NURS 6512 Week 4: Assessment of the Skin, Hair, and Nails
Sample Answer for NURS 6512 Week 4: Assessment of the Skin, Hair, and Nails Included After Question
Something as small and simple as a mole or a discolored toenail can offer meaningful clues about a patient’s health. Abnormalities in skin, hair, and nails can provide non-invasive external clues to internal disorders or even prove to be disorders themselves. Being able to evaluate such abnormalities of the skin, hair, and nails is a diagnostic benefit for any nurse conducting health assessments.
This week, you will explore how to assess the skin, hair, and nails, as well as how to evaluate abnormal skin findings.
Learning Objectives
Students will:
- Apply assessment skills to diagnose skin conditions
- Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for the skin, hair, and nails
- Apply assessment skills to collect patient health histories
Photo Credit: Keri Oberly/Getty Images
Learning Resources
Required Readings
Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.
- Chapter 8, “Skin, Hair, and Nails” (pp. 114-165)
This chapter reviews the basic anatomy and physiology of skin, hair, and nails. The chapter also describes guidelines for proper skin, hair, and nails assessments.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby.
- Chapter 28, “Rashes and Skin Lesions” (pp. 325-343)
This chapter explains the steps in an initial examination of someone with dermatological problems, including the type of information that needs to be gathered and assessed.
Note: Download and use the Adult Examination Checklist and the Physical Exam Summary when you conduct your video assessment of the skin, hair, and nails.
Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Adult examination checklist: Guide for skin, hair, and nails. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby.
This Adult Examination Checklist: Guide for Skin, Hair, and Nails was published as a companion to Seidel’s guide to physical examination (8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). From https://evolve.elsevier.com/
Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Skin, hair, and nails physical exam summary. In Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Elsevier Mosby.
This Skin, Hair, and Nails Physical Exam Summary was published as a companion to Seidel’s guide to physical examination (8th ed.), by Ball, J. W., Dains, J. E., & Flynn, J. A. Copyright Elsevier (2015). From https://evolve.elsevier.com/
Everyday Health, Inc. (2013). Resources for dermatology and visual conditions.
Retrieved from http://www.skinsight.com/info/for_professionals
Clothier, A. (2014). Assessing and managing skin tears in older people. Nurse Prescribing, 12(6), 278–282. Retrieved from http://www.nurseprescribing.com/
Retrieved from the Walden Library Databases.
Watkins, J. (2013a). Skin rashes, part 1: Skin structure and taking a dermatological history. Practice Nursing, 24(1), 30–33. doi:10.12968/pnur.2013.24.1.30
Retrieved from the Walden Library Databases.
Watkins, J. (2013b). Skin rashes, part 2: Distribution and different types of rashes. Practice Nursing, 24(3), 124–127. Retrieved from http://www.practicenursing.com/
Retrieved from the Walden Library Databases.
Watkins, J. (2013c). Skin rashes, part 3: localized rashes. Practice Nursing, 24(5), 235–241. doi:10.12968/pnur.2013.24.5.235
Retrieved from the Walden Library Databases.
Document: Skin Conditions (Word document)
Document: Comprehensive SOAP Exemplar (Word document)
Document: Comprehensive SOAP Template (Word document)
Note: To access the online resources included with the textbook, you need to complete the FREE online registration that is located at https://evolve.elsevier.com/cs/product/9780323172660?role=student.
To Register to View the Content
- Enter the name of the textbook, Seidel’s Guide to Physical Examination (name of text without the edition number) in the Search textbox.
- Complete the registration process.
To View the Content for this Textbook
- Go to https://evolve.elsevier.com/.
- Click on Student Site.
- Type in your Username and Password.
- Click on the Login button.
- Click on the plus sign icon for Resources on the left side of the screen.
- Click on the name of the textbook for this course.
- Expand the menu on the left to locate all the chapters.
- Navigate to the desired content (checklists, videos, animations, etc.).
Note: Clicking on the URLs in the APA citations for the Resources from the textbook will not link directly to the desired online content. Use the online menu to navigate to the desired content.
Required Media
Online media for Seidel’s Guide to Physical Examination
In addition to this week’s media, it is highly recommended that you access and view the online resources included with the course text, Seidel’s Guide to Physical Examination. Focus on the videos and animations in Chapter 8 that relate to the assessment of the skin, hair, and nails.
The following suturing tutorials provide instruction on the basic interrupted suture, as well as the vertical and horizontal mattress suturing techniques:
Tulane Center for Advanced Medical Simulation & Team Training. (2010, July 8). Suturing technique.
