Health Assessment

Name: Kristine Mae M. Merhan Score: ________ _

Course/section: BSN-1B Date: May 5, 2022

SKIN, HAIR, AND NAILS ASSESSMENT

Case Analysis:

Mr. Ryan, a 68-year-old semiretired electrician, comes to the clinic for his annual physical examination.
He reports that he has some “sores” on his right leg that have been there for about 2 months and will not heal.
The nurse practitioner begins the physical assessment and documents the following data regarding Mr. Ryan’s
skin, hair, and nails:
 Hair distribution: Balding at the crown of the scalp and receding hairline. Hair is thin, coarse, and
gray.
 Scalp: Scaling and yellow patches intermittently dispersed on the scalp.
 Mucous membranes: Lips and mouth are dry and pale pink.
 Nails: Brittle and thin; right index finger nail is yellow and thick.
 Chest/abdomen: Barreling of the chest and rounding of the abdominal area.
 Chest hair: Thinning and gray.
 Extremities: Medial right leg and ankle reddened and edematous with several scattered small weeping
areas. No hair growth in this area and skin is ruddy. Left leg and ankle are normal in size. Skin is pale
pink. Capillary refill is less than 2 seconds; skin tag on upper left thigh. Even hair distribution; skin is
warm to touch. Arms are normal in size, hair distribution, and temperature.

a. What data represent abnormal findings based on the information available about the patient?
The abnormal findings in this case are the scaling and yellow patches on the scalp, the dry and pale pink
lips and mouth, the brittle and thin nails and also his right index finger nail is yellow and thick, the
barrel chest and rounded abdominal area, the thinning and gray chest hair, medial right leg and ankle
reddened and edematous with several scattered small weeping areas with no hair growth and a skin that
is ruddy, skin tag on upper left thigh, and the sores that haven't healed in two months.

b. What questions should the nurse ask this patient regarding his past medical history?
The nurse should ask about the patient's current medications, whether he has ever been diagnosed with a
condition or disease, and whether he has a history of long-term discomfort or chronic pain.