HEAD-TO-TOE-ASSESSMENT-NCM-101lectnL.pdf

Head to toe assessment

1. HEAD TO TOE ASSESSMENT
NCM 101n/L –Skills Laboratory
Second Semester, SY: 2022-2023
Prepared by: Prof. Dennis C. Padernilla, RN, MN

2. OBJECTIVES
•Conduct a physical assessment in a systematic
manner.
•Document health assessment findings in a
concise, descriptive, and legally appropriate
manner.
•Describe nursing responsibilities before, during,
and after diagnostic procedures

3. •A head-to-toe assessment should
be done each time you encounter
a patient for the first time each
shift (or visit, for home care, clinic
or office nurses).

4. Which aspects are considered
during a Head to Toe Assessment?
This assessment includes assessment of
the physical, emotional and mental aspects
of all body systems as well as the
environmental and social issues affecting
the patient. The nurse needs to observe for
all of these factors and ask questions as
needed.

5. PREPARATION

6. Which are the 5 vital signs evaluated during
a Head to Toe assessment?
•Wash your hands. Greet and identify the
patient. Explain what you are going to do.
•Provide for privacy.
•Begin with the5 Vital Signs: Temperature,
Pulse, Blood Pressure, RespirationandPain.
•Ask the patient how he/she feels and observe
the environment.
•As you assess the body by systems, observe
for such things as non-verbal cues, mobility
andROM.

7. •Physical examination requires examiner to
develop technical skills = the tools to
gather data
•Use your senses to gather data –TOUCH,
VISION, HEARING, & SMELL

8. 1. INSPECTION
üClose/careful scrutiny –first of an
individual as a whole and then
of each body system
üInspection always comes FIRST
üCompare the client’s R & L sides (symmetry)
üBegins the moment you first meet the person and
develop a “general survey”
üPay attention to their affect (their temperament, mood),
how their dressed, hygiene, etc.

9. 1. INSPECTION
üObserve for: symmetry, norms, size, shape,
color, & behavior
üGeneral inspection –front to back/ side to
side, symmetry, injuries, abnormalities (overall
appearance)
üSystemic inspection –each body system from
head to toe
üInspection requires: good lighting, adequate
exposure, occasional use of instruments
(including otoscope, ophthalmoscope, penlight,
or nasal and vaginal specula) to enlarge your
view

10. 2. PALPATION
üOften confirms points
you made during
inspection
üSense of TOUCH to
asses: texture, temperature, moisture, organ
location and size, swelling, vibration or
pulsation, rigidity or spasticity, crepitation,
presence of lumps or masses, and presence
of tenderness or pain

11. 2. PALPATION
Different parts of the hand are best suited for assessing
different factors:
üFINGERTIPS –best for fine tactile discrimination, as of skin texture,
swelling, pulsation, and determining presence of lumps
üGrasping action of the fingers and thumb –to detect the position, shape,
and consistency of an organ or mass
üTHE DORSAL (BACKS) OF HANDS AND FINGERS—best for
determining temperature b/c the skin here is thinner than on the palms
üBase of fingers or ulnar surface of hand –best for vibration

12. 2. PALPATION
üBIMANUAL PALPATION –requires use of both
hands to envelop or capture certain body parts or
organs such as kidneys, uterus, or adnexa for
more precise delimitation

13. 2. PALPATION
üSkin, organs, glands, vessels, thorax
üLight palpation –rigidity, tenderness, masses
üDeep palpation –enlarged organ, tenderness,
masses
üBimanual palpation –size, tenderness
üUse back of the hand for TEMP
üAlways do non-tender areas first
before painful areas**

14. 3. PERCUSSION
qTapping the person’s skin with short, sharp,
strokes to assess underlying structures
qProduces audible vibration that helps reveal:
location, density, and size of underlying
tissue

15. 3. PERCUSSION
2 METHODS:
1. Direct percussion –or “immediate”, the striking
hand directly contacts body wall (ex. sinus
tenderness)
2. Indirect percussion –or “mediate”, using both
hands, the striking hand contacts stationary hand
fixed on person’s skin (ex. lung percussion)

16. 3. PERCUSSION
PERCUSSION NOTE CHARACTERISTICS:
üRESONANT–low-pitched (hollow)
ex. air-filled lungs, normal lung tissue
üHYPERRESONANT –loud/booming
qnormal over a child’s lung
qABNORMAL in adult hyper-inflated lung with
increased amount of air as in emphysema (someone
with COPD that has huge lungs would be considered
hyperresonant sound)