Retrieved from https://www.youtube.com/watch?v=c-LDmCVtL0o
Retrieved from https://www.youtube.com/watch?v=MFP90aQvEVM
Optional Resources
LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s diagnostic examination (10th ed.). New York, NY: McGraw Hill Medical.
- Chapter 6, “The Skin and Nails”
In this chapter, the authors provide guidelines and procedures to aid in the diagnosis of skin and nail disorders. The chapter supplies descriptions and pictures of common skin and nail conditions.
Assignment 1: Differential Diagnosis for Skin Conditions
Properly identifying the cause and type of a patient’s skin condition involves a process of elimination known as differential diagnosis. Using this process, a health professional can take a given set of physical abnormalities, vital signs, health assessment findings, and patient descriptions of symptoms, and incrementally narrow them down until one diagnosis is determined as the most likely cause.
In this Assignment, you will examine several visual representations of various skin conditions, describe your observations, and use the techniques of differential diagnosis to determine the most likely condition.
To prepare:
- Review the Skin Conditions document provided in this week’s Learning Resources, and select one condition to closely examine for this Assignment.
- Consider the abnormal physical characteristics you observe in the graphic you selected. How would you describe the characteristics using clinical terminologies?
- Explore different conditions that could be the cause of the skin abnormalities in the graphics you selected.
- Consider which of the conditions is most likely to be the correct diagnosis, and why.
- Download the SOAP Template found in this week’s Learning Resources.
To complete:
- Choose one skin condition graphic (identify by number in your Chief Complaint) to document your assignment in the SOAP (Subjective, Objective, Assessment, and Plan) note format, rather than the traditional narrative style. Refer to Chapter 2 of the Sullivan text and the Comprehensive SOAP Template in this week’s Learning Resources for guidance. Remember that not all comprehensive SOAP data are included in every patient case.
- Use clinical terminologies to explain the physical characteristics featured in the graphic. Formulate a differential diagnosis of three to five possible conditions for the skin graphic that you chose. Determine which is most likely to be the correct diagnosis and explain your reasoning using at least 3 different references from current evidence based literature.
Submission and Grading Information
Grading Criteria
Check Your Assignment Draft for Authenticity
To check your Assignment draft for authenticity:
Submit your Week 4 Assignment 1 draft and review the originality report.
Submit Your Assignment by Day 7
Assignment 2: Health History Assessment Video
By Day 7
Submit your video using the Kaltura Mashup tool accessible through the Assignment submission link provided.
Submission and Grading Information
To submit your completed Assignment for review and grading, do the following:
- Please save your Assignment using the naming convention “WK4Assgn+last name+first initial.(extension)” as the name.
- Click the Week 4 Assignment Rubric to review the Grading Criteria for the Assignment.
- Click the Week 4 Assignment link. You will also be able to “View Rubric” for grading criteria from this area.
- Next, from the Attach File area, click on the Browse My Computer button. Find the document you saved as “WK4Assgn+last name+first initial.(extension)” and click Open.
- If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database.
- Click on the Submit button to complete your submission.
Grading Criteria
Check Your Assignment Draft for Authenticity
To check your Assignment draft for authenticity:
Submit your Week 4 Assignment draft and review the originality report.
Submit Your Assignment by Day 7
Assignment 3 (Optional) Practice Assessment: Skin, Hair, and Nails Examination
Advanced practice nurses are required to have the skills and knowledge necessary to perform many different physical assessments and health examinations. In this course, you will demonstrate your abilities in this area by videotaping yourself as you perform various examinations on a volunteer “patient.”
In preparation for the Head-to-Toe Physical Assessment Video due in Week 10, it is recommended that you practice conducting an assessment of the skin, hair, and nails this week.
Note: This is an optional practice physical assessment. You do not have to capture a video of this assessment, as no submission is required.
To prepare:
- Arrange an appropriate time and setting with your volunteer “patient” to perform a skin, hair, and nails examination. Note: Your volunteer’s Video Release form must be submitted prior to the exam.
- Download and review the Skin, Hair, and Nails checklist provided in this week’s Learning Resources.
To complete:
- Perform the skin, hair, and nails examination, covering all of the areas listed in the checklist.
Week in Review
This week, you examined several visual representations of various skin conditions. In addition, you applied appropriate assessment skills in diagnosing skin conditions to determine the most likely condition.
Next week, you will explore how to properly assess the head, neck, eyes, ears, nose, and throat in order to form accurate diagnoses.
A Sample Answer For the Assignment: NURS 6512 Week 4: Assessment of the Skin, Hair, and Nails
Title: NURS 6512 Week 4: Assessment of the Skin, Hair, and Nails
Comprehensive SOAP Note
Patient Initials: MS Age: 52 Gender: Female
S: This is a 52-year old Caucasian female that is presenting with a chief complaint of a pruritic rash on bilat elbows for the past two weeks.
