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Integumentary: Assessment Findings

The integumentary system findings include pink skin that returns quickly to normal after pinching, fair complexion, dry skin, evenly distributed hair and clean nails. The head is normocephalic and symmetrical. Facial movements are symmetrical. Eyes have transparent sclera and corneas, equal pupils that react to light, intact eyelids and conjunctiva. Ears have auricles aligned with eyes, clear canals and ability to hear normal sounds. The nose is symmetric with clear airways. The mouth has pink mucosa, brown gums and dental issues. The neck is midline without masses. Respirations are quiet, rhythmic and effortless.

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Giselle Estoquia
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45 views4 pages

Integumentary: Assessment Findings

The integumentary system findings include pink skin that returns quickly to normal after pinching, fair complexion, dry skin, evenly distributed hair and clean nails. The head is normocephalic and symmetrical. Facial movements are symmetrical. Eyes have transparent sclera and corneas, equal pupils that react to light, intact eyelids and conjunctiva. Ears have auricles aligned with eyes, clear canals and ability to hear normal sounds. The nose is symmetric with clear airways. The mouth has pink mucosa, brown gums and dental issues. The neck is midline without masses. Respirations are quiet, rhythmic and effortless.

Uploaded by

Giselle Estoquia
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Assessment Findings

Integumentary

When skin is pinched it goes to previous


 Skin state immediately (2 seconds).
With fair complexion.
With dry skin
Evenly distributed hair.
 Hair With short, black and shiny hair.
With presence of pediculosis Capitis.
Smooth and has intact epidermis
With short and clean fingernails and
 Nails toenails.
Convex and with good capillary refill time
of 2 seconds.
Rounded, normocephalic and symmetrical,
Skull smooth and has uniform
consistency.Absence of nodules or masses.
Symmetrical facial movement, palpebral
Face fissures equal in size, symmetric nasolabial
folds.
Eyes and Vision
Hair evenly distributed with skin intact.
 Eyebrows Eyebrows are symmetrically aligned and
have equal movement.
 Eyelashes Equally distributed and curled slightly
outward.
Skin intact with no discharges and no
 Eyelids discoloration.
Lids close symmetrically and blinks
involuntary.
 Bulbar conjunctiva Transparent with capillaries slightly visible
Assessment Findings

 Palpebral Conjunctiva Shiny, smooth, pink

 Sclera Appears white.

 Lacrimal gland, Lacrimal sac,


No edema or tenderness over the lacrimal
Nasolacrimal duct gland and no tearing.

Cornea
Transparent, smooth and shiny upon
inspection by the use of a penlight which is
 Clarity and texture held in an oblique angle of the eye and
moving the light slowly across the eye.
Has [brown] eyes.
 Corneal sensitivity Blinks when the cornea is touched through
a cotton wisp from the back of the client.
Black, equal in size with consensual and
direct reaction, pupils equally rounded and
reactive to light and accommodation,
Pupils pupils constrict when looking at near
objects, dilates at far objects, converge
when object is moved toward the nose at
four inches distance and by using penlight.
When looking straight ahead, the client can
see objects at the periphery which is done
by having the client sit directly facing the
nurse at a distance of 2-3 feet.
Visual Fields The right eye is covered with a card and
asked to look directly at the student
nurse’s nose. Hold penlight in the
periphery and ask the client when the
moving object is spotted.
Assessment Findings

Able to identify letter/read in the


newsprints at a distance of fourteen inches.
Visual Acuity
Patient was able to read the newsprint at a
distance of 8 inches.
Ear and Hearing
Color of the auricles is same as facial skin,
symmetrical, auricle is aligned with the
 Auricles outer canthus of the eye, mobile, firm, non-
tender, and pinna recoils after it is being
folded.
 External Ear Canal Without impacted cerumen.

 Hearing Acuity Test Voice sound audible.

Able to hear ticking on right ear at a


 Watch Tick Test distance of one inch and was able to hear
the ticking on the left ear at the same
distance
Nose and sinuses
Symmetric and straight, no flaring, uniform
 External Nose in color, air moves freely as the clients
breathes through the nares.
Mucosa is pink, no lesions and nasal
 Nasal Cavity septum intact and in middle with no
tenderness.
Symmetrical, pale lips, brown gums and
Mouth and Oropharynx
able to purse lips.
 Teeth With dental caries and decayed lower
molars
Central position, pink but with whitish
 Tongue and floor of the mouth coating which is normal, with veins
prominent in the floor of the mouth.
Assessment Findings

Moves when asked to move without


 Tongue movement difficulty and without tenderness upon
palpation.
Uvula Positioned midline of soft palate.
Present which is elicited through the use of
Gag Reflex
a tongue depressor.
Positioned at the midline without
Neck tenderness and flexes easily. No masses
palpated.
Coordinated, smooth movement with no
Head movement discomfort, head laterally flexes, head
laterally rotates and hyperextends.
Muscle strength With equal strength
Lymph Nodes Non-palpable, non tender
Not visible on inspection, glands ascend
 Thyroid Gland but not visible in female during swallowing
and visible in males.
Thorax and lungs
Posterior thorax Chest symmetrical
Spine vertically aligned, spinal column is
 Spinal alignment straight, left and right shoulders and hips
are at the same height.
With normal breath sounds without
Breath Sounds
dyspnea.
 Anterior Thorax Quiet, rhythmic and effortless respiration

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