Tina Jones – Skin, Hair, and Nails Results Health Assessment – January 2023

Transcript

All Lines (157)Interview Questions (27)Statements (0)Exam Actions (130)

	Hello!
	Hi. I’m Preceptor Diana. I will explain the details of this assignment and your objectives, just as a preceptor would in real life. Pay close attention to this information as it will help guide your exam. At the end of this prebrief, you will answer a short question about the upcoming assignment. During the simulation, you may return to these instructions at any time by scrolling to the top of your transcript.
	What is the situation?
	It’s 4 p.m. on Tina Jones’ second day as a patient here at Shadow General Hospital. In anticipation of Ms. Jones being discharged from the hospital, your role in this simulation is that of a healthcare provider who will assess her skin, hair, and nails for any additional wounds or signs of impaired healing.
	What are my objectives in this assessment?
	In your interview with Ms. Jones, you will gather subjective data by asking about her skin, hair, and nails. These features, which help make up the integumentary system, are often an indicator of overall health. If you discover any disease states, ask about symptoms and the patient’s experiences of them. Your questioning should cover a broad array of the symptoms’ characteristics. You will also inquire into the health history of Ms. Jones’ family with regards to skin, hair, and nails so you can determine her genetic predisposition to any diseases. Regardless of whether you have assessed Tina previously, ask all questions that are medically relevant to her hair, skin, and nails. In addition to collecting subjective data, you will also examine Ms. Jones’ skin, hair, and nails to gather objective data. While you should communicate with patients using accessible, everyday language, it is standard practice to use professional medical terminology everywhere else, such as in documenting physical findings and nursing notes. You may complete the exam activities in any order and move between them as needed.
	What else will this exam involve?
	You will complete nursing tasks to protect the patients safety, privacy, and health. You can document your findings, including vital signs, in the Electronic Health Record. This record provides necessary information for healthcare professionals who will continue patient care. Activities other than Subjective and Objective Data Collection, such as Documentation and Education and Empathy, provide valuable practice for their real-world counterparts. However, they are not automatically graded by the simulation.
	How will I be evaluated?
	In this assignment, you will be evaluated on your Subjective and Objective Data Collection. The evaluation of your interview is dependent on how you word your questions therapeutically and precisely and explore all relevant topics with comprehensive breadth and depth. The evaluation of your physical exam is based on how successfully you report on your physical findings by selecting among clinical terms in the Electronic Health Record. This assignment takes on average between 50 and 70 minutes. You can pause and resume the assignment at any time; your work is always saved automatically.
	How does this assignment prepare me for the real world?
	In this assessment, you will become familiarized with the structure and content of skin, hair, and nail exams so that with real-life patients, you can: º ask effective and comprehensive questions º use therapeutic language º evaluate the patient’s risk of disease, infection, injury, and complications º and obtain and assess objective data.
	In 1 or 2 sentences, answer this question to help prepare for the upcoming exam: What effect might a patient’s diabetes have on their skin?
	Skin may turn brown or red
	Time to begin.
	Hello my name is Nukol
	Hey.
	Checked vitals
	How is foot wound?
	I think it’s getting much better. It had actually been getting worse, but I think being in the hospital has helped.
	Do you have a history of slow healing wounds?
	Usually I heal up fine. . . I’m really surprised this scrape has taken so long to get better. But being in the hospital has helped it.
	Do you have a history of skin conditions?
	No, unless acne counts. I suppose my dry skin counts, too.
	What causes the skin dryness? (Clarified to What do you use for your dry skin?.)
	I put lotion on my skin a lot, and that helps keep it from getting dry, it least for a while. (Clarified to what I do for my dry skin.)
	Do you have acne?
	Yeah, my skin breaks out a lot. . . it is right now.
	How do you treat acne?
	I just wash my face before bed every night.
	Do you have moles?
	I have some moles, yeah.
	Where are the acne located?
	My face breaks out a lot. . . and sometimes my back does, too.
	Is there any mole changes?
	I haven’t noticed anything different about them.
	How is the mole appearance?
	I don’t know. . . they’re just regular moles.
	where is the mole location?
	I think most of my moles are on my back.
	Have you noted changes in skin color? (Clarified to Has your skin changed color?.)
	Yeah, I was noticing recently that the skin on my neck is looking weird. . . it’s definitely getting darker. (Clarified to if my skin has changed color.)
