Skin, Hair and Nails Assessment-Subjective
When completed a skin, hair, and nail assessment, it is important to ask about changes, history, family
history, skin care, skin conditions, medications, etc. Please review the following assessment questions
and responses from a female, Diabetic patient in her 20s. She was admitted with a foot wound which is
infected and healing slowly.
Tip 1: A combination of open and closed questions will yield better patient data. The following details
are facts of the patient's case.
Relevant Medical History
Finding: Asked about foot wound
Finding:Reports swelling has improved(Found)Pro Tip: Specific questions about Tina's wound can help
you to assess the care that she will need. Asking Tina if her wound has any swelling specifies the
symptoms she is experiencing.Example Question:Does your wound have any swelling?
Finding:Reports wound warmth has improved(Available)Pro Tip: Specific questions about Tina's wound
can help you to assess the care that she will need. Asking Tina if her wound is warm to the touch
specifies the symptoms she is experiencing.Example Question:Does your wound feel warm to the touch?
Finding:Reports wound discharge has improved(Found)Pro Tip: Specific questions about Tina's wound
can help you to assess the care that she will need. Asking Tina if there is any discharge coming from her
wound specifies the symptoms she is experiencing.Example Question:Is discharge coming from your
wound?
Finding:Reports wound is still a little red(Found)Pro Tip: Specific questions about Tina's wound can help
you to assess the care that she will need. Asking Tina if her wound has any redness specifies the
symptoms she is experiencing.Example Question:Does your wound have any redness?
Finding:Asked history of slow healing wounds
Finding:Denies history of slow healing wounds(Found)Pro Tip: Specific questions about Tina's wounds
can help you to assess the care that she will need. Asking Tina if she has a history of slow healing
wounds specifies the symptoms she is experiencing.Example Question:Do you have a history of slow
healing wounds?
Finding:Asked current wound healing time
, Finding:Reports wound had been getting worse over the past week(Available)Pro Tip: Specific questions
about Tina's wound can help you to assess the care that she will need. Asking Tina how her foot wound
has been healing specifies the symptoms she is experiencing.Example Question:How has your foot
wound been healing?
Finding:Reports wound has improved with hospital treatment(Found)Pro Tip: Specific questions about
Tina's wound can help you to assess the care that she will need. Asking Tina if the hospital treatment has
improved her foot wound will clarify the symptoms she is experiencing.Example Question:Has being in
the hospital helped your wound?
Finding:Asked about history of skin conditions
Finding:Reports acne(Found)Pro Tip: Soliciting a relevant medical history will help you to more
effectively treat your patient. Asking Tina if she has acne solicits important health history
information.Example Question:Have you ever had acne?
Finding:Reports dry skin(Found)Pro Tip: Soliciting a relevant medical history will help you to more
effectively treat your patient. Asking Tina if her skin has been dry solicits important health history
information.Example Question:Have you ever had dry skin?
Finding:Denies skin cancer(Found)Pro Tip: Soliciting a relevant medical history will help you to more
effectively treat your patient. Asking Tina if she has ever been diagnosed with skin cancer solicits
important health history information.Example Question:Have you ever been diagnosed with skin
cancer?
Finding:Denies skin rashes(Found)Pro Tip: Soliciting a relevant medical history will help you to more
effectively treat your patient. Asking Tina if she has had skin rashes solicits important health history
information.Example Question:Have you had skin rashes?
Finding:Denies sores other than foot wound(Found)Pro Tip: Soliciting a relevant medical history will
help you to more effectively treat your patient. Asking Tina if she has sores solicits important health
history information.Example Question:Do you have sores?
Finding:Reports skin has only itched due to cat exposure(Found)Pro Tip: Soliciting a relevant medical
history will help you to more effectively treat your patient. Asking Tina if her skin has been itching
solicits important health history information.Example Question:Has your skin been itching?
Finding:Denies bruising(Found)Pro Tip: Soliciting a relevant medical history will help you to more
effectively treat your patient. Asking Tina if her skin has been bruising solicits important health history
information.Example Question:Have you noticed unusual bruising?
