Integumentary Assess

Assessment 5) Nodules – Elevated marble like lesion more than

Inspection for color variation:
1) Albinism – General loss of pigmentation
2) Vitiligo – White patches. Different melanin amount
in some areas
3) Erythema – skin redness and warmth
Wound Measurement – Circumference for circular
wounds.
Bedsore Stage 1: Non-blanche redness
Bedsore Stage 2: Shallow pinkish red basin
Bedsore Stage 3: Slough
Bedsore Stage 4: Eschar
1cm wide and deep.
6) Cysts – Nodules that are liquid or semi-solid filles.
E.g sebaceous cysts.
7) vesicles – Circumscribed elevation of skin
containing fluid <0.5 cm diameter. E.g. Acute
dermatitis
8) Bullae – Large vesicle that is >0.5 cm in diameter.
E.g. 2nd degree burns.
9) Pustules – Vesicle filled with cloudy or purulent
fluid. E.g. acne or acute impetigo

Braded Scale Interpretation:

o Very High: 6-10
o High: 11-15 points
o Medium: 16-19 points
o Low; 20-23 points

Skin Lesions:
1) Macules – Flat lesions <1cm diameter. E.g.
Freckles
2) Patches – Flat > 1cm in diameter. E.g. Café Au
Lait
3) Papules – Small firm elevated lesion <1cm in
diameter. E.g. Warts
4) Plaques – Elevated more that 1cm in diameter
e.g. psoriasis