Unit 1 Disorders of Integument System

Skin Assessment
A SKIN ASSESSMENT captures the patient’s
general physical condition, based on careful
inspection and palpation of the skin and
documentation of findings.
History Taking
 Obtain a history of the patient’s skin condition
from the patient, caregiver, or previous medical
records. Go over the detailed family history with
the patient or patient’s family, and make sure all
skin conditions are reviewed.
 Also obtain a history of the patient’s bathing
routine and skin care products.
 Document the soaps, shampoos, conditioners,
lotions, oils, and other topical products that the
patient uses routinely.
 Ask the patient: • about skin changes such as
xerosis (skin dryness), pruritus, wounds, rashes, or
changes in skin pigmentation or color • if skin
appearance changes with the seasons • about any
BY, Ms. Shristi Shrestha, Lecturer Page 1
 changes in nail thickness, splitting, discoloration,
breaking, and separation from the nail bed.
 A change in the patient’s nails may be a sign of a
systemic condition. • about allergies, including
those to medications, topical skin and wound
products, and food. Document findings in the
medical record.
Physical Assessment
This includes assessment of skin color, moisture,
temperature, texture, mobility and turgor, and skin
lesions.
Inspect and palpate the fingernails and toenails,
noting their color and shape and whether any lesions
are present.
Make use of the correct term to describe any lesions
that is find. The following are primary lesions:
 Macule: a flat, non-palpable circumscribed area
(up to 1 cm) of color change that’s brown, red,
white, or tan

BY, Ms. Shristi Shrestha, Lecturer Page 2

  Patch: a flat, non-palpable lesion with changes in
skin color, 1 cm or larger • papule, an elevated,
palpable, firm, circumscribed lesion up to 1 cm
 Plaque: an elevated, flat-topped, firm, rough,
superficial lesion 1 cm or larger, often formed by
coalescence of papules
 Nodule: an elevated, firm, circumscribed,
palpable area larger than 0.5 cm; it’s typically
deeper and firmer than a papule
 Cyst: a nodule filled with an expressible liquid or
semisolid material
 Vesicle: a palpable, elevated, circumscribed,
superficial, fluid filled blister up to 1 cm
 Bulla: a vesicle 1 cm or larger, filled with serous
fluid
 Pustule: which is elevated and superficial, similar
to a vesicle, but is filled with pus
 Wheal: a relatively transient, elevated, irregularly
shaped area of localized skin edema. Most wheals
are red, pale pink, or white.

BY, Ms. Shristi Shrestha, Lecturer Page 3

Secondary lesions can be caused by disease
progression, overtreatment, excessive scratching, or
infection of a primary lesion:
 Scale: a thin flake of dead exfoliated epidermis
 Crust: the dried residue of skin exudates such as
serum, pus, or blood
 Lichenification: visible and palpable thickening
of the epidermis and roughening of the skin with
increased visibility of the normal skin furrows
(often from chronic rubbing)
 Excoriation: linear or punctuate loss of
epidermis, usually due to scratching.
Diagnostic Procedures in Skin
Diagnostic tests are indicated when the cause of a skin
lesion or disease is not obvious from history and
physical examination alone. These include
1. Clinical Photographs: Clinical photography
is a fundamental component of visually oriented
medical fields. It is mainly used for;
 Documentation of condition
 Tracking patient progress
BY, Ms. Shristi Shrestha, Lecturer Page 4
  Evidence in case of future legal action

2. Dermatoscopy : Also named as dermoscopy

refers to the examination of the skin using skin
surface microscopy, and is also called
'epiluminoscopy' and 'epiluminescent microscopy'.
Derm(at)oscopy is mainly used to evaluate
pigmented skin lesions. In experienced hands it
can make it easier to diagnose melanoma.

3. Skin Swab: Usually done for swab culture of

purulent skin infection to detect infection or
colonization with antibiotic-resistant bacteria. For
cutaneous sampling, moisten swab with sterile
saline and roll e-swab along the area of skin to be
sampled.