	when did the neck skin change start?
	I only noticed the skin getting darker pretty recently, like in the last few months. But then I saw some photos of myself from a few years ago and it was getting darker then, so I guess it’s been that way for a while without my realizing it.
	How is your neck skin sensation? (Clarified to Do you have sensation in your neck?.)
	It’s. . . well, it’s definitely been getting darker, but it doesn’t hurt or feel weird or anything, it just looks different. (Clarified to if I have sensation in my neck.)
	When did the body hair start?
	I’ve had at least some hair there for a really long time, but it seems like it gets worse and worse every year.
	have you noted tanning?
	I don’t like tanning. I don’t get much sun, either. I’m not an outdoors person.
	Have you noted changes in nail character?
	My nails are normal. I haven’t noticed any problems with them.
	do you have scalp problem?
	Everything seems fine with my scalp.
	Do you have related medical conditions?
	Well, I have diabetes — I think that can affect your skin sometimes, but don’t quote me.
	do you have family history of hair problems?
	I don’t think so.
	Do you have a family history of skin conditions?
	I don’t think anyone in the family has skin problems.
	Palpated scalp: No tenderness reported, no masses
	Inspected hairline and top scalp
	Inspected right side of head
	Inspected hair on back of head
	Inspected left side of head
	Inspected hairline and top scalp
	Inspected left side of head
	Inspected hair on back of head
	Inspected right side of head
	Inspected hairline and top scalp
	Inspected general face
	Inspected nose and mouth
	Inspected right side of head
	Inspected general face
	Inspected left side of head
	Inspected general face
	Inspected right orbital area and sclera
	Inspected left orbital area and sclera
	Inspected upper conjunctiva
	Inspected lower conjunctiva
	Inspected front of neck
	Inspected right side of neck
	Inspected back of neck
	Inspected left side of neck
	Inspected front of neck
	Inspected left side of neck
	Inspected back of neck
	Inspected right side of neck
	Inspected front of neck
	Inspected anterior chest wall
	Inspected right side of chest wall
	Inspected anterior chest wall
	Inspected left side of chest wall
	Inspected anterior chest wall
	Inspected left side of abdomen
	Inspected front of abdomen
	Inspected right side of abdomen
	Inspected front of abdomen
	Inspected left side of abdomen
	Inspected front of abdomen
	Inspected left arm
	Inspected right arm
	Inspected right elbow
	Inspected left elbow
	Inspected left hand
	Inspected right hand
	Inspected fingernails of right hand
	Inspected fingernails of left hand
	Checked capillary refill in fingernails
	Inspected fingernails of right hand
	Checked capillary refill in fingernails
	Checked capillary refill in fingernails
	Checked capillary refill in fingernails
	Checked capillary refill in fingernails
	Checked capillary refill in fingernails
	Checked capillary refill in fingernails
	Checked capillary refill in fingernails
	Inspected upper back
	Inspected mole closely
	Inspected left shoulder
	Inspected upper back
	Inspected right shoulder
	Inspected upper back
	Inspected left shoulder
	Inspected upper back
	Inspected back
	Inspected sacrum closely
	Inspected back
	Inspected front of hips
	Inspected right side of hips
	Inspected back of hips
	Inspected left side of hips
	Inspected front of hips
	Inspected left side of hips
	Inspected back of hips
	Inspected right side of hips
	Inspected front of hips
	Inspected front of legs
	Inspected right leg
	Inspected back of legs
	Inspected left leg
	Inspected front of legs
	Inspected left leg
	Inspected back of legs
	Inspected right leg
	Inspected front of legs
	Inspected front of knees
	Inspected right knee
	Inspected back of knees
	Inspected left knee
	Inspected front of knees
	Inspected left knee
	Inspected back of knees
	Inspected right knee
	Inspected front of knees
	Inspected left ankle
	Inspected front of ankles
	Inspected right ankle
	Inspected front of ankles
	Inspected left ankle
	Inspected front of ankles
	Inspected left foot
	Inspected top of feet
	Inspected right foot
	Inspected top of feet
	Inspected left foot
	Inspected soles of feet
	Inspected right foot
	Inspected soles of feet
	Inspected left foot
	Inspected top of feet
	Inspected left toenails
	Checked capillary refill in toenails
	Checked capillary refill in toenails
	Checked capillary refill in toenails
	Checked capillary refill in toenails
	Checked capillary refill in toenails
	Inspected right toenails
	Checked capillary refill in toenails
	Checked capillary refill in toenails
	Checked capillary refill in toenails
	Checked capillary refill in toenails
	Checked capillary refill in toenails
	Assessed wound location
	Assessed wound exudate: Serosanguineous and purulent exudate noted; no odor noted
	Assessed for necrotic tissue
	Assessed peripheral tissue: Red with slight edema
	Assessed for necrotic tissue
	Tested skin turgor on forearm

Subjective Data Collection: 23 of 23 (100.0%)

Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.

