NURS 6512: Advanced Health Assessment and Diagnostic Reasoning
Week 4: Assessment of the Skin, Hair, and Nails
Something as small and simple as a mole or a discolored toenail can offer meaningful clues about a patient’s health. Abnormalities in skin, hair, and nails can provide non-invasive external clues to internal disorders or even prove to be disorders themselves. Being able to evaluate such abnormalities of the skin, hair, and nails is a diagnostic benefit for any nurse conducting health assessments.
This week, you will explore how to assess the skin, hair, and nails, as well as how to evaluate abnormal skin findings.
Learning Objectives
Students will:
Apply assessment skills to diagnose skin conditions
Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for the skin, hair, and nails
Learning Resources
Required Readings (click to expand/reduce)
Required Media (click to expand/reduce)
Assignment 1: Lab Assignment: Differential Diagnosis for Skin Conditions
Photo Credit: Getty Images/iStockphoto
Properly identifying the cause and type of a patient’s skin condition involves a process of elimination known as differential diagnosis. Using this process, a health professional can take a given set of physical abnormalities, vital signs, health assessment findings, and patient descriptions of symptoms, and incrementally narrow them down until one diagnosis is determined as the most likely cause.
In this Lab Assignment, you will examine several visual representations of various skin conditions, describe your observations, and use the techniques of differential diagnosis to determine the most likely condition.
To Prepare
Review the Skin Conditions document provided in this week’s Learning Resources, and select one condition to closely examine for this Lab Assignment.
Consider the abnormal physical characteristics you observe in the graphic you selected. How would you describe the characteristics using clinical terminologies?
Explore different conditions that could be the cause of the skin abnormalities in the graphics you selected.
Consider which of the conditions is most likely to be the correct diagnosis, and why.
Search the Walden library for one evidence-based practice, peer-reviewed article based on the skin condition you chose for this Lab Assignment.
Review the Comprehensive SOAP Exemplar found in this week’s Learning Resources to guide you as you prepare your SOAP note.
Download the SOAP Template found in this week’s Learning Resources, and use this template to complete this Lab Assignment.
The Lab Assignment
Choose one skin condition graphic (identify by number in your Chief Complaint) to document your assignment in the SOAP (Subjective, Objective, Assessment, and Plan) note format rather than the traditional narrative style. Refer to Chapter 2 of the Sullivan text and the Comprehensive SOAP Template in this week’s Learning Resources for guidance. Remember that not all comprehensive SOAP data are included in every patient case.
Use clinical terminologies to explain the physical characteristics featured in the graphic. Formulate a differential diagnosis of three to five possible conditions for the skin graphic that you chose. Determine which is most likely to be the correct diagnosis and explain your reasoning using at least three different references, one reference from current evidence-based literature from your search and two different references from this week’s Learning Resources.
By Day 7 of Week 4
Submit your Lab Assignment.
Submission and Grading Information
To submit your completed Assignment for review and grading, do the following:
Please save your Assignment using the naming convention “WK4Assgn1+last name+first initial.(extension)” as the name.
Click the Week 4 Assignment 1 Rubric to review the Grading Criteria for the Assignment.
Click the Week 4 Assignment 1 link. You will also be able to “View Rubric” for grading criteria from this area.
Next, from the Attach File area, click on the Browse My Computer button. Find the document you saved as “WK4Assgn1+last name+first initial.(extension)” and click Open.
If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database.
Click on the Submit button to complete your submission.
Learning Resources
Required Readings (click to expand/reduce)
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Chapter 9, “Skin, Hair, and Nails”
This chapter reviews the basic anatomy and physiology of skin, hair, and nails. The chapter also describes guidelines for proper skin, hair, and nails assessments.
Colyar, M. R. (2015). Advanced practice nursing procedures. Philadelphia, PA: F. A. Davis.
Credit Line: Advanced practice nursing procedures, 1st Edition by Colyar, M. R. Copyright 2015 by F. A. Davis Company. Reprinted by permission of F. A. Davis Company via the Copyright Clearance Center.
This section explains the procedural knowledge needed prior to performing various dermatological procedures.
Chapter 1, “Punch Biopsy”
Chapter 2, “Skin Biopsy”
Chapter 10, “Nail Removal”
Chapter 15, “Skin Lesion Removals: Keloids, Moles, Corns, Calluses”
Chapter 16, “Skin Tag (Acrochordon) Removal”
Chapter 22, “Suture Insertion”
Chapter 24, “Suture Removal”
Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center.
