the malleus creates a
knoblike structure at the top of the drum. Check carefully to
be sure there are no tears or breaks in the membrane of the eardrum. The
normal eardrum is translucent, shinny, and pearly gray.
It is free from tears or breaks. A pink or red bulging membrane indicates
inflammation. A white color reveals pus behind it.
The membrane is taut, except for the small triangular pars flaccid near the
top. If cerumen is blocking the tympanic membrane,
warm water irrigation will safely remove the wax.

 You can often tell if the patient has a hearing loss
from a response to conversion. The three types of
hearing loss are conduction, sensorineural, and
mixed. A conduction loss involves an interruption of
sound waves as they travel from the outer ear to
the cochlea of the inner ear because they are not
transmitted through the outer and middle ear
structures. A sensorineural loss involves the inner
ear, the auditory nerve, or the hearing center of the
brain. Sound is conducted through the outer and
middle ear structures, but the continued
transmission of sound becomes interrupted at some
point beyond the bony ossicles. A mixed loss
involves a combination of conduction and sorineural
loss.

Patients working or living around loud noises
are at risk for hearing loss. Older adults
experience an inability to hear high-frequency
sounds and consonants. Deterioration of the
cochlea and thickening of the tympanic
membrane causes older adults to gradually
lose
hearing acuity. They are especially at risk for
hearing loss caused by ototoxicity resulting
from high maintenance doses of antibiotics.

To conduct a hearing assessment, have the patient remove the
hearing aid if worn. Note the patient’s response to questions.
If you suspect a hearing loss, check the patient’s response to the
whispered voice. Test one ear at a time while the patient occludes
the other ear with a finger. Ask the patient to gently move the finger up
and down during the test. While standing 30 cm from the ear
you are testing, cover your mouth so the patient is unable to read your
lips. After exhaling fully, whisper softly toward the unoccluded
ear, reciting random numbers with equally accented syllables such as
“ninefour-ten”. If necessary, gradually increase voice intensity
until the patient correctly repeats the numbers. The test the other ear for
comparison. Seidel and others the patients normally hear
numbers clearly when whispered. You may use a ticking watch to test
hearing acuity, but using the spoken words allows for more
accuracy and control in testing.

If hearing loss is present, there are tests that experienced
practitioners perform using a tuning fork or audiometry.

 Assess the integrity of the nose and sinuses
by inspection and palpation. The patient sits
during the examination. A penlight allows for
gross examination of each naris. A more
detailed examination requires using a nasal
speculum to inspect deeper nasal turbinates.
Do not use a speculum unless a qualified
practitioner is present.

 It is useful to know whether the patient’s health
history indicates exposure to dust or pollutants,
allergies, nasal obstruction, recent trauma,
discharge, frequent infection, headaches, or
postnasal drip. An assessment for a history of
nosebleed includes review of frequency,
amount of bleeding, treatment, and difficulty
stopping bleeding. Also determine whether the
patient has a history of using nasal spray or
drops, including the amount, frequency, and
duration of use. Ask patients if they are been
told that they are snore or if they have difficulty
breathing.

 When inspecting the external nose, observe the
shape, size, skin color, and presence of deformity or
inflammation. The nose is normally smooth and
symmetrical, with the same color as the face.
Recent trauma causes edema and discoloration. If
swelling or deformities exist, gently palpate the ridge
and soft tissue of the nose by placing one finger on
each nasal bridge to the tip. Note any
tenderness, masses, and underlying deviations.
Nasal structures are usually firm and stable.
 Air normally passes freely through the nose
when a person breathes. To assess patency of the
nares, place a finger on the side of the patient’s
nose and occlude one naris. Ask the patient to
breathe with the mouth closed. Repeat the
procedure for the other naris.

As you illuminate the anterior nares, inspect the mucosa for
color, lesions, discharge, swelling, and evidence of bleeding.
If discharge is present, apply gloves. Normal mucoa is pink and moist
without lesions. Pale mucosa with clear discharge
indicates allergy. A mucoid discharge indicates rhinitis. A sinus infection
results in yellowish or greenish discharge. Habitual use of
intranasal cocaine and opioids causes puffiness and increased vascularity
of the nasal mucosa. For the ptient with a
nasogastric tube, check for local excoriation of the naris, characterized by
redness and skin sloughing.

