Name: _______________________________________________ Section: ________

Supervising Clinical Instructor: ___________________________ Date of Lecture Demo:

_____

Assessing the Appearance and Mental Status; Skin, Hair and Nails

Basic Concept:
Assessing the appearance and mental status is an evaluation of the client’s look and
mental state in relation to his/ her culture, socioeconomic status and current circumstances.
Assessing the skin, hair and nails is an overall inspection of the condition of the
integumentary system that provides clues to client’s general health condition. The disease and
disorder of the integumentary system may be local or caused by underlying systemic
condition.

Objectives:
Assessing the appearance and mental status
1. To determine client’s current mental state.
2. To determine reliability of the client’s responses throughout the rest of the
examination
3. To acquire information regarding client’s level of cognition and emotional stability.

Assessing the skin, hair and nails

1. To obtain information about the nutritional and hydration status and overall health
of the patient.
2. To obtain information associated with certain systemic diseases, infection,
immobility, excessive sun exposure, and allergic reactions.

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 appropriate infection control procedures.
3. Provide for client privacy.

Assessing the Appearance and Mental Status

PROCEDURE RATIONALE

1. Observe body build, height, and

weight in relation to the client’s age,
lifestyle, and health.

2. Observe the client’s posture and gait, So Instruct the client to stand and to sit and
standing, sitting, and walking. ask the client to walk at this point to this
point take note for the posture
3. Observe the client’s overall hygiene
and grooming. Relate these to the So we’re going to inspect for any foul odors
person’s activities prior to the and of course the clothing of our patient.
assessment.
 4.

Note body and breathe odor in

relation to activity level.

5. Observe for signs of distress in Also notet for the eye contact to the
posture or facial expression. examiner

6. Note obvious signs of health or

illness.

7. Assess the client’s attitude.

8. Note the client’s affect/mood; assess

the appropriateness of the client’s
responses.
the facial expression for the patient and the
9. Listen for quantity, quality and quality and quantity of the speech
organization of speech.

10. Listen for relevance and organization

of thoughts.

11. Document findings in the client

record.

Assessing the Skin

Materials/ Equipment:
Millimeter ruler
Examination gloves/ clean gloves
Magnifying glass

Preparation:
1. Assemble equipment.

PROCEDURE RATIONALE

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
2. Inspect the skin color. So we are going to determine the skin color
of the client that should be uniformly to the
3. Inspect uniformity of skin color. side of the body.
So assess for skin color so assess the
nearest side to you next is the other side.

Assess edema, if present. Make sure to pinch and palpate for any
lesions by using your index and middle
4. Inspect, palpate, and describe skin finger. Palpate going to the upper
lesions. extremeties.
-Apply gloves if lesions are open or If there is any abnormalities you will need
draining. to use magnifying glass to determine the
type of lesions and to you to properly
-Describe lesions according to visualized it. So note for any freckles,
location, distribution, color, macules or papules.
configuration, size, shape, type, or
structure.
5. Observe and palpate skin moisture.
So we are going to palpate the temperature by
6. Palpate skin temperature.
nearly touching the client and comparing it to
-Compare the two feet and the two
the other skin.
hands using the backs of your
fingers.
The last assessment is we need to
determine the hydration of our client After that we need to make our client
by nearly pinching the skin and take comfortable .
note if the patient is well hydrated it
goes back to its normal So we need to wear gloves too prevent
7. Note skin turgor by lifting and contamination
pinching the skin on an extremity.
So
8. Documents findings in the client
record.
-Draw the location of skin lesions on
body surface diagrams.

Assessing the Hair

Material:
Clean gloves
 PROCEDURE RATIONALE

1. Inquire if client has any history

of the following:
Recent use of hair dyes, rinses, or
curling or straightening
preparations
Recent chemotherapy
Presence of disease
2. Inspect the evenness of growth By using my hand make sure that the hand
over the scalp. is in C form make that when you touch it
there should be evenness in growth. And
3. Inspect hair thickness or thinness. the other side.
Determine the texture of the client by
4. Inspect hair texture and oiliness. inserting a pressure using your thumb make
sure that the hair will not fall.
5. Note presence of infection or
infestation by parting the hair in Determine for the oiliness or dandruff take
several areas and checking note that a minimal dandruff is normal in a
behind the ears and along the normal individual.
hairline at the neck. After that you will need to go to the front of
the client to determine for any forms of
6. Inspect the amount of body hair. receeding hair lines side to side.

7. Document findings in the client

record.

Assessing the Nails

PROCEDURE RATIONALE

1. Inquire if the client has any history

of the following:
Diabetes mellitus
Peripheral circulatory disease
Previous injury
Severe illness

2. Inspect fingernail plate shape to The normal curvature is 160 in angle. There
determine its curvature and angle. should be no inward movement.

3. Inspect fingernail and toenail texture. Determine for any vascular or peripheral
disease.
4. Inspect fingernail and toenail bed Make sure that the cuticle is intact and the
color. surrounding of nails doesn’t have any forms
of deformities.
5. Inspect tissues surrounding nails.
 6. Perform blanch test of capillary
refill. So this is creating pressure into the nail bed
- Press two or more nails between of a client. Add pressure it should be less
your thumb and index fingers; look than 2 second that it would then recoil so
for blanching and return of pink create a pressure using your thumb.
color to nail bed.

