Hair, skin, nails (See below for head, neck and SBAR)

Subjective data Name_______________

Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with permission.

Questions Findings

Current Status

1. Skin problems as described by the assessment partner (ask them to describe all rashes, lesions, dry areas, any oiliness, drainage, bruising, swelling, or pigmentation issues)

2. Reported changes in lesion appearance

3. Reported changes in sensation (pain, pressure, itch, tingling)

4. Reported hair loss or changes

5. Reported nail changes

Past History

1. Previous problems with skin, hair, or nails (treatment and surgery)

Family History

1. Family history of skin problems or skin cancer

Lifestyle and Health Practices

1. Exposure to sun or

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chemicals

2. Daily care of skin, hair, and nails (use of sunscreen, etc.)

Head and neck

Subjective data

Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with permission.

Questions Findings

Current Symptoms as reported by assessment partner

1. Reported nodules or lesions on head or neck.

2. Difficulty moving head or neck.

3. Facial or neck pain or frequent headaches.

4. Dizziness, lightheadedness, spinning sensation, or loss of consciousness.

Past History

5. Previous head or neck problems/trauma/injury (surgery, medication, physical or radiation therapy) results.

Family History

6. Family history of head and/or neck cancer.

7. Family history of migraine headaches.

Lifestyle and Health Practices

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8. Do you smoke or chew tobacco? Amount? Secondhand smoke?

9. Do you wear a helmet or hard hat?

10. Typical posture when relaxing, during sleep, and when working.

11. Satisfaction with appearance.

Objective data: Hair, skin, nails

Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with permission.

Questions Findings

(In this class when describing objective data, you need to use professional terminology. Most students are weak in this area—review the correct terms in your textbook, such as macule, papule, pustule, etc. No using of “spot”, “bump”, etc.!

1. Inspect for generalized color variations (pallor, cyanosis, jaundice, erythema, vitiligo).

2. Inspect for skin reactive conditions, such as breakdown or calluses (if applicable, use staging criteria given in Chapter 13).

3. Describe primary, secondary, or vascular lesions. Describe lesions using clinical terminology—macule, papule, pustule, etc.

4. Palpate texture (rough, smooth) of skin, using

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