CC- “Rash and itching”
HPI- Complaints of a pruritic rash on bilat elbows for the past two weeks. Pt reports that the symptoms appeared after an exacerbation of asthma for which she was prescribed steroids. She reports the rash appears to be extending laterally on bilat forearms. Initially, applying taking cool showers and using hydrocortisone cream temporarily reduced the itching, however for the past 5-6 days the hydrocortisone is no longer effective, and the symptoms appear to be worsening.
Current medications: Multivitamin 1-tab PO daily, CoQ10 1 cap po daily, Claritin 10 mg PO QHS, Albuterol inhaler 2 puffs Q 4-6 hrs. prn. Hydrocortisone cream 1% prn
Allergies: Penicillin: hives
PMH: Marie S. would rate her overall health as fair. Chickenpox, Rubeola, and Rubella as a child. Has seasonal allergies for which she is prescribed Claritin
Surgeries: Appendectomy (1999). Abdominoplasty (2016).
Hospitalizations: childbirth x 2, abdominoplasty (2016)
Immunizations: Vaccinations are all UTD. Last DTAP 3 years ago, last Influenza Vaccine 10/18/18, declined pneumo-vaccine
Social Hx: Married, resides with husband and 2 children ages 30 and 28. Pt has a dog and an African Grey Parrot. She works as an LPN in a drug rehab center. Social drinking, no substance usage such as drug and nicotine. Sleeping between 7- 8 nightly. Enjoys riding her bike, swimming and walking on the beech 4-5 times weekly.
Family Hx: Children are both healthy. Brother 52, H/O HTN and Dyslipidemia. Sister 58, H/O breast cancer in remission and HTN. Parents deceased. Father passed away from stomach cancer at age 62 from stomach cancer with metastasis to liver. Mother died at age 69 from metastatic breast cancer. PGM: died at age 92 from Alzheimer’s, and MGM died at age 89 from complications with diabetes
Lifestyle: In a monogamous relationship with her husband of 32 years. Religion (Christian) attends church weekly. Wears a seat belt while driving. ADL’s appropriate, executive function intact.
Psychiatric: Presents with as pleasant and cooperative, maintains good eye contact, appears calm and focused.
ROS:
Constitutional: Patient denies any changes in weight; no loss or no gain, denies tiredness, denies chills
HEENT: Eyes: No visual changes reported. Ears, Nose, Throat: No hearing loss or earaches, no neck stiffness or rhinorrhea.
Eyes: Denies blurry vision, no redness and drainage noted, sclera clear
Skin: Significant for erythema and scaly silvery plaque on bilat elbows and abdominal surgical scars.
Ears, Nose, Throat: Patient denies having any hearing loss, able to swallow without any pain. No rhinorrhea, sneezing, nasal congestion sore throat or a cough.
Lungs: normal breathing pattern, even and unlabored breathing
Cardiovascular: Denies any chest pain and discomfort, displaced PMI or peripheral edema.
Abdomen: Denies any abdominal pain and discomfort, normal bowel movement patterns, no upset stomach.
O:
PE: Height 5’6”, Weight 153 pounds BMI: 24.6
VS: BP 124/72, T 98.8, P 62, R 18 Sao2 99%
Physical exam:
General: M.S is a 52 y/o female that presents to the office, awake, alert and oriented to all spheres. General Appearance: appropriately dressed, no signs of malnourishment, and well developed. Able to speak in complete sentences, no distress noted.
HEENT: Head normocephalic. No dryness, lesions, scars, redness or swelling.
Eyes: conjunctiva clear, sclera non-icteric, PERRLA, EOMs intact. No exudates or hemorrhages
Ears: Tympanic membranes pearly gray and intact, no drainage, light reflex noted. Pinna and tragus non-tender. Hearing intact
Nose: Nares patent without exudate. Mucosa pink and moist. Nasal septum midline without deviation. Sinuses non-tender to palpation. No external lesions or drainage.
Throat: Oropharynx pink and moist without lesions or exudate. No obvious caries or periodontal disease. Tonsils 1+ bilaterally. No tooth decay noted. Tongue midline, smooth, pink without lesions.
Neck: supple, no cervical lymphadenopathy or tenderness noted. Thyroid midline, small, non-enlarged and non-tender. No JVD present.
CV: Heart S1 and S2 noted, RRR, no murmurs, noted. Peripheral pulses equally bilaterally
Lungs: Lungs clear to auscultation in all fields. Respirations unlabored, no shortness of breath.