17. 3. PERCUSSION
PERCUSSION NOTE CHARACTERISTICS:
üTYMPANY–high pitched/drum-like
ex. stomach (air-filled stomach)
üDULL—soft-high-pitched, thud-like
ex. dense organs (heart, liver, spleen)
üFLAT –a dead stop of sound, absolute dullness.
When no air is present
ex. over thigh muscles, bone, or tumor

18. 3.4. AUSCULTATION
üLISTENING to sounds produced by the body (ex.
heart and blood vessels, lungs, abdomen)
üMost body sounds are very soft and must be
channeled through a stethoscope

19. 3.4. AUSCULTATION
üFor HIGH PITCHED SOUNDS –use the
diaphragm (lung sounds, normal heart sounds,
bowel sounds)
üFor LOW PITCHED SOUNDS –use the bell
(remember: “bel-low”) ex. extra heart sounds or
murmurs, blood vessels, gallops
üNEVER LISTEN THROUG CLOTHES
üPitch-tone, frequency

20. HEENT/NEURO

21. HEAD, FACE, & NECK

22. •A HEENT examination is a portion
of a physical examination; it
principally concerns the Head,
Eyes, Ears, Nose and Throat.

23. THE HEAD –STRUCTURE & FUNCTION
•Cranial bones: frontal, parietal, occipital,
temporal Sutures
•Facial bones –14
•Cervical support –C7
üC7 = important landmark when processing
anatomical structures
•Glands
•Temporal artery

24. THE NECK –STRUCTURE & FUNCTION
qConduit
üBlood vessels
üMuscles
üNerves
üLymphatics
üViscera (respiratory/digestive)
qNeck muscles
üSternocleidomastoid
ütrapezius

25. THE NECK –STRUCTURE & FUNCTION
qThyroid gland
üendocrine gland
ühighly vascular
üsynthesizes + secretes T3 + T4 hormones that
stimulate the rate of cellular metabolism
qThyroid cartilage
qHyoid bone

26. LYMPH/LYMPHATICS
üDrains the head and neck of excess interstitial fluid via lymph
nodes
üLymph nodes line the cervical spine and neck regions as well
as along the face and jaw
ünodes slowly filter the lymph and engulf pathogens,
preventing harmful substances from entering the circulation
üNodes are accessible to examination only in four areas:
vhead and neck (greatest supply)
varms
vaxillae
vinguinal area
•

27. LYMPH/LYMPHATICS
üBe familiar with the direction of the drainage
patterns of the lymph nodes. When nodes are
enlarged, check the area they drain for the source
of the problem. Explore the area proximal
(upstream) to the enlarged node. All head and
neck structures eventually drain into the deep
cervical chain.
üThe head and neck have a rich supply of 60-70
lymph nodes

28. LYMPH NODES OF HEAD/NECK
1. Preauricular= in front of the ear
2. Posterior auricular (mastoid) = superficial to the mastoid process
3. Occipital = at the base of the skull
4. Submental= midline, behind the tip of the mandible
5. Submandibular = halfway b/w the angle & the tip of the mandible
6. Jugulodigastric(tonsillar) = under the angle of the mandible
7. Superficial cervical = overlying the sternocleidomastoid muscle
8. Deep cervical = deep under the sternocleidomastoid muscle
9. Posterior cervical = in the posterior triangle along the edge of the
trapezius muscle
10. Supraclavicular = just above and behind the clavicle, at the
sternocleidomastoid muscle

29. Headache
Frequency/Severity
üany unusually frequent or unusually severe headaches? Gradual or
suddenly? Mild/moderate/severe?
Character
üthrobbing (pounding or shooting) or aching (constant pressure,
dull)?
Course & Duration
üwhat time of the day do they occur (morning, evening, awaken you
from sleep)?; how long do they last (hours, days)?; have you noted
any daily headaches or several within a time period?
Associated factors
üany relation to any other symptoms:
nausea, vomiting? (note which came first: headache or
nausea). Vision changes, pain w/ bright lights, Neck pain or
stiffness, fever, weakness, moodiness, stomach problems?

