Name: Zoe Jeanne M.

Garciano Course & Year: BSN-1

Hair, Face, Nose, Neck, Skin, and Nails

Definition: Evaluating objective anatomically through palpating

Purpose:

 To palpate and inspect the hair, head, face, nose, neck, skin, and nails in their size, consistency,
tenderness etc.

Equipment:

• Examination light
• Penlight
• Magnifying glass
• Centimeter ruler
• Gloves
• Wood’s light
• Examination gown or drape
• Braden Scale for Predicting Pressure Sore Risk

Rationale:

1. Preliminaries
a. This is done in order to lessen the anxiety and feelings of insecurity to the patient and for
them to understand. And to build a trusting relationship that leads to build rapport
b. It is needed to effectively assess the patient. And to avoid struggle and delay in giving the
care that patients need.
c. This will show your concern to the patient’s welfare and display your awareness of a
critical components of the patient safety, and to reduce transmission of microorganisms.
d. This is done to show concern for their privacy, for the patient to feel respected and at ease
or comfortable.
2. To evaluate state of the skin and to detect local and systemic diseases. While palpating the skin
consider the color, moisture, temperature, texture, mobility and turgor edema and lesions of the
skin because the skin color, temperature, and condition are good indicators of the patient’s
condition and circulatory status. In which, the mobility, the skin is well flexible enough and not
hard to palpate.
Normal Findings: Color is even without obvious lesions: light to dark beige-pink in light-
skinned client; light tan to dark brown or olive in dark-skinned clients
Abnormal Findings: Abnormal findings include extreme pallor, flushed, or yellow in light
skinned client; loss of red tones and ashen gray cyanosis in dark-skinned client
3. To know the general health, state of nutrition, occupation and level of self-care of the client. In
fact, the nails are normally transparent, smooth and convex, intact and without inflammation and
firm
 Normal Findings: smooth, without pits or grooves. They're uniform in color and consistency and
free of spots or discoloration

Abnormal Findings: discoloration (dark streaks, white streaks, or changes in nail color) changes
in nail shape (curling or clubbing) changes in nail thickness (thickening or thinning) nails that
become brittle
4. To know the abnormalities of the hair, valuate the appearance of the scalp, whether it is generally
excessively oily or dry. Look for localized lesions and inflammatory skin diseases.

Normal Findings: Shiny and Smooth. Good Elasticity. Shed A Few Strands Daily. Detangles
Easily
Abnormal Findings: Dull and Dry Hair. Damaged hair is deprived of the natural oils on the
outer layer of your hair Tangles. Damaged hair is prone to tangles. When the cuticle does not lay
flat, it can cause frizz.
Brittleness And Breakage
5. To evaluate whether there are head lice which are tiny insects that feed on blood from the human
scalp. An infestation of head lice most often affects children and usually results from the direct
transfer of lice from the hair of one person to the hair of another
Normal Findings: No presence of lice
Abnormal Findings: Lice is present in the hair
6. To know whether there is redness and scaling that may indicate seborrheic dermatitis and
pigmented nevi that raise melanoma
Normal Findings: No presence of scaliness, lumps, nevi, or other lesions on the scalp.
Abnormal Findings: No presence of scaliness, lumps, nevi, or other lesions on the scalp.
7. To see that there is an enlarged skull that would signify hydrocephalus or Paget disease of bone.
Palpable tenderness or bony step-offs may be present after trauma

Normal Findings: Head size and shape vary, especially in accord with ethnicity. Usually the
head is symmetric, round, erect, and in midline. No lesions are visible
Abnormal Findings: Acorn-shaped, enlarged skull bones are seen in Paget’s disease of the bone.
8. To determine the both sides of the face, right and left, whether they are alike. The more
asymmetrical, the less sexually attractive one is, likely because facial asymmetry is related to
illness and disease or excessive blinking.
Normal Findings: The body parts are equally bilaterally and are in relative proportion to each
other
Abnormal Findings: There are parts that are not equally bilaterally and are not in relative
proportion to each other
9. To inspect any deformities or asymmetry of the nose and observe nasal mucosa and nasal septum.