7. Document findings in the client

record.
Adopted from Kozier and Erb’s Fundamentals of Nursing (2015).
Berman, Audrey, et.al. (2015). Kozier and Erb’s Fundamentals of Nursing: Concept, Process and Practice, 10th
ed
Weber, Janet R., et.al. (2014). Health Assessment in Nursing, 5th ed.

PERFORMANCE CHECKLIST
Name: __________________________________________ Date of Return Demo:
__________

Assessing the Appearance and Mental Status; Skin, Hair and Nails

Criteria for evaluation or rating the student’s performance:

1 - Performs the step or procedure independently, correctly and appropriately. Shows

excellent attitude and gives the correct rationale of the step/ procedure to be performed.
Answers the question/s correctly and analyzes the situation on or before performing the
procedure.
2 – Performs more independently with increasing dependability but occasionally needing
assistance. Shows very satisfactory attitude and gives the correct rationale of the step/
procedure to be performed but occasionally needing follow-up instructions and explanations.
3 – Performs expected step/ procedure but needs supervision, follow-up instructions and
explanations. Has knowledge about the topic, step or procedure but needs reinforcement.
4 – Performs with close supervision. The student needs repeated, specific, detailed guidance
and direction to be able to perform the step/ procedure correctly and appropriately. There is a
need to improve performance.
5 – Performs with very close supervision. The student shows poor or no interest in the step/
procedure to be performed; cannot answer the question raised by the supervising clinical
instructor based on the step or procedure to be performed; unable to grasp understanding of
the topic or procedure; unable to perform the required step and state the rationale after being
instructed, guided or directed. Student’s behavior is inappropriate and potentially harmful to
the client.

1 2 3 4 5
ASSESSMENT
1. Verifies the client’s identity.
PLANNING
1. Reviews previously learned concepts and principles.
2. Explains the procedure to the client and how the client can
cooperate.
3. Prepares and assembles all equipment.
IMPLEMENTATION
1. Introduces self.
2. Performs hand hygiene.
3. Provides client privacy.
Assessing appearance and mental status:
4. Observes body build, height, and weight in relation to the client’s
age, lifestyle, and health.
5. Observes the client’s posture and gait, standing, sitting, and
walking.
6. Observes the client’s overall hygiene and grooming.
7. Relates observation on overall hygiene and grooming to the
person’s activities prior to the assessment.
8. Notes body and breathe odor in relation to activity level.
9. Observes for signs of distress in posture or facial expression.
10. Notes obvious signs of health or illness.
11. Assesses the client’s attitude.
12. Notes the client’s affect/mood.
13. Assesses the appropriateness of the client’s responses to your
question and to affect/ mood.
14. Listens for quantity, quality and organization of speech.
15. Listens for relevance and organization of thoughts.
Assessing the Skin:
16. Inquires if client has any history of the following:
a. Pain or itching
b. Presence and spread of any lesions, bruises, abrasions, or
pigmented spots
c. Skin problems
d. Associated clinical signs
e. Problems in other family members
f. Related systemic conditions
g. Use of medications, lotions, or home remedies
h. Excessively dry or moist feel to the skin
i. Tendency to bruise easily
j. Any association of the problem to a season of the year
17. Inspects the skin color.
18. Inspects uniformity of skin color.
19. Assesses edema, if present.
20. Inspects, palpates, and describes skin lesions.
a. Applies gloves (if lesions are open or draining).
b. Describes lesions according to:
b1. location,
b2. distribution,
b3. color,
b4. configuration,
b5. size,
b6. shape,
b7.type, or
b8. structure.
21. Observes and palpates skin moisture.
22. Palpates skin temperature.
a. Compares the two feet and the two hands using the backs of your
fingers.
23. Notes skin turgor by lifting and pinching the skin on an extremity.
Assessing Hair:
24. Inquires if client has any history of the following:
a. Recent use of hair dyes, rinses, or curling or straightening
preparations
b. Recent chemotherapy
c. Presence of disease
25. Inspects the evenness of growth over the scalp.
26. Inspects hair thickness or thinness.
27. Inspects hair texture and oiliness.
28a. Notes presence of infection or infestation by parting the hair in
 several areas and;
b. checks behind the ears and along the hairline at the neck.
29. Inspects the amount of body hair.
Assessing nails:
30. Inquires if the client has any history of the following:
a. Diabetes mellitus
b. Peripheral circulatory disease
c. Previous injury
d. Severe illness
31. Inspects fingernail plate shape to determine its curvature and
angle.
32. Inspects fingernail and toenail texture.
33. Inspects fingernail and toenail bed color.
34. Inspects tissues surrounding nails.
35. Performs blanch test of capillary refill.
a. Presses two or more nails between your thumb and index fingers.
b. Looks for blanching and return of pink color to nail bed.
36. Performs hand hygiene.
37. Documents findings in the client record.
38. For skin assessment, draws the location of skin lesions on body
surface diagrams.
EVALUATION
1. Observes appropriate infection control measures throughout the
performance of the procedure.
2. Applies related and relevant principles / concepts.
3. Distinguishes what is normal findings and deviation to normal
findings,
4. Relates findings or assessment to client’s culture, socioeconomic
status and current circumstances, certain condition or disorder.
5. Shows understanding of the terms, description or findings stated.
6. Performs the procedure with mastery and confidence.
7. Shows a positive and caring attitude towards the client.

Comments and Suggestions:

Rating: ______
Signature of Supervising Clinical Instructor: _______________________