Page 365 - Saunders Comprehensive Review For NCLEX-RN

resonance, hyperresonance, tympany,
dullness, or flatness.
4. Auscultation: Involves listening with a stethoscope to
sounds produced by the body for presence and
quality, such as heart, lung, or bowel sounds
C. Vital signs
1. Includes temperature, radial pulse (apical pulse may
be measured during the cardiovascular assessment),
respirations, blood pressure, pulse oximetry, and
presence of pain (refer to Chapter 10 for information
on vital signs, pulse oximetry, and pain)
2. Height, weight, and nutritional status are also
assessed.
V. Body Systems Assessment
A. Integumentary system: Involves inspection and palpation of skin,
hair, and nails.

1. Subjective data: Self-care behaviors, history of

skin disease, medications being taken, environmental
or occupational hazards and exposure to toxic
substances, changes in skin color or pigmentation,
change in a mole or a sore that does not heal

2. Objective data: Color, temperature

(hypothermia or hyperthermia); excessive dryness or
moisture; skin turgor; texture (smoothness, firmness);
excessive bruising, itching, rash; hair loss (alopecia) or
nail abnormalities such as pitting; lesions (may be
inspected with a magnifier and light or with the use
of a Wood’s light [ultraviolet light used in a darkened
room]); scars or birthmarks; edema; capillary filling
time (Boxes 12-3 and 12-4; Table 12-2)
3. Dark-skinned client
a. Cyanosis: Check lips and tongue for a
gray color; nailbeds, palms, and soles
for a blue color; and conjunctivae for
pallor.
b. Jaundice: Check oral mucous
membranes for a yellow color; check
the sclera nearest to the iris for a
yellow color.
c. Bleeding: Look for skin swelling and
darkening and compare the affected
side with the unaffected side.
d. Inflammation: Check for warmth or a
shiny or taut and pitting skin area, and
compare with the unaffected side.

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