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Skin hair nails
Nursing Assessment (MVB 2324 )
Indian River State College
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Skin hair nails
Subjective Data Collection: 23 of 23 (100%)
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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
(Found)
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
(Found)
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
(Found)
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?
(Available)
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:
Finding:
Reports arms and legs get dry
(Found)
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
(Available)
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 antibiotics were ineffective
(Found)
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
(Available)
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
(Available)
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
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.
(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
(Found)
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
(Found)
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
(Found)
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:
(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)
Skin hair nails
Course: Nursing Assessment (MVB 2324 )
University: Indian River State College
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