Chapter 28, “Rashes and Skin Lesions”
This chapter explains the steps in an initial examination of someone with dermatological problems, including the type of information that needs to be gathered and assessed.
Note: Download and use the Student Checklist and the Key Points when you conduct your assessment of the skin, hair, and nails in this Week’s Lab Assignment.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Skin, hair, and nails: Student checklist. In Seidel’s guide to physical examination (9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Skin, hair, and nails: Key points. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center.
Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.
Chapter 2, “The Comprehensive History and Physical Exam” (Previously read in Weeks 1 and 3)
VisualDx. (n.d.). Clinical decision support. Retrieved June 11, 2019, from http://www.skinsight.com/info/for_professionals
This interactive website allows you to explore skin conditions according to age, gender, and area of the body.
Clothier, A. (2014). Assessing and managing skin tears in older people. Nurse Prescribing, 12(6), 278–282.
Document: Skin Conditions (Word document)
This document contains five images of different skin conditions. You will use this information in this week’s Discussion.
Document: Comprehensive SOAP Exemplar (Word document)
Document: Comprehensive SOAP Template (Word document)
Shadow Health Support and Orientation Resources
Use the following resources to guide you through your Shadow Health orientation as well as other support resources:
Frey, C. [Chris Frey]. (2015, September 4). Student orientation [Video file]. Retrieved from https://www.youtube.com/watch?v=Rfd_8pTJBkY
Shadow Health. (n.d.). Shadow Health help desk. Retrieved from https://support.shadowhealth.com/hc/en-us
Document: Shadow Health. (2014). Useful tips and tricks (Version 2) (PDF)
Document: Shadow Health Nursing Documentation Tutorial (Word document)
Document: Student Acknowledgement Form (Word document)
Note: You will sign and date this form each time you complete your DCE Assignment in Shadow Health to acknowledge your commitment to Walden University’s Code of Conduct.
Optional Resources
LeBlond, R. F., Brown, D. D., & DeGowin, R. L. (2014). DeGowin’s diagnostic examination (10th ed.). New York, NY: McGraw Hill Medical.
Chapter 6, “The Skin and Nails”
In this chapter, the authors provide guidelines and procedures to aid in the diagnosis of skin and nail disorders. The chapter supplies descriptions and pictures of common skin and nail conditions.
Ethicon, Inc. (n.d.-a). Absorbable synthetic suture material. Retrieved from https://web.archive.org/web/20170215015223/http://academicdepartments.musc.edu/surgery/education/resident_info/supplement/suture_manuals/absorbable_suture_chart.pdf
Ethicon, Inc. (2006). Dermabond topical skin adhesive application technique. Retrieved from https://web.archive.org/web/20150921174121/http://academicdepartments.musc.edu/surgery/education/resident_info/supplement/suture_manuals/db_application_poster.pdf
Ethicon, Inc. (2001). Ethicon needle sales types. Retrieved from https://web.archive.org/web/20150921171922/http://academicdepartments.musc.edu/surgery/education/resident_info/supplement/suture_manuals/needle_template.pdf
Ethicon, Inc. (n.d.-b). Ethicon sutures. Retrieved from https://web.archive.org/web/20150921202525/http://academicdepartments.musc.edu/surgery/education/resident_info/supplement/suture_manuals/suture_chart_ethicon.pdf
Ethicon, Inc. (2002). How to care for your wound after it’s treated with Dermabond topical skin adhesive. Retrieved from https://web.archive.org/web/20150926002534/http://academicdepartments.musc.edu/surgery/education/resident_info/supplement/suture_manuals/db_wound_care.pdf
Ethicon, Inc. (2005). Knot tying manual. Retrieved from https://web.archive.org/web/20160915214422/http://academicdepartments.musc.edu/surgery/education/resident_info/supplement/suture_manuals/knot_tying_manual.pdf
Ethicon, Inc. (n.d.-c). Wound closure manual. Retrieved from https://web.archive.org/web/20170829043048/http://academicdepartments.musc.edu/surgery/education/resident_info/supplement/suture_manuals/eth
Online media for Seidel’s Guide to Physical Examination
In addition to this week’s media, it is highly recommended that you access and view the online resources included with the text, Seidel’s Guide to Physical Examination. Focus on the videos and animations in Chapter 8 that relate to the assessment of the skin, hair, and nails.
Note: To access the online resources included with the text, you need to complete the FREE online registration that is located at https://evolve.elsevier.com/cs/product/9780323172660?role=student .