30. Head Injury
qLOC (loss of consciousness)
and then fall? note: LOC
BEFORE a fall may have a
cardiac issue (ex. heart block)

31. Dizziness
•Tell me what you mean by dizziness.
•“I feel like I’m going to faint” suggests PRESYNCOPE = a light-headed,
swimming sensation or feeling or fainting or falling caused by decreased
blood flow to brain or heart irregularity causing decreased cardiac
output.
•“I feel like I’m spinning” suggests VERTIGO = a true rotational spinning
often from labyrinthine-vestibular disorder in inner ear
With objective vertigo
person feels like the room is spinning
With subjective vertigo
person feels like he or she is spinning (the perception is
that the person spins)
Vertigo–true rotational spinning from neurologic disease

32. Neck Pain limitation of motion?
Lumps or Swelling dysphagia = difficulty swallowing
Head/Neck surgery? surgery for head and neck
cancer often is disfiguring and increases risk for
body image disturbance.

33. INSPECT & PALPATE SKULL
Size and shape
ünormocephalic = term that denotes a round symmetric
skull that is appropriately related to body size
Deformities:
ümicrocephaly = abnormally small head
ümacrocephaly = abnormally large head (hydrocephaly,
acromegaly)

34. Temporal area
üpalpate the temporal artery above the zygomatic (cheek)
bone b/w the eye and the top of the ear
Abnormal findings: the artery looks tortuous, feels
hardened, and is tender with temporal
arteritis.

35. INSPECT THE FACE
Symmetry –facial features should always be symmetric
(expect symmetry of eyebrows, nasolabial folds, and sides
of mouth)
Abnormal findings:
qmarked asymmetry w/ central brain lesion
(ex. stroke) or peripheral cranial nerve 7 damage
(Bells Palsy).
Why pay attention to the symmetry of eyebrows/nasolabial
folds?
Gives you an indication of neurological fxn

36. HAIR

37. INSPECTION & PALPATION OF THE HAIR
qColor–hair color comes from melanin production (may vary
from pale blonde to total black)
qTexture–scalp hair may be fine or thick and may look
straight, curly, or kinky. Should look shiny (may be lost with
some beauty products)
Abnormal findings:
üNote dull, coarse, or brittle scalp hair.
üGray, scaly, well-defined areas w/ broken hairs
accompany tineacapitis, a ringworm infection found
mostly in school-age children

38. INSPECTION & PALPATION OF THE HAIR
qDistribution –Abnormal findings: absent or sparse
genital hair suggests endocrine abnormalities.
Hirsutism= excess body hair (also indicated
endocrine abnormalities)
qLesions–all areas should be clean + free of lesions
or pest inhabitants
Abnormal findings: head or pubic lice

39. ABNORMAL FINDINGS OF HAIR
SEBORRHEIC DERMATITIS (cradle cap)
thick, yellow-to-white, greasy, adherent scales with mild
erythema on scalp + forehead; very common in early infancy.
TINEA CAPITIS (scalp ringworm)
rounded, patchy hair loss on scalp, leaving broken-off hairs,
pustules, and scales on the skin. Caused by fungal infection, highly
contagious. Lesions may fluoresce blue-green under Wood’s light.
TOXIC ALOPECIA
patchy, asymmetric balding that accompanies severe illness or
use of chemotherapy in which growing hairs are lost and resting
hairs are spared. Regrowth appears after illness or discontinuation
of toxin.
•

40. ABNORMAL FINDINGS OF HAIR
ALOPECIA AREATA
sudden appearance of round/oval balding patch usually with
smooth, soft, hairless skin underneath. Unknown cause. When
limited to a few patches, person usually has complete regrowth.
TRAUMATIC ALOPECIA(traction alopecia)
linear or oval patch of hair loss along hair line, a part, or
scattered distribution; caused by trauma from hair rollers, tight
braiding/ponytail
TRICHOTILLOMANIA
traumatic self-induced hair loss usually the result of
compulsive twisting or plucking. Forms irregularly shaped
patch, with broken-off, stub-like hairs of varying lengths; person
is never completely bald

41. ABNORMAL FINDINGS OF HAIR
PEDICULOSIS CAPITIS ( head lice)
FOLLICULITIS(“razor bumps”)
superficial inflammatory infection of hair follicles.
HIRSUTISM
excess body hair in females forming a male sexual pattern
FURUNCLE AND ABSCESS
red, swollen, hard, tender, pus-filled lesion caused by
acute, localized bacteria (usually staph) infection.
üFuruncles are usually caused by infected hair follicles.
üAbscesses are caused by traumatic introduction of bacteria
into skin. They’re usually larger + deeper than furuncles.

