Nursing Fundamentals: Key Concepts in Assessment
This document outlines essential concepts in nursing assessment, covering various
body systems and fundamental examination techniques.
1. Skin Assessment
Edema: What is edema? Swelling caused by excess fluid trapped in the
body's tissues.
Skin Turgor: Where do you pinch to assess skin turgor? Back of the
forearm or sternum.
Vascularity: How do you check for vascularity? Apply pressure to the
skin and observe for blanching (temporary paleness) followed by return
of color.
Temperature Assessment: Temperature is best assessed using the dorsal
(back) portion of the hand.
Pallor: Where to look for pallor? Nails, nail beds, and lips.
Cyanosis: Best place to check for cyanosis? Lips.
Erythema: What is erythema? Redness of the skin.
Types of Edema:
o Dependent edema: Swelling in gravity-dependent areas (e.g., legs
and feet when standing).
o Pitting edema: Indentation remains in the skin after pressure is
applied.
o Edema due to inflammation/injury: Localized swelling at the site of
inflammation or trauma.
o Edema due to obstruction: Swelling caused by blockage of
lymphatic or venous flow.
, Braden Scale: Used to predict patients at risk for skin breakdown
(pressure ulcers).
Braden Scale Score: Score range is 6-23. A lower score indicates a greater
risk.
Largest Organ: Largest organ in the body is the skin.
Lesion Measurement: Lesions are measured in centimeters (cm).
Macule: Define macule. A flat, non-palpable change in skin color,
smaller than 1 cm.
Macule Example: Example of a macule: freckle, petechiae.
Nodule: Define nodule. An elevated, solid mass, deeper and firmer than
a papule, measuring 1-2 cm.
Nodule Example: Example of a nodule: wart.
Tumor: Define tumor. A solid mass that extends deep through
subcutaneous tissue, larger than 1-2 cm.
Tumor Example: Example of a tumor: epithelioma.
Wheal: Define wheal. An irregularly shaped, elevated area of superficial
localized edema, varying in size.
Wheal Example: Example of a wheal: hive (urticaria), mosquito bite.
Vesicle: Define vesicle. A circumscribed elevation of the skin filled with
serous fluid, smaller than 1 cm.
Vesicle Example: Example of a vesicle: herpes simplex, chickenpox.
Most Common Skin Abnormality: Most common skin abnormality is
basal cell carcinoma.
ABCD Assessment:
o A: Asymmetry - One half unlike the other half.
o B: Border - Irregular, scalloped, or poorly defined border.
, o C: Color - Varied colors within the lesion (e.g., shades of brown,
black, red, white, blue).
o D: Diameter - Larger than 6 mm (about the size of a pencil eraser),
although melanomas can be smaller.
Pustule: Define pustule. A circumscribed elevation of the skin similar to
a vesicle but filled with pus, varying in size.
Pustule Example: Example of a pustule: acne, staphylococcal infection.
Ulcer: Define ulcer. A deep loss of skin surface that extends to the
dermis and frequently bleeds and scars, varying in size.
Ulcer Example: Example of an ulcer: venous stasis ulcer.
Atrophy: Define atrophy. Thinning of the skin with loss of normal skin
furrows, with the skin appearing shiny and translucent; varies in size.
Atrophy Example: Example of atrophy: arterial insufficiency.
Ecchymosis: Define ecchymosis. A discoloration of the skin resulting
from bleeding underneath, typically causing bruising.
Hematoma: Define hematoma. A solid swelling of clotted blood within
the tissues; often described as a "goose egg" or blood underneath the
skin.
2. Head and Neck Assessment
Normal Nail Angle: Normal nail bed angle is 160 degrees.
Normal Capillary Refill Time: Normal capillary refill time is less than 3
seconds.
Hyperopia: Define hyperopia. Farsightedness; the ability to see distant
objects clearly but close objects appear blurry.
Myopia: Define myopia. Nearsightedness; the ability to see close objects
clearly but distant objects appear blurry.
