1 Assignment 2 A
Hair, skin, nails (See below for head, neck and SBAR)
Subjective data
As will all the upcoming assessments, document the assessment on an adult since they will be able to answer history questions, etc., and are assenting to
your assessment by working with you on it.
Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with permission. Questions
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 Findings 2 Lifestyle and Health
Practices
1. Exposure to sun or
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
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 Findings 3 migraine headaches.
Lifestyle and Health
Practices
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.
Objective data: Hair, skin, nails
Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with permission. Questions 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 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.! 4 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. 5 Questions
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
finger in the sternal notch, feeling to Findings 6 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
posterior triangle) 7 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?) 8 Recommendation
(What needs to happen
next?)

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• 1506514560-nursing assignment 2 of 1.docx