42. SKIN
The skin
covers and
protects the
internal
structures of
the body.
It consists of
two distinct
layers: the
epidermis
and the
dermis.
Subcutane
ous tissue
lies beneath
these layers.
Epidermis
■Outer layer
■Made of squamous
epithelial tissue
Dermis
■Thick, deeper layer
■Consists of connec-
tive tissue and an ex-
tracellular material
(matrix), which con-
tributes to the skin’s
strength and pliability
■Location of blood
vessels, lymphatic
vessels, nerves, hair
follicles, and sweat
and sebaceous glands
Subcutaneous tissue
■Beneath dermis and
epidermis
■Consists mostly of
adipose and other
connective tissues
Stratum
corneum
Pore of
sweat gland
Free
nerve
ending
Eccrine
sweat gland
Hair bulb
Sensory
nerve fibers
Autonomic
nerve
fibers
Artery Vein

43. SKIN

44. FXNS OF SKIN:
•PROTECTION—skin minimizes injury from physical,
chemical, thermal, and light-wave sources
•PREVENTS PENETRATION –skin is barrier that
stops invasion of microorganisms and loss of water
and electrolytes from within the body
•PERCEPTION—skin is a vast sensory surface
holding the neurosensory end-organs for touch, pain,
temperature, and pressure

45. FXNS OF SKIN:
•TEMPERATURE REGULATION—skin allows heat
dissipation through sweat glands and heat storage
through subcutaneous insulation
•IDENTIFICATION—people identify one another by
unique combos of facial characteristics, hair, skin color,
and even fingerprints
•COMMUNICATION—emotional expression –vascular
mechanisms such as blushing or blanching

46. FXNS OF SKIN:
•IDENTIFICATION—people identify one another by
unique combos of facial characteristics, hair, skin
color, and even fingerprints
•COMMUNICATION—emotional expression –
vascular mechanisms such as blushing or
blanching
•WOUND REPAIR –skin allows cell replacement of
surface wounds

47. FXNS OF SKIN:
•ABSORPTION AND EXCRETION –skin allows
limited excretion of some metabolic wastes, by-
products of cellular decomposition such as
minerals, sugars, amino acids, cholesterol, uric
acid, and urea
•PRODUCTION OF VITAMIN D –skin is the
surface on which UV light converts cholesterol
into vitamin D

48. EPIDERMAL APPENDAGES & FXN
HAIR–threads of keratin (tough fibrous
protein)
Hair growth is cyclical (w/ active +
resting phases). Each follicle fxns
independently (while some hairs are
resting, others are growing)

49. EPIDERMAL APPENDAGES & FXN
2 TYPES OF HAIR
1. VELLUS HAIR = covers most of body
2. TERMINAL HAIR = darker, thicker hair
that grows on scalp, eyebrows, pubic area,
axillae, and face/chest for males

50. SEBACEOUS GLANDS –“oil glands” produce a
protective lipid substance, sebum, which is
secreted through the hair follicles. Sebum
oils + lubricates the skin + hair and forms an
emulsion w/ water that slows down water
loss from the skin. Dry skin results from loss
of water not from loss of oil. Most abundant
in scalp, forehead, face, and chin.
EPIDERMAL APPENDAGES & FXN

51. SWEAT GLANDS –2 types:
1. Eccrine glands –open directly onto the skin surface
and produce SWEAT = a dilute saline solution. Widely
distributed throughout the body + mature in 2-month
old infant
2. Apocrine glands –produce a thick, milky secretion
and open into the hair follicles. Located mainly in
axillae, anogenital area, nipples, and navel and are
vestigial in humans. Become active during puberty +
secretion occurs w/ emotional + sexual stimulation.
Bacteria on skin surface react w/ apocrine sweat and
produce musky body odor.
EPIDERMAL APPENDAGES & FXN

52. NAILS–hard plates of keratin on
dorsal edges of fingers + toes
Pink color from the
underlying nail bed of highly
vascular epithelial cells
EPIDERMAL APPENDAGES & FXN

53. •Previous history of skin disease
•Change in pigmentation
•Change in mole
•Excessive dryness or moisture
•Pruritis = itching
•Excessive bruising
Assessment Phase

54. •Rash or lesion
•Medications
•Hair loss
•Change in nails
•Environmental or occupational hazards
•Self-care behaviors
Assessment Phase

