Tina Jones Nursing Progress Notes Skin, Hair, and Nails Completed Shadow Health Assessment

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Patient presented for assessment, gave consent for examination. Patient in good spirits and conversational throughout exam. PMH: diabetes, hypertension. Patient admitted for wound to R plantar foot. ... Upon inspection, serosangineous/ purulent drainage noted. Postive granulation noted, no necrotic tissue present, red peripherial tissue noted, edmea noted. Patient reports wound was healing slowly. Denies history of delayed healing of injuries or wounds Patient reports improvemnt of swelling, warmth, and discharge since admission to hospital. Denies any odor. Current pain level 5/10. Patient reports headache and blurred vision when reading or studing starting "a few months ago". Last eye exam "as a kid at the doctor" . Denies family hx of eye disease. Educated the importance of regular eye exams r/t diabetes. Denies current eye pain, itching, burning or discharge. No abnormalities noted. Patient reports acne since middle school, increased when she is due to menstrate. Seen provider in highschool was prescirbed tetracycline and prescibed topical cream in the past with no improvement. No further follow up for acne reported by patient. Currently uses facewash every night before bed with minimal improvement. Patient reports acne on her face and back. Reports face is oily, does not dry out from facewash. Patient reports an increase in body hair "all over" for "a really long time". Pt specifies increased hair on face, abdomen and nipples. Denies family history. Reports she noticed the skin in the folds of her neck have become darker over the past few month but in photos from "a few years ago" skin was darker. Reports skin on her neck "could be getting thicker" Denies pain or itching in this area. Discoloration noted upon examination. Mole noted on upper R shoulder, Patient denies any changes in moles. Reports "just regular moles". Patient reports dry skin on arms and legs, uses lotion with positive effect. Denies current or past history of eczema. Educated Diabetes can cause flakes or plaques to form on the front of your legs, to keep moisturized and not to scratch or pick the areas. Patient verbalized understanding. Patient denies any abnormal masses currently on body. None noted. Denies any recent rashes, itching, unusual brusing. Reports itching only occurs when she has prolonged exposure to cats.No other sores reported outside of R foot wound. Patient denies any personal of family history of skin cancer. Patient reports wearing sunscreen when in the sun. Educated Wearing sunscreen outside, even if it isn't sunny is an important way to decrease risk of skin cancer. Patient verbalized understanding. Patient did not have any questions at the conclusion of exam. Educated to follow up with nursing if any questions should arise. Patient verbalized understanding. [Show More]

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