Health Assesment M6

Conduct an assessment on the body system listed below. Record the history and physical examination findings accurately, listing how you performed the techniques and what you found. After all objective and subjective information is collected write a 1-page Word document Summary/Nursing Note.

Body System:

  • Skin

Collect the following Objective Data: Describe how each area was inspected, list all findings.

1. Inspect and palpate the skin, noting its color, vascularity, edema, moisture, temperature, texture, thickness, mobility, turgor, and any lesions.

2. Inspect the fingernails, noting color, shape, and any lesions.

3. Inspect the hair, noting texture, distribution, and any lesions.

Collect the following Subjective Data: Document your patient’s response.

1. Any past skin disease?

2. Any change in skin color or pigmentation?

3. Any changes in a mole?

4. Excessive dryness or moisture?

5. Any skin itching?

6. Any excess bruising?

7. Any skin rash or lesions?

8. Taking any medications?

9. Any recent hair loss?

10. Any change in nails?

11. Any environmental hazards for skin?

12. How do you take care of skin? Sunscreen?

13. What is your amount of sun exposure? Indoor tanning?

Answer:

Nursing Note:

Patient: [Name], [Age], [Gender] Date: [Date]

Skin Assessment:

Objective Data:

  1. The skin was inspected and palpated, with the following findings:
  • Color: [Insert color description]
  • Vascularity: [Insert description]
  • Edema: [Insert description]
  • Moisture: [Insert description]
  • Temperature: [Insert description]
  • Texture: [Insert description]
  • Thickness: [Insert description]
  • Mobility: [Insert description]
  • Turgor: [Insert description]
  • Lesions: [Insert description, if any]
  1. The fingernails were inspected, with the following findings:
  • Color: [Insert color description]
  • Shape: [Insert shape description]
  • Lesions: [Insert description, if any]
  1. The hair was inspected, with the following findings:
  • Texture: [Insert texture description]
  • Distribution: [Insert description]
  • Lesions: [Insert description, if any]

Subjective Data:

  1. The patient reported a history of [Insert response].
  2. There have been [Insert response] in skin color or pigmentation.
  3. The patient reported [Insert response] in moles.
  4. The patient reported [Insert response] in skin dryness or moisture.
  5. The patient reported [Insert response] in skin itching.
  6. The patient reported [Insert response] in excessive bruising.
  7. The patient reported [Insert response] in skin rash or lesions.
  8. The patient reported taking [Insert response] medications.
  9. The patient reported [Insert response] in recent hair loss.
  10. The patient reported [Insert response] in nails.
  11. The patient reported [Insert response] in environmental hazards for skin.
  12. The patient reported [Insert response] in skin care, including [Insert response] in sunscreen use.
  13. The patient reported [Insert response] in sun exposure and [Insert response] in indoor tanning.

Summary: The patient’s skin assessment revealed [Insert description of overall findings]. The patient reported [Insert relevant subjective information]. Further assessment and interventions may be necessary to address any identified skin issues.

 

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