55. •General pigmentation—observe SKIN
TONE. Normally even/consistent w/ genetic
background (varies from: pinkish tan, ruddy
dark tan, or light to dark brown and may
have yellow or olive undertones. Dark
skinned people usually lighter pigmentation
on palms, nail beds, + lips)
COLOR

56. •ABNORMAL FINDINGS:
VITILIGO–complete absence of melanin pigment in
patchy areas or white or light skin
Common/benign pigmented areas
1. FRECKLES –(ephelides) small, flat, macules of brown
melanin pigment that occur on sun-exposed skin
COLOR

57. 2. MOLES –(nevus) clump of melanocytes, tan-to-brown
color, flat or raised. Acquired nevi have symmetry,
small size (6mm or less), smooth borders, and single
uniform pigmentation)
JUNCTIONAL NEVUS –macular only and occurs in
children + adolescents
COMPOUND NEVUS –in adults (progresses to this
from junctional?), macular and papular
COLOR

58. 3. BIRTHMARKS–may be tan to brown in color
Abnormal characteristics of pigmented lesions =
“ABCDE”:
A –asymmetry (not regularly round or oval)
B –border irregularity (ragged edges)
C –color variation (brown/tan, black, blue, red, white, or
combo)
D –diameter greater than 6 mm (size of pencil eraser)
E –elevation or enlargement (rapidly changing, devt Of
itching/burning/bleeding in a mole)
COLOR

59. Widespread Color Change –note any color change over the entire
body
•PALLOR (white)
pallor is common in acute high-stress states (anxiety
or fear) b/c of the powerful peripheral vasoconstriction
from SNS stimulation. Skin can also look pale w/
vasoconstriction from exposure to cold + from cig smoking
in the presence of edema.
Abnormal findings: ashen gray color in dark skin or marked
pallor in light skin occurs w/ anemia, shock, and arterial
insufficiency
COLOR

60. •ERYTHEMA
intense redness of the skin, from excess blood
(hyperemia) in the dilated superficial capillaries. Expected
with: fever, local inflammation, or emotional rxnslike blushing in
vascular flush areas (cheeks, neck, upper chest). Erythema w/
fever or local inflammation has an increased skin temperature from
the increased rate of blood flow.
Abnormal findings: erythema occurs with polycythemia,
venous stasis, CO poisoning, and extravascular presence
of RBCs
COLOR

61. •CYANOSIS
BLUISH blotchy color from deceased
perfusion. The tissues have high levels of
deoxygenated blood.
Abnormal findings: indicated hypoxemia-
occurs w/ shock, cardiac arrest, heart failure,
chronic bronchitis, and congenital heart
disease
COLOR

62. COLOR
NOTE Cyanosis can be a non-specific sign.
•A person who is anemic could have hypoxemia
w/o ever looking blue, b/c not enough Hbis
present (either oxygenated or reduced) to color
the skin.
•oOn other hand, w/ polycythemia, person looks
ruddy blue at all times and may not be hypoxemic.
This person just cannot fully oxygenate the
massive number of RBCs.

63. •JAUNDICE
a yellowish skin color indicated rising amounts of
bilirubin in the blood.
Does not occur normally
Abnormal findings: occurs with hepatitis, cirrhosis, sickle-cell
disease, transfusion rxns, and hemolytic disease of newborn.
Light or clay-colored stools and dark urine often accompany
jaundice in light + dark skinned people.
COLOR

64. HYPOTHERMIA
generalized coolness may be induced (ex.
hypothermia used for surgery or high fever). Localized
coolness expected with an immobilized extremity (limb
in a cast or with IV infusion)
Abnormal findings: generalized --accompanies shock
+ cardiac arrest. Localized –occurs in peripheral arterial
insufficiency + Raynaud disease
COLOR

65. HYPERTHERMIA
generalized hyperthermia occurs w/ increased metabolic
rate such as in fever or after heavy exercise. A localized
hyperthermic area occurs w/ trauma, infection, or sunburn
Abnormal findings: hyperthyroidism has an increased
metabolic rate, causing warm, moist skin.
COLOR

66. Moisture –perspiration normally appears on face, hands,
axillae, and skinfolds in response to activity, a warm
environment, or anxiety.
Diaphoresis –profuse perspiration, accompanies an
increased metabolic rate (heavy activity or fear)
Dehydration –Normally there is none, and mucous
membrane should look smooth and moist
Abnormal findings: with dehydration, the mucous membranes
are dry, the lips look patched and cracked. With extreme
dryness, skin is fissured, resembling cracks in a dry lake bed
MOISTURE