This document outlines essential concepts in nursing assessment, covering various
body systems and fundamental examination techniques.
1. Skin Assessment
Edema: What is edema? Swelling caused by excess fluid trapped in the
body's tissues.
Skin Turgor: Where do you pinch to assess skin turgor? Back of the
forearm or sternum.
Vascularity: How do you check for vascularity? Apply pressure to the
skin and observe for blanching (temporary paleness) followed by return
of color.
Temperature Assessment: Temperature is best assessed using the dorsal
(back) portion of the hand.
Pallor: Where to look for pallor? Nails, nail beds, and lips.
Cyanosis: Best place to check for cyanosis? Lips.
Erythema: What is erythema? Redness of the skin.
Types of Edema:
o Dependent edema: Swelling in gravity-dependent areas (e.g., legs
and feet when standing).
o Pitting edema: Indentation remains in the skin after pressure is
applied.
o Edema due to inflammation/injury: Localized swelling at the site of
inflammation or trauma.
o Edema due to obstruction: Swelling caused by blockage of
lymphatic or venous flow.
, Braden Scale: Used to predict patients at risk for skin breakdown
(pressure ulcers).
Braden Scale Score: Score range is 6-23. A lower score indicates a greater
risk.
Largest Organ: Largest organ in the body is the skin.
Lesion Measurement: Lesions are measured in centimeters (cm).
Macule: Define macule. A flat, non-palpable change in skin color,
smaller than 1 cm.
Macule Example: Example of a macule: freckle, petechiae.
Nodule: Define nodule. An elevated, solid mass, deeper and firmer than
a papule, measuring 1-2 cm.
Nodule Example: Example of a nodule: wart.
Tumor: Define tumor. A solid mass that extends deep through
subcutaneous tissue, larger than 1-2 cm.
Tumor Example: Example of a tumor: epithelioma.
Wheal: Define wheal. An irregularly shaped, elevated area of superficial
localized edema, varying in size.
Wheal Example: Example of a wheal: hive (urticaria), mosquito bite.
Vesicle: Define vesicle. A circumscribed elevation of the skin filled with
serous fluid, smaller than 1 cm.
Vesicle Example: Example of a vesicle: herpes simplex, chickenpox.
Most Common Skin Abnormality: Most common skin abnormality is
basal cell carcinoma.
ABCD Assessment:
o A: Asymmetry - One half unlike the other half.
o B: Border - Irregular, scalloped, or poorly defined border.
, o C: Color - Varied colors within the lesion (e.g., shades of brown,
black, red, white, blue).
o D: Diameter - Larger than 6 mm (about the size of a pencil eraser),
although melanomas can be smaller.
Pustule: Define pustule. A circumscribed elevation of the skin similar to
a vesicle but filled with pus, varying in size.
Pustule Example: Example of a pustule: acne, staphylococcal infection.
Ulcer: Define ulcer. A deep loss of skin surface that extends to the
dermis and frequently bleeds and scars, varying in size.
Ulcer Example: Example of an ulcer: venous stasis ulcer.
Atrophy: Define atrophy. Thinning of the skin with loss of normal skin
furrows, with the skin appearing shiny and translucent; varies in size.
Atrophy Example: Example of atrophy: arterial insufficiency.
Ecchymosis: Define ecchymosis. A discoloration of the skin resulting
from bleeding underneath, typically causing bruising.
Hematoma: Define hematoma. A solid swelling of clotted blood within
the tissues; often described as a "goose egg" or blood underneath the
skin.
2. Head and Neck Assessment
Normal Nail Angle: Normal nail bed angle is 160 degrees.
Normal Capillary Refill Time: Normal capillary refill time is less than 3
seconds.
Hyperopia: Define hyperopia. Farsightedness; the ability to see distant
objects clearly but close objects appear blurry.
Myopia: Define myopia. Nearsightedness; the ability to see close objects
clearly but distant objects appear blurry.
