head to toe assessment?

psu_213, BSN, RN · Feb 6, 2015

how does a student (3 weeks in) assess the integumentary system?
For example: pallor: no paleness observed (is that appropriate)?
scalp & hair: color, firm, combed ( what if it's dyed)
nails: pink, no clubbing, trimmed
eyes: color, no jaundice around conjunctiva
mucous membranes: moist, pink, no lesions on skin
edema: No swelling, puffiness
on an unrelated note: how is CMS (circulation, movement, respiration) assessed in the head-to-toe assessment?

You basically have it there. Go head to toe. Is the skin intact? What color is it? Any abnormal markings? Clean, dry, moist, etc.?

As for CMSâ€¦how would you test if circulation is sufficient in a limb? What would indicate an individual is not getting enough blood to their extremities? What about movement? What movements are you going to test and how? S is for sensation. Be sure to look for differences in each from one side compared with the other.

Use you assessment book as a reference!

Jenngirl34RN · Feb 6, 2015

You aren't so much assessing hair or eye color as you are assessing the health appearance of the hair and eyes. It does not matter if the hair is dyed. Is it dry and brittle? Is it dirty and matted? Is the scalp dry or flaky or overly oily? Is there broken skin on the scalp? Are there any thinning spots or patches of missing hair (and that applies to body hair as well). For eyes, is there redness? Dryness? Jaundice? How does the skin around the eyes look? Is the conjunctiva pink and healthy looking? Are there any sores? Are there missing eyelashes?

My point is that you will not put the patient's eye and hair color in your assessment data, unless doing so is somehow relevant to their condition. In all of your assessments you will be looking for signs of health and wellness, or lack thereof. What does healthy skin look like? What would unhealthy signs be?

As far as circulation, movement, and sensation (CMS) it is the same thing. What are the signs of poor circulation? What would you see in the extremities if someone had circulation issues? Movement and sensation are pretty easy to test-you should be able to tell if someone is having trouble moving an extremity or cannot feel touch properly.

Assessments take practice but really just come down to you asking yourself "what should I expect to see in this person and how is what I am actually seeing different from that expectation and what can that mean?" For example, I would expect a person with healthy circulation to have a capillary refill of less than 3 seconds. If I check the cap refill on my patient and it is at 4 seconds, and the skin is cool and pale, I am going to suspect circulation issues and act accordingly.

AlmostNurseJ · Feb 7, 2015

Well you're assessing their skin. Is it dry or moist? Are there any incisions, wounds, pressure areas, bruises, skin tears, fragile turgor, rashes, excoriation? What's the color? Is it pink and well perfused, cyanotic, or erythema? What's the temperature? Is it cool or really warm?

Do they have any dressings? Are they clean dry and intact? What are the measurements of the wound?

Is the hair dry and brittle? Do they have patches of hair missing on their scalp?

Are the nails brittle? Are they clubbing?

Are the eyes symmetrical? Is the conjunctiva pink and moist? Is the sclera white?

Any abnormal lesions or markings?

Like someone above said, it's about assessing the condition of health of the skin and hair, not so much the color

One way to assess circulation is by cap refill.

Movement of what? You can assess movement by their ability to move. Do they have full range of motion in all extremities?

Respirations are assessed based on their lung sounds and their breathing efforts. Is their breathing labored? Are they using accessory muscles to breathe? Is their chest moving symmetrical with each breathe? Are they breathing fast or slow? Is it regular?

I hope this answers your questions