Finding:Followed up on skin dryness
Finding:Reports arms and legs get dry(Found)Pro Tip: Establishing information about any skin condition
Tina experiences will help you to most effectively treat her symptoms. Asking Tina if her skin gets dry
When completed a skin, hair, and nail assessment, it is important to ask about changes, history, family
history, skin care, skin conditions, medications, etc. Please review the following assessment questions
and responses from a female, Diabetic patient in her 20s. She was admitted with a foot wound which is
infected and healing slowly.
Tip 1: A combination of open and closed questions will yield better patient data. The following details
are facts of the patient's case.
Relevant Medical History
Finding: Asked about foot wound
Finding:Reports swelling has improved(Found)Pro Tip: Specific questions about Tina's wound can help
you to assess the care that she will need. Asking Tina if her wound has any swelling specifies the
symptoms she is experiencing.Example Question:Does your wound have any swelling?
Finding:Reports wound warmth has improved(Available)Pro Tip: Specific questions about Tina's wound
can help you to assess the care that she will need. Asking Tina if her wound is warm to the touch
specifies the symptoms she is experiencing.Example Question:Does your wound feel warm to the touch?
Finding:Reports wound discharge has improved(Found)Pro Tip: Specific questions about Tina's wound
can help you to assess the care that she will need. Asking Tina if there is any discharge coming from her
wound specifies the symptoms she is experiencing.Example Question:Is discharge coming from your
wound?
Finding:Reports wound is still a little red(Found)Pro Tip: Specific questions about Tina's wound can help
you to assess the care that she will need. Asking Tina if her wound has any redness specifies the
symptoms she is experiencing.Example Question:Does your wound have any redness?
Finding:Asked history of slow healing wounds
Finding:Denies history of slow healing wounds(Found)Pro Tip: Specific questions about Tina's wounds
can help you to assess the care that she will need. Asking Tina if she has a history of slow healing
wounds specifies the symptoms she is experiencing.Example Question:Do you have a history of slow
healing wounds?
Finding:Asked current wound healing time
, Finding:Reports wound had been getting worse over the past week(Available)Pro Tip: Specific questions
about Tina's wound can help you to assess the care that she will need. Asking Tina how her foot wound
has been healing specifies the symptoms she is experiencing.Example Question:How has your foot
wound been healing?
Finding:Reports wound has improved with hospital treatment(Found)Pro Tip: Specific questions about
Tina's wound can help you to assess the care that she will need. Asking Tina if the hospital treatment has
improved her foot wound will clarify the symptoms she is experiencing.Example Question:Has being in
the hospital helped your wound?
Finding:Asked about history of skin conditions
Finding:Reports acne(Found)Pro Tip: Soliciting a relevant medical history will help you to more
effectively treat your patient. Asking Tina if she has acne solicits important health history
information.Example Question:Have you ever had acne?
Finding:Reports dry skin(Found)Pro Tip: Soliciting a relevant medical history will help you to more
effectively treat your patient. Asking Tina if her skin has been dry solicits important health history
information.Example Question:Have you ever had dry skin?
Finding:Denies skin cancer(Found)Pro Tip: Soliciting a relevant medical history will help you to more
effectively treat your patient. Asking Tina if she has ever been diagnosed with skin cancer solicits
important health history information.Example Question:Have you ever been diagnosed with skin
cancer?
Finding:Denies skin rashes(Found)Pro Tip: Soliciting a relevant medical history will help you to more
effectively treat your patient. Asking Tina if she has had skin rashes solicits important health history
information.Example Question:Have you had skin rashes?
Finding:Denies sores other than foot wound(Found)Pro Tip: Soliciting a relevant medical history will
help you to more effectively treat your patient. Asking Tina if she has sores solicits important health
history information.Example Question:Do you have sores?
Finding:Reports skin has only itched due to cat exposure(Found)Pro Tip: Soliciting a relevant medical
history will help you to more effectively treat your patient. Asking Tina if her skin has been itching
solicits important health history information.Example Question:Has your skin been itching?
Finding:Denies bruising(Found)Pro Tip: Soliciting a relevant medical history will help you to more
effectively treat your patient. Asking Tina if her skin has been bruising solicits important health history
information.Example Question:Have you noticed unusual bruising?
Finding:Followed up on skin dryness
Finding:Reports arms and legs get dry(Found)Pro Tip: Establishing information about any skin condition
Tina experiences will help you to most effectively treat her symptoms. Asking Tina if her skin gets dry