67. Texture –normal skin feels smooth and firm, w/ an even
surface
Abnormal findings:
HYPERTHYROIDISM –skin feels smoother and softer, like
velvet
HYPOTHYROIDISM –skin feels rough, dry, flaky
TEXTURE

68. Thickness –epidermis is uniformly thin over most of
the body (thickened areas normal on palms + soles)
Abnormal findings: very thin, shiny skin (atrophic)
occurs with arterial insufficiency
THICKNESS

69. Edema –fluid accumulating in the interstitial spaces, NOT present
normally
TO CHECK
imprint thumbs firmly 3-4 sec, if it leaves dent in the skin =
“PITTING” means edema is present. Graded on a
4-point scale:
1 = Mild pitting, slight indentation, no perceptible swelling
2 = moderate pitting, indentation subsides rapidly
3 = deep pitting, indentation remains for a short time
4 = very deep pitting, indentation lasts a long time
EDEMA

70. Mobility & Turgor –pinch up a large fold of skin
MOBILITYis the ease of skin to rise
TURGOR is its ability to return to place promptly when
released
Turgor tells you about hydration state!
Abnormal findings:
Mobility is decreased with edema (also scleroderma “hard
skin” is a connective tissue disorder associated w/ decrease
mobility)
Poor turgor is evident with severe dehydration or extreme
weight loss(the pinched skin recedes slowly or “tents”
and stands by itself
MOBILITY & TURGOR

71. Vascularity & Bruising—any bruising (contusion)
should be consistent w/ the expected trauma of life.
Normally there are no venous dilations or
varicosities.
VASCULARITY & BRUISING

72. PETECHIAE= caused by bleeding from superficial
capillaries, will not blanch. May indicate abnormal clotting
factors.
PURPURA= flat, macular hemorrhage, seen in
thrombocytopenia. May occur in old age when blood leaks
from capillaries in response to minor trauma.
MORE ABNORMAL FINDINGS OF THE
SKIN

73. vBASAL CELL CARCINOMA
most common form of skin cancer. Starts as a skin colored
papule with a translucent top
vSQUAMOUS CELL CARCINOMA
erythematous scaly patch with sharp margins, 1 cm or more.
Less common than basal cell carcinoma. Growth is rapid.
vMALIGNANT MELANOMA
usually brown in color; irregular borders; many arise from
preexisting nevi; may have flaking, scaling, oozing, texture
vKAPOSI’S SARCOMA
advanced AIDS; widely disseminated lesions involving skin,
mucous membranes, and visceral organs
Skin Cancers

74. ümay be primary or secondary lesions!
üPRIMARY LESION—when a lesion develops on
previously unaltered skin
üSECONDARY LESION –when a lesion changes
over time or changes because of scratching or
infection
SKIN LESIONS

75. If lesions are present, note the:
üColor
üElevation –flat, raised, or pedunculated
üPattern or shape –the grouping or distinctness of each lesion (ex.
annular, grouped, confluent, linear). Pattern may be characteristic of
certain disease.
üSize in cm –use ruler to measure (avoid descriptions like “quarter size” or
“pea-size”)
üLocation + distribution on body –is it generalized or localized to areas of a
specific irritant; around jewelry, watchband, eyes?
üAny exudate –note its color + any odor (exudate = anything coming
out/oozing/draining from the skin)
SKIN LESIONS

76. PRIMARY SKIN LESIONS
MACULE
•Solely a color change
•Flat and circumscribed
•Less than 1 cm
Ex:
freckles, flat nevi (mole),
hypopigmentation,
measles, scarlet fever
PATCH
•Macules larger than 1 cm
Ex:
Mongolian spot, vitiligo,
café au laitspot, measles rash

77. PRIMARY SKIN LESIONS
PAPULE
•Something you can feel
(solid, elevated,
circumscribed)
•Less than 1 cm diameter
•Caused by superficial
thickening in epidermis
Ex. elevated nevus (mole),
wart (verruca)
NODULE
•Solid, elevated, hard or soft
•Larger than 1 cm
•May extend deeper into dermis than papule
•Ex. fibroma, xanthoma