To Register to View the Content
Go to https://evolve.elsevier.com/cs/product/9780323172660?role=student
Enter the name of the textbook, Seidel’s Guide to Physical Examination (name of text without the edition number) in the Search textbox.
Complete the registration process.
To View the Content for this Text
Go to https://evolve.elsevier.com/
Click on Student Site.
Type in your username and password.
Click on the Login button.
Click on the plus sign icon for Resources on the left side of the screen.
Click on the name of the textbook for this course.
Expand the menu on the left to locate all the chapters.
Navigate to the desired content (checklists, videos, animations, etc.).
Note: Clicking on the URLs in the APA citations for the Resources from the textbook will not link directly to the desired online content. Use the online menu to navigate to the desired content.
Suturing Tutorials
The following suturing tutorials provide instruction on the basic interrupted suture, as well as the vertical and horizontal mattress suturing techniques
Tulane Center for Advanced Medical Simulation & Team Training. (2010, July 8). Suturing technique [Video file]. Retrieved from https://www.youtube.com/watch?v=c-LDmCVtL0o
Note: Approximate length of this media program is 5 minutes.
Mikheil. (2014, April 22). Basic suturing: Simple, interrupted, vertical mattress, horizontal mattress [Video file]. Retrieved from https://www.youtube.com/watch?v=MFP90aQvEVM
Note: Approximate length of this media program is 9 minutes.
Incision and Drainage of an Abscess (a common procedure in primary care)
New England Journal of Medicine (NEJM). (2013, September 30). NEJM abscess incision and drainage [Video file]. Retrieved from https://www.youtube.com/watch?v=MwgNdrA18fM&list=PL9UKTUFtRDcNq4–Vf2NYfUANEyObfeNm&index=8
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Comprehensive SOAP
Comprehensive SOAP Template
Patient Initials: _JR______ Age: __62_____ Gender: ___M____
SUBJECTIVE DATA:
Chief Complaint (CC): Annual physical examination and complains about possible psoriasis due to past medical condition.
History of Present Illness (HPI): Jimmie Rollins is a 62-year old African-American male who presents to the clinic for psoriasis. Onset was when he was in high school by the PCP. New plaques developing in other parts of the skin. Jimmie denies any pain, fever, exposure to contact irritants or taking a new medication. He denies of lifestyle changes. He reports no personal incidence or family history of skin cancer.
Medications: Over the Counter daily men’s multivitamin dose for three months.
Allergies: NKDA (No Known Drug Allergies)
Past Medical History (PMH): Psoriasis
Past Surgical History (PSH): Repair of a torn rotator cuff of the right shoulder at age 43 (Dr. Bakker, Grand Haven, MI).
Sexual/Reproductive History: Heterosexual and not sexually active.
Personal/Social History: Denied ETOH, drug use or smoking.
Immunization History: All immunizations are up-to-date. He received the latest immunization in 2017 against influenza. He received the pneumococcal vaccine the following year.
Significant Family History: Both parents are alive and elderly. He has three siblings, two brothers, and one sister. He is widowed and currently lives with his two daughters who are in their early and late twenties. The two daughters and two brothers live in the neighborhood. One of the brothers has a psoriasis condition that is under treatment.
Lifestyle: Jimmie is a retired advanced nurse at a local hospital. He has been widowed for 8 years. He lives in his own home together with one of his sons, his wife, and grandchildren. The other children live around his home area. He takes a walk every morning and evening. He goes to watch football with his 5 peers at a local football stadium every week. He attends a Catholic mass daily. Together with his peers, they take dinner at a local restaurant twice a week.
Review of Systems:
General: Mr. Jimmie is a well-developed and nourished African-American male. He is alert and cooperative. He answers all questions appropriately and remembers events accurately. The man is also in good hygiene.
HEENT: Vision and hearing are in good condition. He wears eyeglasses. His eye checkup that was carried 6 months ago indicated no possibility of glaucoma, photophobia or excessive tearing. His ears are in good condition without any infection or discharge. He reports no epistaxis or history of sinus infection. Nares patent bilaterally. No sinus tenderness Buccal mucosa intact. The last dental exam was taken on 1/09/2018. He denies bleeding gums, ulceration, and lesions. He has no dental appliances. He has no difficulty chewing as well as swallowing.
Neck: Diffuse involvement of scalp and preauricular cheek. Plaque involvement of central face with the erythema.
Breasts: He reports no history of rashes, lesions or masses.
Respiratory: Diaphragmatic excursion is symmetrical. Breath sound is clear.