Cardiovascular: S1 and S2 noted, Regular rate and rhythm. No cardiomegaly, thrills or murmurs. Denies chest tightness, denies any heaviness in the chest. No palpitations or edema, peripheral pulses palpable.
Gastrointestinal: Abdomen round, soft, with tympanic bowel sounds noted in all four quadrants. No organomegaly, tenderness, masses, or a hernia.
Skin: warm, red, inflamed, raised silvery plaque to bilat elbows. Positive Aupitz sign
Primary diagnosis:
Psoriasis (ICD-10 L40)
Psoriasis is a chronic benign condition that results in inflammatory changes in the stratum corneum of the skin. It is characterized by erythema and well-demarcated, slightly raised scaly plaques that are most occur on the scalp, elbows, knees and intergluteal folds. It is frequently inherited and often patients complain of pain and pruritis to the affected site. Psoriasis can also impact the nails causing them to become thick and pitted. Individuals with moderate to severe cases of this condition often refer to it as being emotionally and physically disabling, as it has a significant impact on their quality of life. (Fenstermacher & Hundson, 2016).
Secondary diagnosis:
Atopic dermatitis (ICD-10- L20.89)
Atopic dermatitis, also referred to as eczema is a chronic inflammatory condition of the skin that normally begins in childhood. It is characterized by dry, inflamed itchy skin that often occurs on the face, scalp, neck and skin folds. (McPherson, 2016). In more severe cases, the lesions associated with eczema may result in excoriation because of scratching and rubbing and lichenification (thickening of the skin) may occur. In adults, erythematous plaques may also develop and oozing and weeping from the lesions may also occur. Although the cause of atopic dermatitis is unknown, the research found that in more than 50% of the cases in children was due to food sensitivity, and stress appeared to exacerbate the symptoms. (Fenstermacher & Hundson, 2016). Atopic dermatitis, allergies, and asthma are referred to as the “atopic triad” and are often heredity.
Differential diagnosis
Lichen Planus (ICD-10-L43.9)
Lichen Planus is a fairly common inflammatory skin disorder that normally affects the wrists, forearms, lower legs and genitals. The etiology of Lichen planus is unknown, however; it is thought to be autoimmune in nature. LP is characterized by a shiny, macular purplish rash that is triggered by the immune system. The lesions can vary in size from 2mm to more than 1cm and may appear in lines or clusters. It is reported that Lichen planus affects 0.5% to 2.0% of the general population and is more common in middle-aged women. LP can also be seen in young children, however; the occurrence is rare. (Gupta & Jawanda, 2015). The lesions are also common in the oral mucosa and are seen in approximately 50% of reported cases. Pt’s typically do not experience pain unless the lesions in the mouth ulcerate.
Differential diagnosis
Basal Cell Carcinoma (ICD-10- C44.311)
Basal cell Carcinoma (BCC) is the most common type of skin cancer in the United States as opposed to Melanoma, which has the highest incidence of morbidity. One out of 3 cancers diagnosed in the United States and 80% of new cancers are Basal cell carcinoma (Fenstermacher & Hundson, 2016). The primary cause of Basal cell carcinoma is exposure to the sun and UV lights. It is more common in fair-skinned people and is commonly seen on the face, the tip of the nose, forehead, and ears. Approximately 25-30% of these tumors are found on the nose due to direct exposure to the sun. The nose also has the highest level of re-occurrence status post-excision. (Wollina, Bennewitz & Langner, 2014). Characteristic findings is a pearly, waxy bump or lesion, with an ulcerated center and well-defined margin. BCC begins in the lower part of the epidermis and migrates to the stratum corneum. It is a slow-growing form of cancer, that if detected early, has >99% cure rate. However, with a larger legion, the 5-year survival rate drops to a whopping 42% (Fenstermacher & Hundson, 2016).
References
Gupta, S., & Jawanda, M. K. (2015). Oral Lichen Planus: An Update on Etiology, Pathogenesis, Clinical Presentation, Diagnosis, and Management. Indian journal of dermatology, 60(3), 222-9.
Fenstermacher, K. & Hundson, B. T. (2016). Practice Guidelines for Family Nurse Practitioners (4th ed.). St. Louis, MO: Elsevier.
McPherson T. (2016). Current Understanding in Pathogenesis of Atopic Dermatitis. Indian journal of dermatology, 61(6), 649-655.
Wollina, U., Bennewitz, A., & Langner, D. (2014). Basal cell carcinoma of the outer nose: overview of surgical techniques and analysis of 312 patients. Journal of cutaneous and aesthetic surgery, 7(3), 143-50.