To review the septum and turbinates, have the patient tip the head back
slightly to give you a clearer view. Illuminate the septum and look for
alignment, perforation, or bleeding. Normally the septum is close to the
midline and thicker anteriorly than posterirly. Normal mucosa is pink and
moist, without lesions. A deviated septum obstructs breathing and interferes
with passage of a nasogastric tube. Perforation of the septum often occurs
after repeated use of intranasal cocaine. Note any polyps or purulent
drainage. Advanced, experienced clinicians use a nasal speculum for this
procedure.

 The examination of the sinuses is limited to
palpation. In cases of allergies or infection, the
interior of the sinuses becomes inflamed and
swollen. The most effective way to assess for
tenderness is by externally palpating the frontal
and maxillary facial areas. Palpate the frontal
sinus by exerting pressure with the thumb up
and under the patient’s eyebrow. Gentle upward
pressure elicits tenderness easily if sinus
irritation is present. Do not apply pressure to the
eyes. If tenderness of sinuses is present, the
sinuses may be transilluminated. This
procedure, however, requires advanced
experience.

 Assess the mouth and pharynx to detect signs
of overall health, determine oral hygiene
needs, and develop therapies for patients with
dehydration, restricted intake, oral trauma, or
oral airway obstruction. To assess the oral
cavity use a penlight and tongue depressor or
single gauze square. Wear gloves when
contacting mucous membranes. Have the
patient sit or lie during the examination. You are
also able to assess the oral cavity while
administering oral hygiene.

 Determine if the patient wears dentures or
retainers and if they fit comfortably. An
assessment of a recent change in appetite or
weight often points to a problem with chewing
or swallowing. Assess the patient’s dental
hygiene practices and when the patient last
visited a dentist. To rule out the risks for mouth
and throat cancer, ask if the patient
smokes, chews tobacco, or smokes a pipe and
consumes alcohol. Also assess for a history of
pain or lesions of the mouth and pain with
chewing. It helps to know if a tonsillectomy or
adenoidectomy has been performed.

 Inspect the lips for
color, texture, hydration, contour, and lesions.
With the patient’s mouth closed, view the lips
from end to end. Normally they are
pink, moist, symmetrical, smooth and without
lesions. Lip color in the dark-skinned patient
varies from pink to plum. Have female patients
remove their lipstick before the examination.
Anemia causes pallor of the lips, with cyanosis
caused by respiratory or cardiovascular
problems. Any lesions such as nodules or
ulcerations can be related to
infection, irritation, or skin cancer.

 To review the inner oral mucosa, have the
patient open the mouth slightly and gently
pull the lower lip away from the teeth.
Repeat this process for the upper lip. Inspect
the mucosa for color, hydration, texture, and
lesions such as ulcers, abrasions, or cysts.
Normally the mucosa is a glistening pink.
Varying shades of hyperpigmentation are
normal in 10% of whites after age 50 and up
to 90% of blacks by the same age. Palpate
any lesions with a gloved hand for
tenderness, size, and consistency.

To inspect the buccal mucosa, ask the patient to open the
mouth and then gently retract the cheeks with a tongue
depressure or gloved finger covered with gauze. A penlight
illuminates the posterior mucosa. View the surface of the
mucosa from right to left and top to bottom. Normal mucosa
is glistering, pink, soft, moist, and smooth. For patients with
normal pigmentation the buccal mucosa is a good site to
inspect for jaundice and pallor. In older adults, the mucosa is
normally dry because of reduced salivation. Thick white
patches are often a precancerous lesion seen in heavy
smokers and alcoholics. Palpate for any buccal lesions by
placing the index finger within the buccal cavity and the
thumb on the outer surface of the cheek.

 Examine the gums or gingivae for
color, edema, retraction, bleeding, and lesions. If a patient wears
dentures, irregularity or lesions of the gums creates discomfort
and significantly impairs the ability to chew. Ask the patient to
remove dentures for a complete assessment. Healthy gums are
pink, moist, smooth, and tightly fit around each tooth. Dark-
skinned patients may have patchy pigmentation. In older adults
the gums are usually pale. Using gloves, palpate the gums to
assess for lesions, thickening, or masses. Normally, there is no
tenderness. Spongy gums that bleed easily indicated periodontal
disease or vitamin C deficiency.