• Found:

Indicates an item that you found.

• Available:

Indicates an item that is available to be found.

Category

Scored Items

 

Experts selected these topics as essential components of a strong, thorough interview with this patient.

Patient Data

Not Scored

A combination of open and closed questions will yield better patient data. The following details are facts of the patient’s case.

Relevant Medical History

Finding:

Asked about foot wound

Finding:

Reports swelling has improved

(Available)

Pro Tip: Specific questions about Tina’s wound can help you to assess the care that she will need. Asking Tina if her wound has any swelling specifies the symptoms she is experiencing.

Example Question:

Does your wound have any swelling?

Finding:

Reports wound warmth has improved

(Available)

Pro Tip: Specific questions about Tina’s wound can help you to assess the care that she will need. Asking Tina if her wound is warm to the touch specifies the symptoms she is experiencing.

Example Question:

Does your wound feel warm to the touch?

Finding:

Reports wound discharge has improved

(Available)

Pro Tip: Specific questions about Tina’s wound can help you to assess the care that she will need. Asking Tina if there is any discharge coming from her wound specifies the symptoms she is experiencing.

Example Question:

Is discharge coming from your wound?

Finding:

Reports wound is still a little red

(Available)

Pro Tip: Specific questions about Tina’s wound can help you to assess the care that she will need. Asking Tina if her wound has any redness specifies the symptoms she is experiencing.

Example Question:

Does your wound have any redness?

Finding:

Asked history of slow healing wounds

Finding:

Denies history of slow healing wounds

(Found)

Pro Tip: Specific questions about Tina’s wounds can help you to assess the care that she will need. Asking Tina if she has a history of slow healing wounds specifies the symptoms she is experiencing.

Example Question:

Do you have a history of slow healing wounds?

Finding:

Asked current wound healing time

Finding:

Reports wound had been getting worse over the past week

(Found)

Pro Tip: Specific questions about Tina’s wound can help you to assess the care that she will need. Asking Tina how her foot wound has been healing specifies the symptoms she is experiencing.

Example Question:

How has your foot wound been healing?

Finding:

Reports wound has improved with hospital treatment

(Found)

Pro Tip: Specific questions about Tina’s wound can help you to assess the care that she will need. Asking Tina if the hospital treatment has improved her foot wound will clarify the symptoms she is experiencing.

Example Question:

Has being in the hospital helped your wound?

Finding:

Asked about history of skin conditions

Finding:

Reports acne

(Found)

Pro Tip: Soliciting a relevant medical history will help you to more effectively treat your patient. Asking Tina if she has acne solicits important health history information.

Example Question:

Have you ever had acne?

Finding:

Reports dry skin

(Found)

Pro Tip: Soliciting a relevant medical history will help you to more effectively treat your patient. Asking Tina if her skin has been dry solicits important health history information.

Example Question:

Have you ever had dry skin?

Finding:

Denies skin cancer

(Available)

Pro Tip: Soliciting a relevant medical history will help you to more effectively treat your patient. Asking Tina if she has ever been diagnosed with skin cancer solicits important health history information.

Example Question:

Have you ever been diagnosed with skin cancer?

Finding:

Denies skin rashes

(Available)

Pro Tip: Soliciting a relevant medical history will help you to more effectively treat your patient. Asking Tina if she has had skin rashes solicits important health history information.

Example Question:

Have you had skin rashes?

Finding:

Denies sores other than foot wound

(Available)

Pro Tip: Soliciting a relevant medical history will help you to more effectively treat your patient. Asking Tina if she has sores solicits important health history information.

Example Question:

Do you have sores?

Finding:

Reports skin has only itched due to cat exposure

(Available)

Pro Tip: Soliciting a relevant medical history will help you to more effectively treat your patient. Asking Tina if her skin has been itching solicits important health history information.

Example Question:

Has your skin been itching?

Finding:

Denies bruising

(Available)

Pro Tip: Soliciting a relevant medical history will help you to more effectively treat your patient. Asking Tina if her skin has been bruising solicits important health history information.

Example Question:

Have you noticed unusual bruising?

Finding:

Followed up on skin dryness

Finding:

Reports arms and legs get dry

(Available)

Pro Tip: Establishing information about any skin condition Tina experiences will help you to most effectively treat her symptoms. Asking Tina if her skin gets dry solicits important health information.

Example Question:

What part of your skin gets dry?

Finding:

Reports using lotion

(Found)

Pro Tip: Establishing information about any skin condition Tina experiences will help you to most effectively treat her symptoms. Asking Tina how she treats skin dryness solicits important health information.

