Body System

Conduct an assessment on the body system listed below. Record the history and physical examination findings accurately, listing how you performed the techniques and what you found. After all objective and subjective information is collected write a 1-page Word document Summary/Nursing Note.

Body System:

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  • Skin

Collect the following Objective Data: Describe how each area was inspected, list all findings.

1. Inspect and palpate the skin, noting its color, vascularity, edema, moisture, temperature, texture, thickness, mobility, turgor, and any lesions.

2. Inspect the fingernails, noting color, shape, and any lesions.

3. Inspect the hair, noting texture, distribution, and any lesions.

Collect the following Subjective Data: Document your patient’s response.

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. 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 skin? Sunscreen?

13. What is your amount of sun exposure? Indoor tanning?