I.
VITAL SIGNS
Review the NORMAL VALUES, the medical terms for abnormal low and high values
Routes and strategies
Client preparation and Precautions/Contraindications
II. HEIGHT
Use the tape measure (per group)
(Use the centimeters calibration & attach in the smooth edges wall)
The head, shoulders, buttocks and the sole of the feet should touch the wall (Use 6
inches’ ruler to determine accurately the height of the patient)
No using of footwear during the height – taking
III. WEIGHT
Use the weighing scale (use either kilograms or pounds as instructed by the CI
assigned)
All scales should be adjusted to ZERO
Unload the client with unnecessary materials attached so as not to hamper accurate
results
Ideal time to weigh: every early morning (immediately after waking up)
Same set of clothing as much as possible during weight – taking
IPPA Examination
(Reminder: When assessing and in contact with the patient’s skin and mucosa always wear clean
gloves!)
IV. SKIN, HAIR and NAILS
A. INSPECTION OF THE SKIN
1. Color
Cyanosis
(Check the conjunctiva, palms, lips, soles, buccal mucosa and tongue)
BLUE/PURPLE discoloration of the skin and mucous membranes due to the
tissues near the skin surface being low on oxygen)
Erythema
(Palpate area for warmth)
RED discoloration of the skin due to increase of blood flow to different
tissues in the body
Jaundice
(Examine the sclera and hard palate I if in natural light if possible for a yellowish
color)
Also known as ICTERUS
A yellowish pigmentation of the skin, the conjunctival membranes over the
sclera and other mucous membranes
Pallor
(Check the conjunctiva palms, lips, soles, buccal mucosa, tongue, nail beds, Palms
and soles)
Pale color can be caused by illness, emotional shock or stress
2. Bleeding
- See for unusual rashes or petechiae (tiny purplish red dots)
- Skin color can determine for the VASCULARITY
3. Lesions
- Look for any sign skin disruptions and unusual growths
B. PALPATION OF THE SKIN
Moisture
(Skin should be relatively dry with a minimal amount of perspiration)
Temperature
(Palpate the skin bilaterally for temperature using the DORSAL
SURFACE of your hands and fingers – MOST SENSITIVE to TEMPERATURE
CHANGES)
WARM skin suggests normal circulation and COOL skin suggests abnormal
circulation and maybe an underlying disorder
Tenderness
(Palpate for pain and discomforts)
Medical definitions include:
a. Easily bruised or fragile
b. Painful or sore
Texture and Turgor
(Check the texture noting its thickness and mobility. It should look smoothly and intact)
(For turgor, gently squeeze the skin on the forearm or sterna area between your thumb
and forefinger. If the skin quickly returns to its original shape slowly over 30 seconds
or maintains a tented position the skin has poor skin turgor)
SIGNIFICANCE: Hydration Status
Edema
(Examine the area for decreased color and palpate for tightness)
Also known as “DROPSY” or “HYDROPSY”
Abnormal accumulation of fluid beneath the skin or in one or more cavities of the body
that produces swelling
C. INSPECTION OF THE HAIR
Color
(Consider the race and environmental and lifestyle background)
(E.g. black, light brown, golden yellow… pls. indicate if the hair is natural or dyed)
Distribution
(Check for the evenness of growth, thick or thinness of hair, texture and oiliness,
note presence or infections and manifestations by parting the hair in several areas,
behind the ears and along the hairline of the neck)
Lesions
(Check abnormal and unusual growths in the scalp area)
D. PALPATION OF THE HAIR
Texture
(Check if its strands are either fine or coarse)
E. INSPECTION OF THE NAILS
Color
(Nail plate is normally colorless and has a convex curve) (Normal angle between the nail
and nailbed is 160 degrees)
Spoon – shaped nail (nail curves upward from the nailbed) also known as
KOILONYCHIA, common with patients with Iron Deficiency Anemia
Clubbing of fingers also known as “Drumstick or Hippocratic Fingers” (Angle is
180 degrees or greater) maybe caused by long term lack of oxygen
SCHAMROTH’S TEST or SCHAMROTH’S WINDOW TEST (originally
demonstrated by South African Cardiologist Dr. Leo Schamroth on himself) is a
popular test for clubbing. When the distal phalanges (bones nearest the
fingertips) of corresponding fingers of opposite are directly opposed (place
fingernails of same finger on opposite hands against each other, nail to nail), a
small diamond – shape “window” is normally apparent between the nail beds. If
this window is obliterated, the test is positive and clubbing is present.
Blanch or Capillary Refill Test (Significance: Peripheral Circulation)
(Press one at a time a specific nail between your thumb and index finger for 5
seconds then look for blanching and return of the pink color to the nailbed ---
should be within 3 seconds)
F. PALPATION OF THE NAILS
Texture
(Normally smooth: excessive thick nails can appear in the elderly or in the presence of
poor circulation or in chronic fungal infection, excessive thins nails can be attributed in
cases of iron deficiency anemia)