Example Question:

How do you treat skin dryness?

Finding:

Followed up on acne

Finding:

Reports having acne since middle school

(Found)

Pro Tip: Acne is a skin disorder resulting from hormones and various other substances on the skin’s oil glands. Asking Tina about her history of acne solicits important information about her health history.

Example Question:

How long have you had acne?

Finding:

Reports current acne

(Found)

Pro Tip: Acne is a skin disorder resulting from hormones and various other substances on the skin’s oil glands. Asking Tina if she currently has acne solicits important information about her health history.

Example Question:

Do you have acne now?

Finding:

Reports acne had been dormant but got worse recently

(Available)

Pro Tip: Acne is a skin disorder resulting from hormones and various other substances on the skin’s oil glands. Asking Tina when she developed acne solicits important information about her health history.

Example Question:

When did you develop acne?

Finding:

Asked about acne treatment

Finding:

Reports last seeing a doctor for acne in high school

(Available)

Pro Tip: Acne is a skin disorder resulting from hormones and various other substances on the skin’s oil glands. Asking Tina when she last saw a doctor about her acne solicits important information about her health history and any treatment plan she was following.

Example Question:

When was the last time you saw a doctor about acne?

Finding:

Reports doctor prescribed antibiotics for acne

(Available)

Pro Tip: Acne is a skin disorder resulting from hormones and various other substances on the skin’s oil glands. Asking Tina how the doctor treated her acne solicits important information about her health history and any treatment plan she was following.

Example Question:

How did the doctor treat your acne?

Finding:

Reports antibiotic for acne was tetracycline

(Available)

Pro Tip: Acne is a skin disorder resulting from hormones and various other substances on the skin’s oil glands. Asking Tina what antibiotic she was prescribed for her acne solicits important information about her health history and any treatment plan she was following.

Example Question:

What antibiotic were you prescribed for your acne?

Finding:

Reports antibiotics were ineffective

(Available)

Pro Tip: Acne is a skin disorder resulting from hormones and various other substances on the skin’s oil glands. Asking Tina what antibiotic she was prescribed for her acne solicits important information about her health history and any treatment plan she was following.

Example Question:

Were the antibiotics effective on your acne?

Finding:

Reports only current treatment is washing her face

(Found)

Pro Tip: Acne is a skin disorder resulting from hormones and various other substances on the skin’s oil glands. Asking Tina how she treats her acne solicits important information about her health history.

Example Question:

How do you treat your acne now?

Finding:

Reports washing her face every night

(Found)

Pro Tip: Acne is a skin disorder resulting from hormones and various other substances on the skin’s oil glands. Asking Tina how she treats her acne solicits important information about her health history.

Example Question:

How do you treat your acne now?

Finding:

Asked acne location

Finding:

Reports acne is located on her face

(Found)

Pro Tip: Acne is a skin disorder resulting from hormones and various other substances on the skin’s oil glands. Asking Tina where her acne is located solicits important information about her health history.

Example Question:

Where is your acne located?

Finding:

Reports acne is located on her back

(Found)

Pro Tip: Acne is a skin disorder resulting from hormones and various other substances on the skin’s oil glands. Asking Tina where her acne is located solicits important information about her health history.

Example Question:

Where is your acne located?

Finding:

Asked if patient has moles

Finding:

Reports moles

(Found)

Pro Tip: Monitoring moles is an important step in detecting skin cancer. Asking Tina about her moles solicits important information about her skin.

Example Question:

Do you have moles?

Finding:

Asked about mole changes

Finding:

Denies mole changes

(Found)

Pro Tip: Monitoring moles is an important step in detecting skin cancer. Asking Tina about changes in her moles solicits important information about her skin.

Example Question:

Have your moles changed at all?

Finding:

Asked about mole appearance

Finding:

Reports moles are “just regular moles”

(Found)

Pro Tip: Monitoring moles is an important step in detecting skin cancer. Asking Tina what her new moles are like solicits important information about her skin.

Example Question:

What are your moles like?

Finding:

Asked about mole location

Finding:

Reports moles are located on her back

(Found)

Pro Tip: Monitoring moles is an important step in detecting skin cancer. Asking Tina where her moles are located solicits important information about her skin.

Example Question:

Where are your moles located?

Finding:

Asked about changes in skin color

Finding:

Reports folds in neck are getting darker

(Found)

Pro Tip: Changes in skin color can be the symptom of various diseases, disorders, or conditions. Asking Tina about changes in skin color solicits relevant information about a symptom she might be experiencing.

