Clinical Communicator

November 2016

Skin Assessment

The skin is the largest organ in the body. Careful assessment of it can reveal underlying health conditions that would warrant referral and treatment. Skin that is healthy and intact is the body’s first line of defense against infection. It protects underlying tissue and organs from trauma, maintains hydration, helps to regulate body temperature, has sensory abilities, and promotes wound healing.

When assessing skin, you will use both inspection and palpation techniques. Some tools you find useful to perform a thorough assessment are a ruler, tongue blade, penlight, and magnifying glass. Observe the skin’s overall appearance. Do you note anything that needs closer assessment? When inspecting and palpating, focus on color, texture, turgor, moisture, and temperature.

  • Color- is there bruising, pallor, erythema, cyanosis?
  • Texture- is the skin rough or dry?
  • Turgor- poor turgor from edema or dehydration (skin takes more than 30 seconds to return to normal)
  • Moisture- should not be excessively diaphoretic or overly dry
  • Temperature- palpate bilaterally and compare; use dorsal surface of hands and fingers; is there generalized or localized heat or coolness?


Lesions may be seen on inspection. These can be normal variations in texture or pigmentation (birthmarks, freckles) or abnormal, signaling a potential problem. Primary lesions are the beginning lesions of most skin problems. Secondary lesions arise from primary ones. When assessing a lesion, note the characteristics. Is it solid or fluid-filled? Is there drainage? Describe the pattern, location, distribution, border, color, and size.


Common Primary Lesions

Macule- flat, circumscribed area of altered skin color, generally less than 1cm; examples- freckle, flat nevus

Papule- raised, circumscribed, solid area; generally less than 1cm; examples- elevated nevus, wart

Vesicle- elevated, circumscribed; contains serous fluid; less than 1cm; example- early varicella

Nodule- hard of soft, solid elevated area; greater than 1cm; examples- hard cyst or keloid

Pustule- elevated, circumscribed; contains pus

Patch- macule that is greater than 1cm; examples- Mongolian or café au lait spots


Common Secondary Lesions

Scales- compact, dry flakes of skin; example- psoriasis

Crust- thickened, dry exudate left when vesicle or pustule bursts and dries up; example- impetigo

Ulcer- deep depression extending into dermis, irregular shape; example- pressure sore


Vascular Skin Lesions

Purpura- non-blanching purple spots caused by bleeding from small vessels

Petechiae- purpura less than 3mm in diameter

Ecchymosis- purpura greater than 1cm

Hematoma- collection of blood outside the vessel

Hemangioma- papule made up of blood vessels

Rashes

The sight of a rash can cause alarm in students, parents, and teachers. What is it? Is it contagious? At the same time, it may be difficult for the school nurse to identify what may be causing the rash. When assessing skin rashes, it’s also important to assess for other symptoms and get a detailed history about the rash as possible.


Non-contagious rashes:

  • Urticaria—hives; 1-8cm red, raised plaques with sharp borders; can occur anywhere on body—allergic reaction; also assess for respiratory symptoms and angioedema; remove causative agent (if known) and treat symptoms
  • Contact dermatitis- irritant or allergic reaction to a substance; itching, edema, erythema, weeping/oozing seen on parts of the skin that come into direct contact with irritant
  • Atopic dermatitis—eczema; erythema, edema, vesicles, and weeping/oozing; lichenification and hypo/hyper pigmentation seen in chronic eczema; seen in creases and warm, moist areas of body; can develop secondary infection; treat with cool compresses, emollient, and/or steroid cream


Contagious rashes:

  • Molluscum Contagiosum- starts as 1-2mm shiny papules, dome-shaped, firm; may increase to 5mm nodule; spread by skin-to-skin contact
  • Impetigo- strep or staph infection; primary macule, papule or plaque becomes a secondary lesion with crust or scaling; lesion ruptures and serum dries to honey-colored crust; spread by close physical contact
  • Ringworm- annular, scaly, erythematous plaque; spreads to other parts of body, and to others by contact; cover rash while at school

  • Scabies- macules, papules, and linear erythematous lesions (classic burrow lesion is linear, curved, or S-shaped); intense itching, worse at night; spread by close body contact


Contagious illnesses with rash:

  • Chickenpox
  • Measles, rubella
  • Fifth disease
  • Coxsackie virus
  • Meningococcal meningitis


The great outdoors:

  • Tick-transmitted diseases
    • Lyme disease- “bulls-eye” lesion
    • Rocky Mountain Spotted Fever- discrete, macular rash on wrists, ankles, palms, soles of feet
  • Poison ivy/oak/sumac- delayed reaction to sap-like material of the plants; linear or nonlinear papulo- vesicular lesions, intense itching; vesicles drain serous fluid (fluid from lesion is not contagious); washing after contact with plant is key
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PISD Exclusion Guidelines Pertaining to Rashes and Lesions

  • Undetermined rash over any part of the body
  • Undiagnosed scaly patches on body or scalp
  • Intense itching with signs/symptoms of secondary infection
  • Open, draining lesions

Abrasions & Lacerations

Injury to the skin can range from a minor scratch to a severe wound needing immediate intervention. Here, assessment is all about inspecting the wound. With more severe wounds, be sure to include a neurovascular assessment distal to the injury. Determine the proper triage category:

