As you have assessed your patient, which finding would require attention from the Module 2 assessment?

Assignment 2 A

Hair, skin, nails (See below for head, neck and SBAR)

Subjective data Name_______________

Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with permission.

Questions Findings

Current Status

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)

2. Reported changes in lesion appearance

3. Reported changes in sensation (pain, pressure, itch, tingling)

4. Reported hair loss or changes

5. Reported nail changes

Past History

1. Previous problems with skin, hair, or nails (treatment and surgery)

Family History

1. Family history of skin problems or skin cancer

Lifestyle and Health Practices

1. Exposure to sun or

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chemicals

2. Daily care of skin, hair, and nails (use of sunscreen, etc.)

Head and neck

Subjective data

Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with permission.

Questions Findings

Current Symptoms as reported by assessment partner

1. Reported nodules or lesions on head or neck.

2. Difficulty moving head or neck.

3. Facial or neck pain or frequent headaches.

4. Dizziness, lightheadedness, spinning sensation, or loss of consciousness.

Past History

5. Previous head or neck problems/trauma/injury (surgery, medication, physical or radiation therapy) results.

Family History

6. Family history of head and/or neck cancer.

7. Family history of migraine headaches.

Lifestyle and Health Practices

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8. Do you smoke or chew tobacco? Amount? Secondhand smoke?

9. Do you wear a helmet or hard hat?

10. Typical posture when relaxing, during sleep, and when working.

11. Satisfaction with appearance.

Objective data: Hair, skin, nails

Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with permission.

Questions Findings

(In this class when describing objective data, you need to use professional terminology. Most students are weak in this area—review the correct terms in your textbook, such as macule, papule, pustule, etc. No using of “spot”, “bump”, etc.!

1. Inspect for generalized color variations (pallor, cyanosis, jaundice, erythema, vitiligo).

2. Inspect for skin reactive conditions, such as breakdown or calluses (if applicable, use staging criteria given in Chapter 13).

3. Describe primary, secondary, or vascular lesions. Describe lesions using clinical terminology—macule, papule, pustule, etc.

4. Palpate texture (rough, smooth) of skin, using

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palmar surface of three middle fingers.

5. Palpate temperature (cool, warm, hot) and moisture (dry, sweaty, oily) of skin, using dorsal side of hand.

6. Palpate thickness of skin with fingerpads.

7. Palpate mobility and turgor by pinching up skin over sternum.

8. Palpate for edema, pressing thumbs over feet or ankles.

Scalp and Hair

9. Inspect color.

10. Inspect amount and distribution.

11. Inspect and palpate for thickness, texture, oiliness, lesions, and parasites.

Nails

12. Inspect for grooming and cleanliness.

13. Inspect for color and markings.

14. Inspect shape.

15. Palpate texture and consistency.

16. Test for capillary refill.

Objective data: Head, neck and lymph nodes

Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with permission.

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Questions Findings

Head and Face

1.Inspect head for size, shape, and configuration.

2.Palpate head for consistency while wearing gloves.

3. Inspect face for symmetry, features, movement, expression, and skin condition.

4. Palpate temporal artery for tenderness and elasticity.

5. Palpate temporomandibular joint for range of motion, swelling, tenderness, or crepitation by placing index finger over the front of each and asking client to open mouth.

Neck

6. Inspect neck while it is in a slightly extended position (and using a light) for position, symmetry, and presence of lumps and masses.

7. Inspect movement of thyroid and cricoid cartilage and thyroid gland by having client swallow a small sip of water.

8. Inspect cervical vertebrae by having client flex neck.

9. Inspect neck range of motion by having client turn chin to right and left shoulder, touch each ear to the shoulder, touch chin to chest, and lift chin to ceiling.

10. Palpate trachea by placing your

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finger in the sternal notch, feeling to each side, and palpating the tracheal rings.

11. Palpate the thyroid gland.

12. Auscultate thyroid gland for bruits (use both bell and diaphragm of stethoscope).

Lymph nodes: Palpate lymph nodes for size/shape, mobility, and tenderness (refer to display on characteristics of lymph nodes)

13..Preauricular nodes (front of ears)

14. Postauricular nodes (behind the ears)

15. Occipital nodes (posterior base of skull)

16. Tonsillar nodes (angle of the mandible, on the anterior edge of the sternocleidomastoid muscle)

17. Submandibular nodes (medial border of the mandible); do not confuse with the lobulated submandibular gland

18. Submental nodes (a few centimeters behind the tip of the mandible); use one hand

19. Superficial cervical nodes (superficial to the sternomastoid muscle)

20. Posterior cervical nodes (posterior to the sternocleidomastoid and anterior to the trapezius in the

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posterior triangle)

21. Deep cervical chain nodes (deep within and around the sternomastoid muscle)

22. Supraclavicular nodes (hook fingers over clavicles and feel deeply between the clavicles and the sternomastoid muscles)

SBAR

As you have assessed your patient, which finding would require attention from the Module 2 assessment? (Skin, Hair, Nails, Head, Neck, Eyes, Ears, Mouth, Nose, Throat, or Sinuses). Select a problem you feel to be of importance and address it using the SBAR form. If you have a healthy assessment partner, it may be as simple as addressing that he/she should utilize sunscreen or ceases using unsafe tanning methods. If your assessment partner has chronic health problems in one of the module areas, you may address one of those problems below.

SBAR Situation (What is the most important problem you have identified? When did it start, and how severe is it?)

Background

(The evidence—Health history relating to this problem, what is being done, and what assessment findings are most important now.)

Assessment

(What do you think the problem is—which direction does it seem to be going?)

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Recommendation

(What needs to happen next?)

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