Example Question:

How has the skin on your neck changed?

Finding:

Asked about neck skin sensation

Finding:

Denies itchy neck skin

(Available)

Pro Tip: Establishing information about the character of Tina’s skin, like whether the skin on her neck is itchy, will allow you to compare her symptoms and assess her condition.

Example Question:

Is the skin on your neck itchy?

Finding:

Denies neck skin tingling

(Available)

Pro Tip: Establishing information about the character of Tina’s skin, like whether the skin on her neck is tingly, will allow you to compare her symptoms and assess her condition.

Example Question:

Does the skin on your neck tingle?

Finding:

Denies neck skin pain

(Found)

Pro Tip: Establishing information about the character of Tina’s skin, like whether the skin on her neck hurts, will allow you to compare her symptoms and assess her condition.

Example Question:

Does the skin on your neck hurt?

Finding:

Reports belief that neck skin has thickened

(Available)

Pro Tip: Establishing information about the character of Tina’s skin, like whether the skin on her neck is thickening, will allow you to compare her symptoms and assess her condition.

Example Question:

Has the skin on your neck thickened?

Finding:

Asked about neck skin change onset

Finding:

Reports a photograph from years earlier shows darkening skin

(Found)

Pro Tip: Establishing information about the character of Tina’s skin, like when she noticed the skin on her neck changing, will allow you to compare her symptoms and assess her condition.

Example Question:

When did you notice the skin on your neck change?

Finding:

Reports perceiving that skin was darkening in the last few months

(Found)

Pro Tip: Establishing information about the character of Tina’s skin, like when she noticed the skin on her neck changing, will allow you to compare her symptoms and assess her condition.

Example Question:

When did you notice the skin on your neck change?

Finding:

Asked about changes in body hair

Finding:

Reports increase in body hair

(Available)

Pro Tip: Changes in body hair can indicate a change in hormone levels. Asking Tina if her body hair has changed solicits important health history information.

Example Question:

Have you had changes in your body hair?

Finding:

Reports increased hair on face

(Available)

Pro Tip: Changes in body hair can indicate a change in hormone levels. Asking Tina if her body hair has changed solicits important health history information.

Example Question:

Where do you have body hair?

Finding:

Reports increased hair on abdomen

(Available)

Pro Tip: Changes in body hair can indicate a change in hormone levels. Asking Tina if her body hair has changed solicits important health history information.

Example Question:

Where do you have body hair?

Finding:

Reports increased hair around nipples

(Available)

Pro Tip: Changes in body hair can indicate a change in hormone levels. Asking Tina if her body hair has changed solicits important health history information.

Example Question:

Where do you have body hair?

Finding:

Asked about body hair onset

Finding:

Reports body hair has been increasing for a long time

(Found)

Pro Tip: Changes in body hair can indicate a change in hormone levels. Asking Tina when the amount of body hair started to increase solicits important health history information.

Example Question:

When did the amount of body hair start to increase?

Review of Systems

Finding:

Asked about hair and scalp problems

Finding:

Denies scalp problems

(Found)

Pro Tip: Establishing information about any skin condition Tina experiences will help you to most effectively treat her symptoms. Asking Tina if she has scalp problems solicits important health information.

Example Question:

Do you have scalp problems?

Finding:

Denies problems with head hair

(Available)

Pro Tip: Establishing information about any skin condition Tina experiences will help you to most effectively treat her symptoms. Asking Tina if she had problems with the hair on her head solicits important health information.

Example Question:

Have there been problems with the hair on your head?

Finding:

Denies dandruff

(Available)

Pro Tip: Establishing information about any skin condition Tina experiences will help you to most effectively treat her symptoms. Asking Tina if she has dandruff solicits important health information.

Example Question:

Do you have dandruff?

Finding:

Asked about nails

Finding:

Denies change in character of nails

(Found)

Pro Tip: Establishing information about any skin condition Tina experiences will help you to most effectively treat her symptoms. Asking Tina if she has had changes in her nails solicits important health information.

Example Question:

Have you had nail changes?

Finding:

Denies nail fungus

(Available)

Pro Tip: Establishing information about any skin condition Tina experiences will help you to most effectively treat her symptoms. Asking Tina if she has nail fungus solicits important health information.

Example Question:

Do you have nail fungus?

Finding:

Asked about tanning and sun exposure

Finding:

Denies tanning

(Found)

Pro Tip: Sun exposure can directly affect a patient’s skin. Asking Tina about her sun exposure habits, like whether or not she tans, will help you to determine whether she is at risk for skin cancer.

Example Question:

Do you tan?

