ADVENTIST MEDICAL CENTER COLLEGE
BRGY. SAN MIGUEL, ILIGAN CITY
SCHOOL OF NURSING
HEALTH ASSESSMENT
Related Learning Experience
Second Semester, AY 2021 - 2022
Assessment of the Skin, Hair and Nails
Name: Samantha C. Templado
I.
Section: BSN1A
Date: March 7, 2022
Score _____
Collecting Subjective Data: The Nursing Health History
Preliminaries
1. Gather equipment (gloves, exam light, penlight, magnifying
glass, centimeter ruler, wood lamp if available).
2. Demonstrate courtesy and explain procedure to client.
3. Do hand hygiene.
4. Provide privacy.
History of Present Health Concern
Skin
1. Are you experiencing any current skin problems such as
rashes, lesions, dryness, oiliness, drainage, bruising, swelling,
or changes in skin color? What aggravates the problem? What
relieves it?
2. Do you have any birthmarks or moles? If so, please describe
them. Have any of them changed color, size, or shape?
3. Do you know how to check the warning signs or
characteristics (ABCDE’s) of skin cancer?
4. Have you notice any change in your ability to feel pain,
pressure, light touch, or temperature variations?
5. Are you experiencing any pain, itching, tingling, or
numbness?
6. Are you taking medications (prescribed or “over the
counter”), using any ointments and creams, herbal or
nutritional supplements, or vitamins? If so, how long have you
been taking each of these?
Findings
The client is Ms. Rona Gem Templado,
21 years old, is experiencing skin
itching but denies other skin problems
such as rashes, lesions, dryness,
oiliness, drainage, bruising, swelling or
changing of skin color. According to
the client, flee of her dog aggravates
her itching and taking a bath daily
relieves it.
The client do have moles “mga alom
lang pero dili sila buhi small black
circles lang, unnoticeable” as the client
verbalized. The client denies having the
presence of birthmark on her body.
The client stated that she does not
know how to look for skin cancer
warning signs, yet she is negative on
the ABCDE test's characteristics.
According to the client she didn’t
notice any change in her ability to feel
pain, pressure, light touch, and
temperature variations “wala man” as
verbalized.
The client stated that she is
experiencing the presence of itching in
her skin, but denies the presence of
tingling or numbness.
The client is not taking any
medications or using any ointments,
creams, herbal or nutritional
supplements to intervene her itching.
But she stated that she is taking a
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7. Do you have trouble controlling your odor?
8. Do you perceive yourself to have excessive perspiration?
Personal History
9. Do you recall having severe sunburns as a child?
10. Describe any previous problems with skin including any
treatment or surgery and its effectiveness.
11. Have you had any recent hospitalizations or surgeries?
12. Have you ever had any allergic skin reactions to food,
medications, plants, or other environmental substances?
Have you had a recent viral or bacterial illness?
13. For female clients: Are you pregnant? Are your menstrual
periods regular?
14. Do you have a history of self-injury?
Family History
15. Has anyone in your family had a recent illness, rash, or
other skin problem or allergy? Describe.
16. Has anyone in your family had skin cancer?
17. Do you have a family history of keloids?
vitamin C, specifically immunPro since
the pandemic has begun.
The client stated that she has no trouble
in controlling her body controlling
odor.
The client didn’t experience excessive
perspiration “sakto lang dili lang pud
grabe kayo” as verbalized.
According to the client, she didn’t
recall having severe sunburn when she
was still a child, but do experience
sunburns every time they went to the
sea. “di pud grabe kayo nasunog lang”
as she verbalized.
The client denies any previous skin
problems including any treatment or
surgery.
According to the client she has never
been admitted.
The client stated that she didn’t have
any allergic reactions to foof,
medications, plants or other
environmental substances.
According to the client, she didn’t
experience any viral or bacterial
illnesses at all.
Since the client is still a student, she
denies being pregnant and stated that
her menstrual cycle is irregular.
Ms. Rona didn’t have any history of
any self-injury.
According to her, her family had no
recent illness, rash, or other skin
concern.
The client stated that no one inside her
family had the presence of skin cancer.
She also stated that all of them in the
family do not have any history of
keloids.
Lifestyle and Practices
18. Do you sunbathe?
According to her, she did experience
sunbathing but only if they are
mountain climbing or hiking. “pag
maghike rami” as verbalized.
19. What is the frequency and duration of sun or tanning-booth She stated that every time she is
exposure?
exposed to the sun, the longest time she
is exposed is 6-7 hours in a day.
20. Do you use sun block and if so what type (specify SPF)?
The client is using a sun block
specifically the olay variant.
21. Do you perform skin self-examination once a month?
The client does not perform any skin
self-examination
22. In your daily activities, are you regularly exposed to
According to the client, she is exposed
chemicals or irritants that may harm the skin (e.g. coal, tar,
to chemicals like bleach and alcohol
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pitch. Creosote. Arsenic compounds, radium, alcohol, hand
foam, latex, bleach, peroxide)?
23. Do you spend long periods of time sitting or lying in one
position?
24. Have you had any exposure to extreme temperatures?
25. Do you have body piercings?
26. Do you have any tattoos?
27. What is your daily routine for skin?
28. What products do you use (e.g., soaps, lotions, oils,
cosmetics, self-tanning products?
29. What kinds of foods do you consume in a typical day?
How much fluid do you drink each day?
30. Do skin problems limit any of your normal activities?
31. Describe skin disorder that prevents you from enjoying
your relationships.
32. How much stress do you have in your life? Describe.
everyday that may harm or irritate her
skin.
“yes, halos all day gahigda rako or
galinkod” as verbalized by the client.
The client had no exposure to any
extreme temperatures.
Client has no body piercings
Client has no tattoos
The client stated that she is using a skin
cleanser specifically the skin white
variant to prevent her skin from
pimples. Other than that there is no
other products she is using for her skin.
The client stated that she is using any
kinds or variants of body soap,
cosmetics and lotions, but denies using
some oils or self-tanning products.
According to the client, the food she
usually intake daily are vegetables and
fishes. And consume 3-4 glasses of
water each day.
Client has no skin problems that limit
her normal activities.
Client has no skin disorder that
prevents her from enjoying her
relationships.
Ms. Rona do experience stress in life.
She specifically mentioned academics
and time management usually causes
her stress.
History of Present Health Concern
Hair and Nails
1. Have you had any hair loss or change in the condition of
your hair? Describe.
2. Have you had any change in the condition or appearance of
your nails? Describe.
Personal Health History
3. Describe any previous problems with hair, or nails,
including any treatment or surgery and its effectiveness.
4. Have you had any recent hospitalizations or surgeries?
5. For female clients: Are you pregnant? Are your menstrual
periods regular?
The client is experiencing the presence
of hair loss. “every panudlay nako
daghan kaayog ma tangtang nga buhok
literal daghan jud kayo" as the client
verbalized.
She also stated that there were no
problems or changes in the condition
and appearance of her nails.
The client has no previous problems
with her hair or nails that needed
surgery or any treatments.
According to the client, she has no
records of recent hospitalizations and
surgeries.
Since the client is still a student, she
denies being pregnant and stated that
her menstrual cycle is irregular.
Lifestyle and Health Practices
1. In your daily activities, are you regularly exposed to
According to the client, she is exposed
chemicals or irritants that may harm the hair & nails (e.g. coal, to chemicals like bleach and alcohol
tar, pitch. Creosote. Arsenic compounds, radium, alcohol, hand everyday that may harm or irritate her
foam, latex, bleach, peroxide)?
hair or nails.
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2. What is your daily routine for hair & nails?
3. What products do you use (e.g., razor type, hair spray,
shampoo, hair coloring, nail enamel)?
4. How do you cut your nails?
5. What kinds of foods do you consume in a typical day? How
much fluid do you drink each day?
6. Describe hair & nails disorder that prevents you from
enjoying your relationships.
The client stated that for her hair
routine, just taking a bath, applying
shampoo daily and conditioner
alternately. For her nails, brushing it
every night and cutting or shaping it
every time it grows.
She said that she uses shampoo or
conditioner in any kinds for her hair,
and sometimes apply nail polish on her
nails.
The client said that she cuts her nails
with the use of nail cutter gently and
carefully to avoid wounds.
According to the client, the food she
usually intake daily are vegetables and
fishes. And consume 3-4 glasses of
water each day.
The client has no hair or nail disorder
that prevents her from enjoying her
relationships.
Score: 86
II.
Collecting Objective Data: Physical Examination
Preliminaries
1. Gather equipment (gloves, exam light, penlight, magnifying glass,
centimeter ruler, wood lamp if available.
2. Demonstrate courtesy and explain procedure to client.
3. Do hand hygiene.
4. Provide privacy.
Skin
1. Note any distinctive odor.
2. Inspect both exposed/ unexposed areas for color/ generalized
color variations ( browness, yellow, redness, pallor, cyanosis,
jaundice, erythema, vitiligo.).
3. Inspect for skin breakdown ( use staging criteria given)
4. Inspect for primary, secondary or vascular lesions (note size,
shape, location, distribution and configuration of lesions. Use
Woodlamp if fungus is suspected.
5. Palpate lesions.
6. Palpate texture (rough, smooth) of the skin using palmar surface
of three middle fingers.
7. Palpate temperature (cool, warm, and hot) and moisture ( dry,
sweaty, and oily) of the skin using dorsal side of the hand.
8. Palpate thickness of skin fingerpads
9. Palpate mobility and skin turgor by pinching up skin over sternum.
Findings