Cardiovascular/Peripheral Vascular: No history of angina reported as well as orthopnea, edema, claudication or arrhythmia.
Gastrointestinal: No history of reflux, vomiting or nausea. No abdominal pain including irregular bowel patterns.
Genitourinary: No history of dysuria, incontinence or irregular urinary patterns. Jimmie is heterosexual and has had no sexual intercourse since the death of his dear wife.
Musculoskeletal: No history of arthritis, gout, arthralgia. He reports a history of rotator cuff injury on his right shoulder.
Psychiatric: Jimmie has no history of depression or anxiety. He denies sleep disturbance or delusion. No suicidal thoughts experienced.
Neurological: No abnormal memory patterns, twitches. He denies gait disturbance or poor coordination. He has no history of falls as well as seizures. No headaches or dizziness.
Skin: The patient reports slight pain on the skin rashes around the arm, shoulder, and chest. The rashes include sores that are dry.
Hematologic: The patient reports no blood disorder.
Endocrine: No endocrine problems reported.
Allergic/Immunologic: The patient denies any allergic reaction including skin and respiratory system.
OBJECTIVE DATA:
Physical Exam:
Vital signs: B/P 110/71, left arm, seated, regular cuff. P 70 and oral T 98.3. BMI 21, Wt 165 lbs, RR, non-labored.
General: Aware and Oriented *3 (A&O), NAD, appears slightly uncomfortable. Dull facial expression. No reported odor or bad breath.
HEENT: Diffuse involvement of preauricular cheek and scalp and plaque involvement of on central face with erythema and scaling.
Neck: Carotids no bruit JVD.
Chest/Lungs: CTA AP&L.
Heart/Peripheral Vascular: RRR without murmur, rub, pulses +2 bilat pedal, radial +2
Abdomen: Mild suprapubic tenderness, diffuse and no rebound, benign, nabs * 4.
Genital/Rectal: Deferred.
Musculoskeletal: age-related atrophy, symmetrical muscle movement, and development. Muscle strength 5/5.
Neurological: DTR intact, CN II – XII intact.
Skin: Well-demarcated, raised plaques, erythematous plaques, white scaly surfaces around arms and chest. No bleeding, discharge or discoloration, nail changes with pitting. Dystrophy with the crumbled nail plate.
ASSESSMENT:
Lab Test and Results: SAO2 98%.
Differential Diagnosis:
Seborrheic dermatitis: The condition affects the scalp causing stubborn dandruff on the hair, beard and mustache, red skin and scaly patches. It affects oily areas including face and chest. It causes red skin as well as itching (Watkins, 2016). The skin changes are associated with inflammation due to common skin organisms. The condition can be identified through physical examination. It is associated with a weak immune system or yeast in the oil secretion.
Eczema: The condition is caused by immune system disorder due to the over-reaction of an allergic nature. The condition is prevalent among children but it fades away as a child grows older. Eczema appears on the knees and elbows. Lab tests and physical examinations are necessary during the diagnosis process.
Psoriasis: The condition is a chronic inflammatory disease. The condition is associated with hereditary bias. The disease interferes with the normal growth of the epidermal cells (Harden, Krueger & Bowcock, 2015). It causes various abnormalities including vascular, immunologic, and biochemical. The condition can be diagnosed through physical examination and lab tests.
Diagnosis/Client Problems: Among the three conditions, eczema is not a possible condition since it appears in the knees and elbows (Watkins. 2016). Additionally, eczema the condition subsides as children grow old. The patient is 62-year old and thus eczema is ruled out as a possible condition. The second possibility is Seborrheic dermatitis has lesions that are erythematous and yellowish hue.it has large greasy scales that are easily detachable (Goman, 2018). Therefore, on the grounds of the different characteristics compared to what the patient is suffering from the condition is ruled out (Ball, Dains, Flynn, Solomon & Stewart, 2019). The remaining possible diagnosis is psoriasis which is evident due to abnormal epidermal growth. It presents whitish and pinkish plaques on the skin. Therefore, a possible condition the patient is suffering from is psoriasis.
Treatment Plan: The treatment plan involves Clobetasol ointment 0.05 percent. The medication is applied on the plaques. BID 14 days. The follow-up appointment is booked after two weeks. The condition of the patient after 14 days will determine the recommendations including drug dosage or referral. Additional lab tests and X-rays are required if the condition persists (Borda & Wikramanayake, 2015). The treatment plan is considerate of the age and health condition of the patient.