78. PRIMARY SKIN LESIONS
WHEAL
üSuperficial, raised transient,
erythematous
üSlightly irregular shape due to
edema (fluid held in tissues)
Ex. mosquito bite, allergic rxn
VESICLE
üElevated cavity containing free fluid
üLess than or equal to 1 cm
üA “blister”
üClear serum flows if wall is ruptured
Ex. herpes simplex, early varicella (chickenpox), herpes
zoster(shingles),

79. PRIMARY SKIN LESIONS
BULLA
üLarger than 1 cm
üUsually single-chambered
üSuperficial in epidermis
üThin-walled, ruptures easily
Ex. friction blister, burns, pemphigus
PUSTULE
üPus in the cavity
üCircumscribed and elevated
Ex. acne, impetigo
CYST
üEncapsulated (literally enclosed think of grape) fluid-filled
cavity in dermis or subcutaneous layer
üTensely elevating skin
Ex. sebaceous cys

80. SECONDARY SKIN LESIONS
Secondary lesions result from a change in a primary lesion
from the passage of time; an evolutionary change.
CRUST
üthickened, dried out exudate left when vesicles/pustules
burst or dry up. Color can vary depending on fluid
ingredients (blood, serum, pus)
Ex. impetigo, scab after abrasion, weeping eczematous
dermatitis

81. SECONDARY SKIN LESIONS
SCALE
compact, desiccated flakes of skin, dry or greasy, silvery
or white, from shedding of dead excess keratin cells.
Ex. after scarlet fever or drug rxn(laminated sheets),
psoriasis (silver, micalike), seborrheicdermatitis (yellow,
greasy), eczema, dry skin

82. SECONDARY SKIN LESIONS
FISSURE
linear crack with abrupt edges; extends into dermis; dry
or moist
ex. cheilosis—at corners of mouth causes by excess
moisture; athletes foot (b/w toes), anal fissures (doesn’t
only happen @ mouth)

83. SECONDARY SKIN LESIONS
ULCER
üdeeper depression extending into dermis
üIrregular shape
üMay bleed
üLeaves scars when heals
Ex. stasis ulcer, pressure sore, chancre
EROSION
üscooped out but shallow depression
üSuperficial
üepidermis lost
ümoist but no bleeding
üheals without scar b/c erosion doesn’t extend into dermis

84. SECONDARY SKIN LESIONS
EXCORIATION
üself-inflicted abrasion
üSuperficial
üSometimes crusted
üScratches from intense itching
Ex. insect bites, scabies, varicella
SCAR
üafter a skin lesion is repaired,
normal tissue is lost and replaced
with connective tissue (collagen).
This is a permanent fibrotic change.
ex. healed area of surgery or injury, acne

85. SECONDARY SKIN LESIONS
KELOID SCAR
üBenign excess of scar tissue beyond sites of original
injury
üLooks smooth, rubbery, shiny and “claw-like”, feels
smooth and firm
üFound in ear lobes, back of neck, scalp, chest, and back
Ex. surgery, acne, ear piercing, tattoos, infections, burns

86. SECONDARY SKIN LESIONS
Lichenification
üprolonged, intense scratching eventually thickens skin
and produces tightly packed sets of papules; looks like
surface of moss (or lichen)

87. SHAPES/CONFIGURATIONS OF LESIONS
Annular = CircularConfluent = lesions run together
(ex. hives)
Discrete = distinct, individual lesions that
remain separate (ex. acne)
Gyrate = twisted, coiled, spirals, snake-
like

88. SHAPES/CONFIGURATIONS OF LESIONS
Grouped = clusters of lesions
(ex. vesicles of contact dermatitis)
Linear = scratch, streak, line, or stripe
Target = resembles iris of eyePolycyclic = annular lesions growing
together

89. SHAPES/CONFIGURATIONS OF LESIONS
ZOSTERIFORM= linear arrangement along a
unilateral nerve route (ex. shingles, herpes)

90. NAILS

91. INSPECTION & PALPATION
OF THE NAILS
Shape & Contour –nail surface normally slightly curved or flat, and the
posterior and lateral nail folds are smooth and rounded. Nail edges are
smooth, rounded, and clean suggesting adequate self-care.
ØThe profile sign—view the index finger @ its profile and note
the angle of the nail base (should be about 160 degrees). Nail
bed is firm to palpation.
Abnormal findings:
üJagged or bitten nails suggest nervous picking habits
üChronically dirty nails –poor self care
üClubbing of nails occurs w/ congenital heart disease, lung cancer,
and pulmonary diseases. In early clubbing the angle straightens out
to 180 degrees and nail bed feels spongy to palpation.