Normal Findings: Color is the same as the rest of the face; the nasal structure is smooth and
symmetric; the client reports no tenderness.
Abnormal Findings: Nasal tenderness on palpation accompanies a local infection.
10. To evaluate whether the openness of the nose is normal or not.
 Normal Findings: The nasal mucosa is dark pink, moist, and free of exudate. The nasal septum
is intact and free of ulcers or perforations. Turbinates are dark pink (redder than oral mucosa),
moist, and free of lesions.
Abnormal Findings: Nasal mucosa is swollen and pale pink or bluish gray in clients with
allergies. Nasal mucosa is red and swollen with upper respiratory infection. Exudate is common
with infection.
11. To know if there is an abnormality of breathing. And to pay respect to them and for them to
understand the process
Normal Findings: Client is able to sniff through each nostril while other is occluded.
Abnormal Findings: Client cannot sniff through a nostril that is not occluded, nor can he or she
sniff or blow air through the nostrils. This may be a sign of swelling, rhinitis, or a foreign object
obstructing the nostrils. A line across the tip of the nose just above the fleshy tip is common in
clients with chronic allergies
12. To assess Physical assessment of the paranasal sinuses, along with the patient's signs and
symptoms, that could help you in identifying certain conditions such as acute sinusitis involving
the frontal or maxillary sinuses
Normal Findings: Gray indicates tissue or water. In your sinuses, which are air-filled cavities,
normal, healthy sinuses should be predominantly black.
Abnormal Findings: Postnasal drip. Discolored nasal discharge (greenish in color) Nasal
stuffiness or congestion. Tenderness of the face (particularly under the eyes or at the bridge of the
nose) Frontal headaches
13. To examine acute or chronic condition of neck stiffness with decreased mobility (especially
rotation), sometimes followed by aches and pains in neck and/or pains in body areas distant from
the neck (eyes, temples, throat, ears, nose, shoulders...), nausea, tinnitus, vertigo, torticollis
Normal Findings: Neck is symmetric with head centered and without bulging masses.
Abnormal Findings: Swelling, enlarged masses, or nodules may indicate an enlarged thyroid
gland, inflammation of lymph nodes, or a tumor
14. To know if the person is attentive and oriented or having a difficulty to move
Normal Findings: Head should be held still and upright
Abnormal Findings: Tremors associated with neurologic disorders may cause a horizontal
jerking movement. An involuntary nodding movement may be seen in patients with aortic
insufficiency. Head tilted to one side may indicate unilateral vision or hearing deficiency or
shortening of the sternomastoid muscle
15. To know muscle strength testing is an important component of the physical exam that can reveal
information about neurologic deficits. It is used to evaluate weakness and can be effective in
differentiating true weakness from imbalance or poor endurance.
Normal Findings: The client can flex, extend, adduct, abduct, rotate, and shrug shoulders against
resistance.
Abnormal Findings: Inability to shrug shoulders against resistance is seen with a lesion of
cranial nerve XI (spinal accessory). Decreased muscle strength is seen with muscle

16. To evaluate any abnormalities of the symmetry, range of motion of the neck and lymph nodes
Normal Findings: The thyroid cartilage, cricoid cartilage, and thyroid gland move upward
symmetrically as the client swallows
 Abnormal Findings: Asymmetric movement or generalized enlargement of the thyroid gland is
considered abnormal
17. To know the location of the lymph node may help in determining the site of malignancy. Diffuse,
bilateral involvement suggests a systemic malignancy (e.g. lymphoma)
Normal Findings: There is no swelling or enlargement and no tenderness.
Abnormal Findings: Enlarged nodes are abnormal.
18. Perform assessment of the Thyroid gland
Normal Findings: No bruits are auscultated
Abnormal Findings: A soft, blowing, swishing sound auscultated over the thyroid lobes is often
heard in hyperthyroidism because of an increase in blood flow through the thyroid arteries.

a. To assess and feel any enlargement of lobes that are easily palpated before swallowing or
the client swallows, usually, you cannot palpate an adult thyroid. Asking the client to do
it to ask permission and to respect the patient.
b. To check the symmetry, consistency and the presence of nodules. Asking the client to do
such things in ordr to ask permission.
c. To check whether there a presence of nodules and abnormality of the thyroid. And of
course to effectively assess the person move behind the person. Ask the person to sit to
ask permission about it and respect him/her.
19. Promotes patient safety and quality of care. Complete and accurate medical record keeping can
help ensure that your patients get the right care at the right time.

References:
American Nurses Association. (2010). Nursing: Scope and standards of practice (2nd ed.). Silver Spring,
MD: Author.

Weber, J. R., & Kelley, J. H. (2014). Health Assessment in Nursing (5th ed). Wolters Kluwer
Health.