Finding:

Reports using sun block

(Available)

Pro Tip: Sun exposure can directly affect a patient’s skin. Asking Tina about her sun exposure habits, like if she uses sun block, will help you to determine whether she is at risk for skin cancer.

Example Question:

Do you use sun block?

Finding:

Reports sun block is SPF 35

(Available)

Pro Tip: Sun exposure can directly affect a patient’s skin. Asking Tina about her sun exposure habits, like the type of sun block she uses, will help you to determine whether she is at risk for skin cancer.

Example Question:

What is the SPF of your sun block?

Finding:

Asked about related medical conditions

Finding:

Reports diabetes

(Found)

Pro Tip: Some medical conditions can affect a patient’s integumentary system. Asking Tina about her medical conditions can help you assess whether or not integumentary symptoms are caused by something larger.

Example Question:

Do you have diabetes?

Relevant Family History

Finding:

Asked family history of hair problems

Finding:

Denies family history of hair problems

(Found)

Pro Tip: Family histories might indicate a genetic predisposition to certain conditions. Asking Tina if she has a family history of hair problems solicits relevant health history.

Example Question:

Does your family have a history of hair problems?

Finding:

Asked family history of skin conditions

Finding:

Denies family history of skin conditions

(Found)

Pro Tip: Family histories might indicate a genetic predisposition to certain conditions. Asking Tina if she has a family history of skin problems solicits relevant health history.

Example Question:

Does your family have a history of skin conditions?

Finding:

Denies family history of skin cancer

Objective Data Collection: 23 of 24 (95.83%)

•  Correct
•  Partially correct

•  Incorrect
•  Missed

 Palpated scalp

1 of 1 point

 

Tenderness (1/2 point)

•  None reported
•  Tenderness reported

Observations (1/2 point)

•  No additional abnormal findings
•  Palpable masses

 Inspected hair

1 of 1 point

 

Distribution (1/3 point)

•  No visible abnormal findings
•  Balding or thinning areas in hair distribution

Texture (1/3 point)

•  Coarse
•  Fine

Scalp Observations (1/3 point)

•  No visible abnormal findings
•  Dandruff
•  Discoloration

 Inspected face

1 of 1 point

 

Appearance (1/2 point)

•  No visible abnormal findings
•  Redness
•  Rash
•  Acne (papules, pustules, or comedones)
•  Moles or skin tags
•  Masses (warts, cysts, or tumors)
•  Freckles, birthmark, melasma, or other discoloration
•  Excessive hair growth
•  Excessive dry or flaking skin
•  Scarring
•  Laceration or wound
•  Bruising

Location Of Observed Abnormal Findings (1/2 point)

•  No additional abnormal findings
•  Forehead
•  Nose
•  Cheeks
•  Chin
•  Upper lip

 Inspected orbital area and eyelids

1 of 1 point

 

Right: Eyebrow (1/6 point)

•  Normal hair distribution
•  Irregular hair distribution

Right: Eyelashes (1/6 point)

•  Normal hair distribution
•  Irregular hair distribution

Right: Eyelid (1/6 point)

•  No visible abnormal findings
•  Ptosis
•  Eyelid edema
•  Lesion
•  Allergic shiners

Left: Eyebrow (1/6 point)

•  Normal hair distribution
•  Irregular hair distribution

Left: Eyelashes (1/6 point)

•  Normal hair distribution
•  Irregular hair distribution

Left: Eyelid (1/6 point)

•  No visible abnormal findings
•  Ptosis
•  Eyelid edema
•  Lesion
•  Allergic shiners

 Inspected neck

1 of 1 point

 

Appearance (1/1 point)

•  No visible abnormal findings
•  Swelling
•  Visible pulsation
•  Visible mass
•  Discoloration

 Inspected anterior chest

1 of 1 point

 

Symmetry (1/2 point)

•  Symmetric
•  Asymmetric

Appearance (1/2 point)

•  No visible abnormal findings
•  Redness
•  Rash
•  Moles or skin tags
•  Masses (warts, cysts, or tumors)
•  Freckles, birthmark, or other discoloration
•  Excessive dry or flaking skin
•  Purpura
•  Striae
•  Laceration, lesion, or wound
•  Bruising
•  Scarring

 Inspected abdomen

0 of 1 point

 

Appearance (No point)

•  No visible abnormal findings
•  Rash
•  Moles or skin tags
•  Freckles, birthmark, or other discoloration
•  Excessive hair growth
•  Excessive dry or flaking skin
•  Purpura
•  Striae
•  Scarring
•  Laceration, lesion, or wound
•  Bruising
•  Masses (warts, cysts, or tumors)