Health Promotion: The patient should eat healthy meals daily including fish, avocado, and walnuts that comprise healthy fats (Borda & Wikramanayake, 2015). It is necessary to drink sufficient water. The patient should maintain a high level of hygiene. It is necessary to avoid contact irritants. The family should also support the patient in living a healthy life. Family members should also be tested as a preventive measure. The health promotion strategies are important in maintaining a healthy family or society to prevent the condition from spreading or undermining public health in society.
Disease Prevention: The patient should avoid contact irritants and foods that may cause skin irritation. Water can also be a cause for skin diseases especially bathing with contaminated water or drinking it. The skin irritants also include chemicals or environmental changes that may affect the skin. Food components especially fats should be reviewed to keep the skin healthy (Harden, Krueger & Bowcock, 2015). It is necessary to get an immunization that will keep the skin protected from all the infections. The patient should also undergo further tests to identify the main cause in order to eliminate it completely.
REFLECTION: The experience of carrying out a comprehensive SOAP has enhanced my skills in providing healthcare to patients. The SOAP approach has taught me to always take a comprehensive approach while handling patients. Specifically, while carrying out a differential diagnosis a comprehensive approach is important to identify all factors before making the final decision. I have also learned that it is important to carefully assess the health condition of a patient through physical examination and lab tests. I have also realized that a wide knowledge of various health conditions helps in narrowing down to one with much ease.
In the future, I will ensure I carry out an intensive check and analysis of the medical background of a patient. The reason is that in many cases conditions such as skin disease could be associated with genetic composition in the family. I will also ensure I add more conditions while carrying out differential analysis to enhance the accuracy of the final conclusion. I will also ensure I consult from other practitioners who have a wide experience in the health conditions that I am reviewing. The consultation is necessary to reduce the possibility of medical misdiagnosis. I will also enhance my knowledge of differential analysis on how to differentiate two conditions that present almost similar conditions. I will acquire the knowledge by learning from my senior health practitioners, reading recommended books and specializing in specific areas of practice in healthcare provision. EFLECTION: The experience of conducting a comprehensive SOAP has improved my ability to provide healthcare to patients. The SOAP method taught me to always take a comprehensive approach when dealing with patients. In particular, when performing a differential diagnosis, a comprehensive approach is required to identify all factors before making a final decision. I’ve also learned that it’s critical to carefully assess a patient’s health status through physical examination and lab tests. I’ve also discovered that having a broad understanding of various health conditions makes it much easier to narrow down to one.
In the future, I will make certain that I conduct a thorough examination and analysis of a patient’s medical history. The reason for this is that in many cases, conditions such as skin disease may be linked to genetic makeup in the family. In order to improve the accuracy of the final conclusion, I will also add more conditions while performing differential analysis. I will also seek advice from other practitioners with extensive experience in the health conditions under consideration. The consultation is required to reduce the likelihood of medical misdiagnosis. I will also improve my knowledge of differential analysis in order to distinguish between two conditions that are nearly identical. I will learn from my senior health practitioners, read recommended books, and specialize in specific areas of practice in healthcare delivery.
I agree with my preceptor based on the evidence presented about the health condition of the patient. The analysis shows that the possible illness that the patient is suffering from is psoriasis. The other conditions have been ruled out on the grounds of a lack of similarity in the symptoms presented. Therefore, I agree with the conclusions and the input of the preceptor. I believe that in future such input is still necessary to help in enhancing patient satisfaction and boosting the patient outcomes.
References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.
Borda, L. J., & Wikramanayake, T. C. (2015). Seborrheic dermatitis and dandruff: a comprehensive review. Journal of Clinical and Investigative Dermatology, 3(2).
Goman, T. (2018). Scalp psoriasis: management and treatment. Journal of Community Nursing, 32(1).
Harden, J. L., Krueger, J. G., & Bowcock, A. M. (2015). The immunogenetics of psoriasis: a comprehensive review. Journal of Autoimmunity, 64, 66-73.
Sherrer, K., & Stott, B. (2016). Untapped potential remains in eczema, psoriasis management. Infectious Diseases in Children, 29(12), 1.
Watkins, J. (2016). Management of eczema and psoriasis in the community. British Journal of Community Nursing, 21(6), 274-279.
Note: Approximate length of this media program is 10 minutes.
Dermablade Use for Shave Biopsies
Dermablade®. (2012, November 9). PersonnaBlades [Video file]. Retrieved from https://www.youtube.com/watch?v=D8u1Y18L9DQ