92. INSPECTION & PALPATION
OF THE NAILS
Consistency–surface is smooth/regular, not brittle or
splitting. Nail thickness uniform.
Color—translucent nail plate is a window to the even, pink nail
bed underneath. Dark-skinned people may have brown-black
pigmented areas or linear bands/streaks along the nail edge.
Abnormal findings:
üCyanosis or marked pallor
üBrown linear streaks (especially sudden appearance) in
light-skinned people may indicate melanoma

93. INSPECTION & PALPATION
OF THE NAILS
Capillary Refill –depress nail edge to blanch and then
release, noting the return of color. Normally, color return is
instant or at least within a few seconds in a cold environment.
This indicates the status of peripheral circulation. A sluggish
color return takes longer than 1 or 2 seconds. (LESS THAN 3
SECONDS)
Abnormal findings:
ücyanotic nail beds or sluggish color return: consider
cardiovascular or respiratory dysfunction

94. ABNORMAL FINDINGS OF
THE NAILS
KOILONYCHIA(Spoon Nails)
ünails are thin and depressed with lateral edges tilted up
forming a “spoon shape”
ümay be due to iron deficiency anemia
PARONYCHIA
üred, swollen, tender inflammation of the nail folds.
üIf acute, it is usually a bacterial infection.
üIf chronic, it is usually a fungal infection from a break in the
cuticle.
BEAU’S LINE
ütransverse groove in nail
üOccurs with trauma which temporarily impairs the nail
formation

95. ABNORMAL FINDINGS OF
THE NAILS
SPLINTER HEMORRHAGES
üappear as red-brown colored linear streaks
üMay occur with bacterial endocarditis or minor trauma to the
nail
LATE CLUBBING
üangle of nail is greater than 180 degrees
üSeen w/ COPD and congenital heart disease and cyanosis
HABIT-TIC DYSTROPHY
üdepression down middle of nail or multiple horizontal ridges,
caused by continuous picking of cuticle by another finger of
same hand

96. ABNORMAL FINDINGS OF
THE NAILS
ONYCHOLYSIS
üslow, persistent fungal infection of fingernails and toenails
(more often).
üFungus causes change in color (green where nail separates
from bed)
üNail crumbling or breaking/loosening usually begins @ distal
edge and progressing proximally
PITTING
üappears as pitting and crumbling of the nails with distal
detachment
üCommon in psoriasis

97. 5. Thoracic region:
•Assess lung and cardiac sounds from
the front and back. Assess them for
character and quality as well as for
the presence or absence of
appropriate sounds or lumps. Palpate
the chest wall and breasts for any
tenderness.

98. 5. Thoracic region:
•Should lung and cardiac sounds be assessed from the front only?
•Which of the following sounds should be measured in lung and cardiac assessment?
•Why should the chest wall and breasts be palpated during assessment of the thoracic region?

99. 6. Abdomen:
•Listen to bowel sounds throughout the 4
quadrants. Palpate for tenderness or
lumps. Palpate the bladder. Ask about
intake and output of bowels and bladder.
Ask about appetite.

100. 6. Abdomen:
In which quadrant/s should bowel
sounds be auscultated?
Should the abdomen also be palpated
for tenderness and/or lumps?
Is it more important to ask the patient
about bowel or bladder output?
Is appetite an important factor when
assessing the abdomen area?

101. 7. Extremities:
•Assess for temperature, capillary fill
andROM. Palpate for pulses. Note any
edema, lesions, lumps or pain.
•ROM = Range of Motion
•What does ROM mean?

102. 8. General Questions:
•Ask the patient how he feels. Has anything
changed recently? Any pain,
burning,SOB, chest pains, change in
bowel or bladder habits/function, change
in sleep habits, cough, discharge from any
orifice, depression, sadness, or change in
appetite?
•SOB = Shortness of Breath
•What does the acronym SOB stand for?

103. 9. Wash your hands.
•Document your findings. Report any
significant changes or findings to the
PCP(primary care practitioner).
•Example of Head to Toe Assessment form:
http://aperiomlc.com/files/An_Easy_Guide_to_Head_to_Toe_Assessment_Vrtis
_12_2008_Website.pdf