 Inspected arms

1 of 1 point

 

Right: Appearance (1/2 point)

•  No visible abnormal findings
•  Redness
•  Rash
•  Moles or skin tags
•  Masses (warts, cysts, or tumors)
•  Freckles, birthmark, or other discoloration
•  Excessive dry or flaking skin
•  Purpura
•  Striae
•  Scarring
•  Laceration, lesion, or wound
•  Bruising

Left: Appearance (1/2 point)

•  No visible abnormal findings
•  Redness
•  Rash
•  Moles or skin tags
•  Masses (warts, cysts, or tumors)
•  Freckles, birthmark, or other discoloration
•  Excessive dry or flaking skin
•  Purpura
•  Striae
•  Scarring
•  Laceration, lesion, or wound
•  Bruising

 Inspected elbows

1 of 1 point

 

Right: Appearance (1/2 point)

•  No visible abnormal findings
•  Redness
•  Rash
•  Masses (warts, cysts, or tumors)
•  Freckles, birthmark, or other discoloration
•  Excessive dry or flaking skin
•  Purpura
•  Scarring
•  Laceration, lesion, or wound
•  Bruising

Left: Appearance (1/2 point)

•  No visible abnormal findings
•  Redness
•  Rash
•  Masses (warts, cysts, or tumors)
•  Freckles, birthmark, or other discoloration
•  Excessive dry or flaking skin
•  Purpura
•  Scarring
•  Laceration, lesion, or wound
•  Bruising

Inspected hands

1 of 1 point

 

Right: Appearance (1/2 point)

•  No visible abnormal findings
•  Redness
•  Moles or skin tags
•  Masses (warts, cysts, or tumors)
•  Freckles, birthmark, or other discoloration
•  Excessive dry or flaking skin
•  Purpura
•  Scarring
•  Laceration, lesion, or wound
•  Bruising
•  Rash

Left: Appearance (1/2 point)

•  No visible abnormal findings
•  Redness
•  Moles or skin tags
•  Masses (warts, cysts, or tumors)
•  Freckles, birthmark, or other discoloration
•  Excessive dry or flaking skin
•  Purpura
•  Scarring
•  Laceration, lesion, or wound
•  Bruising
•  Rash

 Inspected fingernails

1 of 1 point

 

Right: Nail Changes (1/3 point)

•  No visible abnormal findings
•  Pallor
•  Cyanosis
•  Reperfusion
•  Splinter hemorrhages
•  Grooves
•  Fungus
•  Peeling
•  Clubbing
•  Spooning

Left: Nail Changes (1/3 point)

•  No visible abnormal findings
•  Pallor
•  Cyanosis
•  Reperfusion
•  Splinter hemorrhages
•  Grooves
•  Fungus
•  Peeling
•  Clubbing
•  Spooning

Capillary Refill Time (1/3 point)

•  Less than 3 seconds
•  Greater than 3 seconds

 Inspected back and shoulders

1 of 1 point

 

Appearance (1/2 point)

•  No visible abnormal findings
•  Redness
•  Rash
•  Moles or skin tags
•  Freckles, birthmark, or other discoloration
•  Excessive dry or flaking skin
•  Purpura
•  Striae
•  Scarring
•  Laceration, lesion, or wound
•  Bruising

Location Of Abnormal Findings (1/2 point)

•  Right shoulder
•  Left shoulder

 Inspected sacrum

1 of 1 point

 

Appearance (1/1 point)

•  No visible abnormal findings
•  Lesions or pressure sores
•  Redness
•  Rash
•  Moles or skin tags
•  Masses (warts, cysts, or tumors)
•  Freckles, birthmark, or other discoloration
•  Excessive dry or flaking skin
•  Purpura
•  Scarring
•  Laceration or wound
•  Bruising

 Inspected hips

1 of 1 point

 

Appearance (1/1 point)

•  No visible abnormal findings
•  Redness
•  Rash
•  Moles or skin tags
•  Masses (warts, cysts, or tumors)
•  Freckles, birthmark, or other discoloration
•  Excessive dry or flaking skin
•  Purpura
•  Striae
•  Scarring
•  Laceration, lesion, or wound
•  Bruising

 Inspected legs

1 of 1 point

 

Right: Appearance (1/2 point)

•  No visible abnormal findings
•  Edema
•  Redness
•  Rash
•  Moles
•  Masses (warts, cysts, or tumors)
•  Freckles, birthmark, or other discoloration
•  Excessive dry or flaking skin
•  Purpura
•  Striae
•  Scarring
•  Laceration, lesion, or wound
•  Bruising
•  Varicosities