Ask the patient to clench the teeth and smile to observe teeth
occlusion. The upper morals normally rest directly on the lower
molars, and the upper incisors. Note the position and
alignment of teeth. Probe each tooth gently with a tongue
blade when the patient complains of any localized discomfort.
The teeth are normally firmly set.

Determine the quality of a patient’s dental hygiene by
inspecting the teeth. To examine the posterior surface of
the teeth, have the patient open the mouth with lips
relaxed. You will need a tongue depressor to retract the
lips and cheeks, especially when viewing the molars. Note
the color of the teeth and the presence of dental
caries, tartar, and extraction sites. Normal healthy teeth
are smooth, white, and shiny. A chalky white discoloration
of the enamel is an early indication that caries are
forming. Brown or black discolorations indicate formation
of caries. A stained yellow color is from tobacco
use, whereas coffee, tea, and colas cause a brown stain.
In the older adult, loose or missing teeth are common
because bone resorption increases. An older adult’s teeth
often feel rough when tooth enamel calcifies. Yellow and
darkened teeth are also common in the older adult
because of general wear and tear that exposes the darker
underlying dentin.

 Carefully inspect the tongue on all sides and the
floor of the mouth. The patient first relaxes the
mouth and sticks the tongue out halfway. If the
patient protrudes the tongue too far, sometimes
you elicit the gag reflex. Using the
penlight, examine the tongue for
color, size, position, texture, movement, and
coating or lesions. A normal tongue appears
medium or dull red in color, moist, slightly rough
on the top surface, and smooth along the lateral
margins. The tongue remains at midline. Ask
the patient to raise the tongue and move it from
side to side. The tongue should move freely.

The undersurface of the tongue and the
floor of the mouth are highly vascular.
Take extra care to inspect this area, a
common site of origin for oral cancer
lesions. The patient lifts the tongue by
placing its tip on the plate behind the
upper incisors. Inspect for
color, swelling, and lesions such as cysts.
The ventral surface of the tongue is pink
and smooth with large veins between the
frenulum folds.

 Have the patient extend the head
backward, holding the mouth open to allow
you to inspect the hard and soft palates. The
hard palate, or roof of the mouth, is located
anteriorly. The whitish hard palate is dome
shaped. The soft palate extends posteriorly
towards the pharynx. It is normally light pink
and smooth. Observe the palates fir
color, shape texture, and extra bony
prominences or defects. A bony growth or
exostosis, between the two palates is
common.

 Perform an examination of the pharyngeal
structures to rule out infection, inflammation, or
lesions. Have the patient tip the head back
slightly, open the mouth wide, and say “Ah”
while you place the tip of a tongue depressor on
the middle third of the tongue. Take care not to
press the lower lip against the teeth. If you
place the tongue depressor too far
anteriorly, the posterior part of the tongue
mounds up, obstructing the view. Placing the
tongue depressor on the posterior tongue elicits
the gag reflex.

With a penlight, first inspect the uvula and soft palate. Both
structures, which are innervated by the tenth cranial
nerve, rise centrally
as the patient says “Ah”. Examine the anterior and
posterior tonsillar tissue. The posterior pharynx is behind
the pillars. Normally
pharyngeal structures are smooth, pink, and well
hydrated. Small irregular spots of lymphatic tissue and
small blood vessels are
normal. Note edema, petechiae, lesions, or exudates.
Patients with chronic sinus problems frequently exhibit a
clear exudate that
drains along the wall of the posterior pharynx. Yellow or
green exudate indicates infection. A patient with a typical
sore throat has a
reddened and edematous uvula and tonsillar pillars with
possible presence of yellow exudate.

 Assessment of the neck includes assessing the
neck muscles, lymph nodes of the head, carotid
arteries, jugular veins, thyroid gland, and
trachea. Postpone an examination of the carotid
arteries and jugular veins until you assess the
vascular system. Inspect the neck to determine
the integrity of neck structures and to examine
the lymphatic system. An abnormality of
superficial lymph nodes sometimes reveals the
presence of the infection or malignancy.
Examination of the thyroid gland and trachea
also aids in ruling out malignancies. Perform
this examination with the patient sitting.