4. Skin Scrapping: Skin scrapings help

diagnose fungal infections and scabies.
 For fungal infection, scale is taken from the
border of the lesion and placed onto a
microscope slide. KOH exam after skin
scrapping is a simple skin test to check if an
BY, Ms. Shristi Shrestha, Lecturer Page 5
 infection in the skin is caused by fungus. KOH
stands for potassium (K), oxygen (O), and
hydrogen (H). Then a drop of 10 to 20%
potassium hydroxide is added. Hyphae,
budding yeast, or both confirm the diagnosis
of tinea or candidiasis.
 For scabies, scrapings are taken from
suspected burrows and placed directly under a
coverslip with mineral oil; findings of mites,
feces, or eggs confirm the diagnosis. However,
a negative scraping does not rule out scabies.

5. Patch test: Patch testing is a process to detect

allergic contact dermatitis to something a person
has contacted at home, leisure or at work. Allergy
patch testing is used to screen substances to
determine the cause of an allergic skin reaction.
Patches with different suspected irritants
(allergens) are applied to a person’s back and left
in place for 48 hours. The skin is then examined
for signs of a hypersensitive reaction. The types of
allergens tested include hair dye, preservatives,
cosmetics and medications.
BY, Ms. Shristi Shrestha, Lecturer Page 6
 6. Skin Biopsy: There are several types of skin
biopsy:
 Punch: In a punch biopsy, a tubular punch
(diameter usually 4 mm) is inserted into deep
dermal or subcutaneous tissue to obtain a
specimen, which is snipped off at its base.
 Shave: Shaving with a scalpel or razor blade
may be done for more superficial lesions.
Bleeding is controlled by aluminum chloride
solution or electrodesiccation; large incisions
are closed by sutures.
 Excisional: Wedge or elliptical excision of
skin using a scalpel can be done for larger or
deeper biopsies. Pigmented lesions are often
excised for histologic evaluation of depth; if
too superficial, definitive diagnosis may be
impossible. Diagnosis and cure can often be
achieved simultaneously for most small
tumors by complete excision that includes a
small border of normal skin.

BY, Ms. Shristi Shrestha, Lecturer Page 7

 7. Wood light: A Wood light (black light) can
help clinicians diagnose and define the extent of
lesions (e.g., borders of pigmented lesions before
excision). It can help distinguish
hypopigmentation from depigmentation
(depigmentation of vitiligo fluoresces ivory-white
and hypopigmented lesions do not). Erythrasma
fluoresces a characteristic bright orange-red.
Tinea capitis caused by Microsporum canis and
M. audouinii fluoresces a light, bright green.
(Note: Most tinea capitis in the US is caused by
Trichophyton species, which do not fluoresce.)
The earliest clue to cutaneous Pseudomonas
infection (e.g., in burns) may be green
fluorescence.

8. Tzanck testing: Tzanck testing can be used to

diagnose viral disease, such as herpes simplex and
herpes zoster, and is done when active intact
vesicles are present. Tzanck testing cannot
distinguish between herpes simplex and herpes
zoster infections. An intact blister is the preferred
lesion for examination. The blister roof is
BY, Ms. Shristi Shrestha, Lecturer Page 8
 removed with a sharp blade, and the base of the
unroofed vesicle is scraped with a #15 scalpel
blade. The scrapings are transferred to a slide and
stained with Wright stain or Giemsa stain.
Multinucleated giant cells are a sign of herpes
infection.
Nursing Considerations in patients undergoing
diagnostic procedures
 Explain the ordered diagnostic procedure to the patient
and obtain consent if required. Obtaining informed
written consent from the patient before capturing
clinical images is best practice.
 Assist with the procedure
 After procedure apply appropriate dressing and advice
self-care.
 If sutures are used advice person to return for removal
of sutures.
 Document the procedure and send the labeled
specimen to concern laboratory.

BY, Ms. Shristi Shrestha, Lecturer Page 9