Left: Appearance (1/2 point)

•  No visible abnormal findings
•  Edema
•  Redness
•  Rash
•  Moles
•  Masses (warts, cysts, or tumors)
•  Freckles, birthmark, or other discoloration
•  Excessive dry or flaking skin
•  Purpura
•  Striae
•  Scarring
•  Laceration, lesion, or wound
•  Bruising
•  Varicosities

 Inspected knees

1 of 1 point

 

Right: Appearance (1/2 point)

•  No visible abnormal findings
•  Edema
•  Redness
•  Rash
•  Moles
•  Masses (warts, cysts, or tumors)
•  Freckles, birthmark, or other discoloration
•  Excessive dry or flaking skin
•  Purpura
•  Scarring
•  Laceration, lesion, or wound
•  Bruising

Left: Appearance (1/2 point)

•  No visible abnormal findings
•  Edema
•  Redness
•  Rash
•  Moles
•  Masses (warts, cysts, or tumors)
•  Freckles, birthmark, or other discoloration
•  Excessive dry or flaking skin
•  Purpura
•  Scarring
•  Laceration, lesion, or wound
•  Bruising

 Inspected ankles

1 of 1 point

 

Right: Appearance (1/2 point)

•  No visible abnormal findings
•  Edema
•  Redness
•  Rash
•  Moles
•  Masses (warts, cysts, or tumors)
•  Freckles, birthmark, or other discoloration
•  Excessive dry or flaking skin
•  Purpura
•  Scarring
•  Laceration, lesion, or wound
•  Bruising

Left: Appearance (1/2 point)

•  No visible abnormal findings
•  Edema
•  Redness
•  Rash
•  Moles
•  Masses (warts, cysts, or tumors)
•  Freckles, birthmark, or other discoloration
•  Excessive dry or flaking skin
•  Purpura
•  Scarring
•  Laceration, lesion, or wound
•  Bruising

 Inspected feet

1 of 1 point

 

Right: Appearance (1/2 point)

•  No visible abnormal findings
•  Rash
•  Moles
•  Masses (warts, cysts, or tumors)
•  Freckles, birthmark, or other discoloration
•  Purpura
•  Scarring
•  Laceration, lesion, or wound
•  Bruising
•  Bunion
•  Callus or corn
•  Skin fungus

Left: Appearance (1/2 point)

•  No visible abnormal findings
•  Rash
•  Moles
•  Masses (warts, cysts, or tumors)
•  Freckles, birthmark, or other discoloration
•  Purpura
•  Scarring
•  Laceration, lesion, or wound
•  Bruising
•  Bunion
•  Callus or corn
•  Skin fungus

 Inspected toenails

1 of 1 point

 

Right: Nail Changes (1/3 point)

•  No visible abnormal findings
•  Pallor
•  Cyanosis
•  Reperfusion
•  Splinter hemorrhages
•  Grooves
•  Fungus
•  Peeling
•  Clubbing

Left: Nail Changes (1/3 point)

•  No visible abnormal findings
•  Pallor
•  Cyanosis
•  Reperfusion
•  Splinter hemorrhages
•  Grooves
•  Fungus
•  Peeling
•  Clubbing

Capillary Refill Time (1/3 point)

•  Less than 3 seconds
•  Greater than 3 seconds

 Assessed wound location

1 of 1 point

 

Injured Surface (1/2 point)

•  Dorsal
•  Plantar

Injury Site (1/2 point)

•  Hindfoot
•  Midfoot
•  Forefoot

 Assessed wound exudate

1 of 1 point

 

Character (1/1 point)

•  No exudate
•  Bloody
•  Serosanguineous
•  Serous
•  Purulent
•  Foul purulent (yellow or green, with odor)

 Assessed for necrotic tissue

1 of 1 point

 

Observations (1/2 point)

•  Absent
•  Minimal
•  Moderate
•  Excessive

Type (1/2 point)

•  No necrotic tissue
•  Yellow slough
•  Brown eschar
•  Black eschar

 Assessed peripheral tissue

1 of 1 point

 

Color (1/2 point)

•  No notable color difference
•  Pink
•  Purple
•  Red

Observations (1/2 point)

•  No additional observations
•  Edema
•  Cellulitis
•  Callus
•  Tracking

 Tested skin turgor

1 of 1 point

 

Observations (1/1 point)

•  No tenting
•  Tenting

 

Needs help with similar assignment?

We are available 24x7 to deliver the best services and assignment ready within 3-4 hours? Order a custom-written, plagiarism-free paper

Get Answer Over WhatsApp Order Paper Now