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) Patient denies having any skin problems. No visible lesions found on assessment. 2. Reported changes in lesion appearance Patient has no lesions present. 3. Reported changes in sensation (pain, pressure, itch, tingling) No skin lesions noted. Patient denies having any pain, pressure, itch or tingling of skin. 4. Reported hair loss or changes Patient denies having hair loss at the moment. Patient also denies having any problem with hair. 5. Reported nail changes No reported nail changes
Past History 1. Previous problems with skin, hair, or nails (treatment …show more content…
Inspect for skin reactive conditions, such as breakdown or calluses (if applicable, use staging criteria given in Chapter 13). Upon assessment, patient had no skin condition. Skin Is dry and intact with no lesion present. 3. Describe primary, secondary, or vascular lesions. Describe lesions using clinical terminology—macule, papule, pustule, etc. Patient has no lesions present anywhere on skin. Patient denied having any lesion anywhere on the skin.
4. Palpate texture (rough, smooth) of skin, using palmar surface of three middle fingers. Patient's skin is warm and dry to touch. No rough edges or irregularities noted. 5. Palpate temperature (cool, warm, hot) and moisture (dry, sweaty, oily) of skin, using dorsal side of hand. Patient's skin temperature is warm and dry to touch. 6. Palpate thickness of skin with fingerpads. No tenderness noted when palpating patient's skin. Patient also has elastic skin turgor. 7. Palpate mobility and turgor by pinching up skin over sternum. Patient has elastic skin turgor. He has elastic recoil on chest wall. 8. Palpate for edema, pressing thumbs over feet or ankles. No signs and symptoms of edema present. No JVD or bruit noted. No edema in hands and feet bilaterally.
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Past History 1. Previous problems with skin, hair, or nails (treatment …show more content…
Inspect for skin reactive conditions, such as breakdown or calluses (if applicable, use staging criteria given in Chapter 13). Upon assessment, patient had no skin condition. Skin Is dry and intact with no lesion present. 3. Describe primary, secondary, or vascular lesions. Describe lesions using clinical terminology—macule, papule, pustule, etc. Patient has no lesions present anywhere on skin. Patient denied having any lesion anywhere on the skin.
4. Palpate texture (rough, smooth) of skin, using palmar surface of three middle fingers. Patient's skin is warm and dry to touch. No rough edges or irregularities noted. 5. Palpate temperature (cool, warm, hot) and moisture (dry, sweaty, oily) of skin, using dorsal side of hand. Patient's skin temperature is warm and dry to touch. 6. Palpate thickness of skin with fingerpads. No tenderness noted when palpating patient's skin. Patient also has elastic skin turgor. 7. Palpate mobility and turgor by pinching up skin over sternum. Patient has elastic skin turgor. He has elastic recoil on chest wall. 8. Palpate for edema, pressing thumbs over feet or ankles. No signs and symptoms of edema present. No JVD or bruit noted. No edema in hands and feet bilaterally.
Scalp and