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10 Cards in this Set
- Front
- Back
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Establish a Relationship
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Intro to pt
Show concern Ensure privacy Wash hands |
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General Appearance Review
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Ex. 45 y.o. male
Appears in good health Calm and cooperative Well groomed, dressed appropriately. Good eye contact |
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Review of systems Hair, skin and nails
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Have you had any: Skin rashes, excessive itching, change in skin color, mole that changed shape size or colors, any lumps or bumps, ulcers or sores that don't heal, problems w/ easy bruising or bleeding?
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ROS Skin con't
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Any changes in your hair? Thinning, falling out, pain w/ brushing. Experiencing any excessive sweating. Any previous nail problems or changes? Any questions for me?
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Patient comfort and modesty
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Are you comfortable? Drape pt appropriately (Tell Her)
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Skin What are you checking for?
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Color, texture, lesions, moisture, edema, hair distribution. (Anterior, posterior, lateral, between the web spaces, soles of feet, behind the ears)
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Skin What are you palpating for?
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Temperature, moisture, edema, turgor, tenderness, lumps, bumps, rashes, lesions, scars noted.
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Hair Inspection and Palpation
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Distribution, quantity, presence of lesions on scalp, extraneous materials (scales, infestations)
dry, oily, moist, flaking, bugs texture(balding, receding, thinning |
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Nail inspection
Fingers and toes |
Configuration (round,square,bitten), color of bed, integrity, cleanliness, length, lesions, pus, swelling, ingrown. Check web spaces!!
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Palpation of nails for?
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Integrity, tenderness, adherence (strong, any lift, intact)
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