(-) in any distinctive
odor
(+) of tan lines
(+) of browness in
exposed areas
(-) of jaundice or yellow
(-) of erythema


(-) skin breakdown
(-) vascular lesions

(-) lesions

(+) smooth skin texture
(+) warm temperature
(+) oily moisture
(+) thickness or calluses
(-) mild dehydration
(-) skin turgor







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10. Palpate for edema, pressing thumb over feet or ankles,

(-) edema in the feet or
ankles
Scalp and Hair
11. Inspect color
12. Inspect amount and distribution. Assess areas for the pattern. Note
whether there is actual hair loss, with smooth skin beneath,
whether hair has been broken off near the scalp, with palpable
stubble over the skin.




(+) natural black color
(+) in hair loss
(+) with smooth scalp
(+) hair has been broken
off near scalp
(+) stubble on skin
(+) thickness of scalp
(-) parasites or
dandruffs
(-) oiliness
(-) lesions
13. Inspect and palpate for thickness, texture, and oiliness, lesions
and parasites





Nails
14. Inspect for grooming, and cleanliness

15. Inspect for color and markings.


16. Inspect shape. Have patient place fingers together and note
space (opening) between nails.




17. Palpate texture and consistency.
18. Test for capillary refill. Gently press on nail and note blanching
and release and note speed or refill ( color return)
Score: 36
Total Score: 122 points
Assessed by:




(-) dirt present in the
nails
(+) pinkish color of
nails
(-) any color polish on
nails
(-) markings on nails
(-) any distinct space
opening between nails
(+) good shape of nails.
(+) slightly round shape
of nails
(+) firm nails
(+) smooth or shiny nail
texture
(+) translucent
Test for capillary refill
(2sec)
____________________________
Signature over Printed Name of CI
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