Health Assessment

  

Hello, this assignment is for health assessment, specifically for: Skin, Hair, and Nails. PLEASE Complete ALL patient history from page 1 to page 2; All patient physical exam questions must be answered on the right side which is blank. DO NOT do the last part of Nursing Diagnoses and Collaboration Problems. The teacher does NOT want the answers to be: this is normal and you should briefly describe each answer you give on the right side of each question that is asked on the left side. YOU MUST CREATE A CLINICAL CASE that is consistent with what the teacher is asking, and the clinical case must be from a patient with a diagnosis of Skin, Hair, and Nails. Please complete all the fields, do not leave anything blank except Diagnostics and Collaboration Problems.

The bibliography is Physical Examination and Health Assessment 6th Edition by Carolyn Jarvis

Student Laboratory Guide
Chapter 10: Skin, Hair, and

Nails

With your lab partner assuming the role of a client, conduct a focused history and examination. Your
“student client” may role-play a client with a particular symptom involving the skin, hair, or nails.

History

Date:

Name: Gender:

M F

Age: Race: LMP:

Occupation:

Source of Data:

Immunizations:

Allergies/Reactions:

Presenting Problem (check all that apply):

Pruritus Rash Lesion Pain/discomfort to skin

Changes in
hair

Change in skin
color

Change in skin
texture

Wounds

Changes in
nails

Other: ___

Symptom Analysis of Presenting Problem (onset, location, duration, characteristics, aggravating and
alleviating factors, related symptoms, treatment)

Present Health Status (include medications, dose, and frequency)

Past Medical and Surgical History (include description and dates)

Family History

Social Habits

Mosby items and derived items © 2009, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.

Chapter 10 Skin, Hair, and Nails Page 2

Examination

Examination Technique Findings (document findings below)

Skin

INSPECT the skin for general color.
INSPECT the skin for localized variations in

skin color.

PALPATE the skin for texture, temperature,
moisture, mobility, turgor, and thickness.

Special Circumstances or Advanced Practice

INSPECT and PALPATE the skin for lesions.
o Primary Lesions
o Secondary Lesions
o Vascular Lesions

Skin

Hair

INSPECT and PALPATE the scalp and hair
for surface characteristics, hair, distribution,
texture, quantity, and color.

INSPECT facial and body hair for
distribution, quantity, and texture.

Hair

Nails

INSPECT and PALPATE the nails for shape,
contour, consistency, color, thickness, and
cleanliness.

INSPECT for artificial nails.

Nails

Mosby items and derived items © 2009, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.

Chapter 10 Skin, Hair, and Nails Page 3

Nursing Diagnoses and Collaborative Problems
Based on the subjective and objective data collected above, identify applicable nursing diagnoses and
collaborative problems.

Nursing Diagnoses Collaborative Problems

Mosby items and derived items © 2009, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.

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