JJC Nursing -Regional Write up Skin Hair and Nails Report
Description
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Name:___________________________________________Date:_________________________
Patient Initials:______________________________Age:____________Gender:_____________
I Health History-Subjective Data (yes no answers-all yes answers explain)
1. Any past skin disease__________________________________________________________
2. Any change in skin color or pigmentation?_________________________________________
3. Any changes in a mole?________________________________________________________
4. Excessive dryness or moisture?__________________________________________________
5. Any skin itching?_____________________________________________________________
6. Any excess bruising?__________________________________________________________
7. Any skin rash or lesions?_______________________________________________________
8. Are you taking any medications?_________________________________________________
9. Any recent hair loss?___________________________________________________________
10. Any change in nails?__________________________________________________________
11. Any environmental hazards for skin?_____________________________________________
12. How do you take care of your skin? Sunscreen?____________________________________
13. What is your amount of sun exposure? Indoor tanning?______________________________
______________________________________________________________________________
II Physical Examination
1. Inspect and Palpate Skin
Color_________________________________________________________________________
Pigmentation___________________________________________________________________
Temperature___________________________________________________________________
Moisture________________________________Texture________________________________
Thickness_______________________________ Any Edema____________________________
Mobility and turgor______________________________________________________________
Vascularity and bruising _________________________________________________________
Describe any skin lesions_________________________________________________________
2. Inspect and Palpate Hair
Color_________________________________________________________________________
Texture_______________________________________________________________________
Hair distribution________________________________________________________________
Describe any scalp lesions________________________________________________________
3. Inspect and Palpate Nails
Shape and contour (clubbing noted?)________________________________________________
Consistency____________________________________________________________________
Color_________________________________________________________________________
Capillary refill__________________________________________________________________
Health Assessment-Regional Write Up-2022
Summary-Skin, Hair and Nails
Write a paragraph reporting all of your subjective and objective findings:
Health Assessment-Regional Write Up-2022
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