 Determine if the patient has had a recent cold
or infection or feels weak or fatigued. Screening
for hypothyroidism and hyperthyroidism and risk
factors for human immunodeficiency virus (HIV)
infection is necessary. Also assess if the patient
has been exposed to radiation, toxic
chemicals, or infection. Ask the patient to
describe any history of thyroid problems, head
or neck injury, or pain of head and neck
structures. Finally, ask if the patient is taking
thyroid medication or has a family history of
thyroid disease.

 With the patient sitting and facing you, inspect
the gross neck structures observe for symmetry
of neck muscles, alignment of the trachea, and
any subtle fullness at the neck. Any distension
or prominence of jugular veins and carotid
arteries is abnormal. Ask the patient to flex the
neck with the chin to the chest, hyperextend the
neck backward, and move the head laterally to
each side and then sideways with the ear
moving toward the shoulder. This tests the
sternocleidomastoid and trapezius muscles.
The neck normally moves freely without
discomfort.

 An extensive system of lymph nodes collects
lymph from the
head, ears, nose, cheeks, and lips. With the
patient’s chin raised and head titled slightly
back, first inspect the area where lymph
nodes are distributed and compare both
sides. This position stretches the skin slightly
over any possible enlarged nodes. Inspect
visible nodes for edema, erythema, or red
streaks. Nodes are not normally visible.

Use methodical approach to palpate the lymph nodes to avoid overlooking
any single node or chain. The patient relaxes muscles and tissues by
keeping the neck flexed slightly forward and, if needed, toward you. Palpate
both sides of the neck for comparison. During palpation either face or stand
to the side of the patient for easy access to all nodes. Using the pads of the
middle three fingers of each hand, gently palpate in a rotary motion over the
nodes. Check each node methodically in the following sequence: occipital
nodes at the base of the skull, postauricular nodes over the
mastoid, preauricular nodes just in front of the ear, retropharyngeal nodes
at the angle of the mandible, submandibular nodes, and submental nodes
in the midline behind the mandibular tip. Try to detect enlargement, and
note the location, size, shape, surface
characteristics, consistency, mobility, tenderness, and warmth of the nodes.
If the skin is mobile, move the skin over the area of the nodes. It is
important to press underlying tissue in each area and not simply move the
move the fingers over the skin. However, if you apply excessive
pressure, you will miss small nodes and destroy palpable nodes

To palpate supraclavicular nodes ask the patient to bend the
head forward and relax the shoulders. You may have to hook the
index
and third finger over the clavicle, lateral to the
sternocleidomastoid muscle, to palpate these nodes. Palpate the
deep cervical nodes
only with your fingers hooked around the sternocleidomastoid
muscle.
Normally lymph nodes are not easily palpable. Lymph nodes
that are large, fixed, inflamed, or tender indicate a problem such
as
local infection, systemic disease, or neoplasm. Tenderness
almost always indicates inflammation. A problem involving a
lymph node
of the head and neck may mean an abnormality in the mouth,
throat, abdomen, breasts, thorax, or arms. These are the areas
drained
by the head and neck nodes.

 The thyroid gland lies in the anterior lower
neck, in front of and to both sides of the
trachea. The gland is fixed to the trachea with
the isthmus overlying the trachea and
connecting the two irregular, cone-shaped
lobes. Inspect the lower neck over the thyroid
gland for obvious masses and symmetry. Offer
the patient a glass of water, and , while
observing the neck, have the patient swallow.
This maneuver helps to visualize an abnormally
enlarges thyroid by palpating for more subtle
masses; this technique will not be discussed
here.

 The trachea is a part of the upper airway that
you directly palpate. It is normally located in the
midline above the suprasternal notch. Masses
in the neck or mediastinum and pulmonary
abnormalities cause displacement laterally.
Have the patient sit or lie down during
palpation. Determine the position of the trachea
by palpating at the superasternal notch, slipping
the thumb and index fingers to each side. Note
if your finger and thumb shift laterally. Do not
apply forceful pressure to the trachea because
this elicits coughing.

Assessment on Skin, Hair & Nails / HEENT

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Assessment on Skin, Hair & Nails / HEENT