SCRIPT IN ASSESSING SKIN, HAIR AND NAILS

Activity D

Nursing interview guide to collect subjective data from the client.

Questions:

Current symptoms

1. Skin problems

 Rashes

 Lesions

 Dryness

 Oiliness

 Drainage

 Bruising

 Swelling

 Pigmentation

2. Changes in lesion appearance

3. Feeling changes

 Pain

 Pressure

 Itch

 Tingling

4. Hair loss or changes

5. Nail changes
6. Body odor problems

Past history

1. Previous problems with skin, hair, or nails

 Treatment or surgery

2. Allergic reactions

Family History

1. Family history of skin problems or skin cancer

Lifestyle And Health Practices

1. Exposure to sun or chemicals

2. Daily care of skin, hair, and nails

3. Usual diet and exercise patterns

Activity E

Physical Assessment Guide To Collect Objective Data

Questions:

1. Gather equipment

 Gloves

 Exam light

 Penlight

 Magnifying glass

 Centimeter ruler

 Wood lamp
2. Explain procedure to the client

3. Ask client to gown

Skin

1. Note any distinctive odor.

2. Inspect for generalized color variations

 Brownness

 Yellow

 Redness

 Pallor- is an absence of

 Cyanosis

 Jaundice

 Erythema

 Vitiligo

3. Inspect for skin breakdown (use staging criteria given in chapter 13

4. Inspect for primary, secondary, or vascular lesions.

 Note size, shape, location, distribution, and configuration

 Use wood lamp if fungus is suspected

5. Palpate lesions

6. Palpate texture of skin, using palmar surface of three middle fingers

 Rough

 Smooth

7. Palpate temperature and moisture of skin using dorsal side of hand

Temperature

 Cool

 Warm hot

Moisture

 Dry

 Sweaty

 Oily

8. Palpate thickness of skin with finger pads

9. Palpate mobility and turgor by pinching up skin over sternum

10. Palpate for edema pressing thumbs over feet or ankles

Scalp and Hair

1. Inspect color

2. Inspect amount and distribution

3. Inspect and palpate for thickness, texture, oiliness, lesions, and parasites

Nails

1. Inspect for grooming and cleanliness

2. Inspect for color and markings

3. Inspect shape

4. Palpate texture and consistency

5. Test for capillary refill

Analysis of data
1. Formulate nursing diagnoses

 Wellness

 Risk

 Actual

2. Formulate collaborative problems

3. Make necessary referrals