  • Non-urgent- superficial abrasion or wound; small splinter or foreign body
    • Clean wound using aseptic technique, bandage; remove protruding splinter; contact parent based on need
  • Urgent- contaminated wound that needs thorough cleaning; facial laceration; puncture wound to foot; wound requires sutures (deep, more than 1” in length, over joint); bleeding can be controlled
    • Control bleeding with direct pressure; cover/protect wound; apply butterfly bandage to wound needing sutures; observe student; contact parent
  • Emergent- significant blood loss; crush injury; amputation; penetrating wound; absent distal pulse; slow capillary refill; altered LOC; respiratory distress
    • EMS; support ABCs; control bleeding; elevate/immobilize extremity; RN observe student; contact parent

Bites & Stings

When assessing a student or adult who complains of being bitten or stung, there are key things to note:

  • Time the bite/sting occurred
  • Location of bite/sting on body (face, hands, feet may be more serious)
  • Type of bite/sting
  • Number of bites/stings
  • Intensity of pain
  • Previous exposure/allergic reaction to same type of bite/sting
  • Wound characteristics (redness, swelling, drainage, bruising, size)
  • Inspection for foreign body (stinger, tooth, tick)


Human Bite

With human bites, there is an increased risk of infection due to the high amount of oral bacteria. You would expect to see redness, some swelling, and possible bruising. Clean the area thoroughly, apply bandage if needed, and apply ice. Refer if there is new redness days after the bite, fever, drainage, or streaking. Be sure to check the immunization status of both the biter and the person who was bitten.

Animal Bite

When bitten by a pet or a wild animal, the concerns are infection, exposure to rabies, and venom. If the bite is minor, flush the area, bandage, and apply ice. For deep punctures, apply pressure and refer for treatment. If rabies exposure is suspected, contact local animal control and refer the victim to the ER. For snake bites, it is crucial to know the type of snake bit. Refer the victim to the ER for possible treatment with antivenom. Monitor for infection after the bite.

Insect & Arachnid Bites/Stings

The average person can safely tolerate 10 stings/lb. of body weight. The main concern with insect bites and stings is anaphylaxis. Be prepared to treat undiagnosed anaphylaxis. For bee stings, inspect the area for the stinger and remove it carefully (scrape with stiff cardboard or credit card--do not squeeze). Localized pain and itching, redness, and a small wheal are expected reactions. Ice can be applied for comfort. If you are assessing a tick bite, and the tick is still attached, remove it by carefully grasping it with fine-point tweezers close to the skin and pulling firmly. Wash the area with soap and water. Bites from arachnids with neurotoxic venom (brown recluse, black widow, some scorpions) will lead to severe systemic reactions. Refer immediately.


Assess the area and any other signs and symptoms and determine the appropriate triage category:

  • Non-urgent- mild localized allergic reaction without systemic/respiratory symptoms; mild pain; mild pruritus; stinger or tick present
    • Clean bite area with soap and water; remove stinger/tick; observe for 20 minutes; contact parent based on need; will likely return to class
  • Urgent- symptoms of mild systemic reaction with wheezing, progressive pain/edema, normal vital signs; deep puncture wound; moderate pain; laceration requiring sutures; nausea/vomiting; human bite with broken skin
    • Clean bite area with soap and water, irrigate as indicated; observe closely; report animal bite to local authority; contact PCC if suspect venomous bite; contact parent to transport for medical care
  • Emergent- symptoms of anaphylaxis or history of anaphylactic reaction; symptoms of respiratory distress; hypotension; cardiac arrest; loss of consciousness; known exposure to toxin; severe pain
    • EMS; support ABCs; perform CPR as indicated; administer IM epinephrine; RN continuously monitor student/adult; contact parent; notify administrator

Test Yourself

1. What are some of the key assessment points when assessing an insect bite?

a. Time it occurred

b. Location of the bite

c. Number of bites

d. All of the above


2. A student comes to the clinic after a bee sting. You note the stinger is still in his right arm, localized erythema, and mild pain. What triage category would you classify this as?

a. Non-urgent

b. Urgent

c. Emergent


3. After you have scraped the stinger off with a credit card, cleaned with soap and water, and applied an ice pack, the student starts to wheeze and you note the redness has spread. What triage category would you classify this as?

a. Non-urgent

b. Urgent

c. Emergent


4. Bites on fingers and face are considered more dangerous.

a. True

b. False


5. A 6th grade student comes into the clinic complaining of having stepped on a nail while running outside. What kind of wound is this?

a. Laceration

b. Abrasion

c. Puncture

d. Avulsion


6. The nail is lodged deep into the foot. Pulses are present distally. Moderate amount of bleeding is present, but controllable. What triage category would you classify this as?

a. Non-urgent

b. Urgent

c. Emergent


7. Three days later, the same student returns to the clinic complaining of pain to the bottom of the injured foot. What signs and symptoms would indicate a possible wound infection?

a. Swelling and erythema

b. Tenderness

c. Area warm to touch

d. All of the above


8. A student comes to the clinic with a splinter which is not protruding. What interventions are appropriate for you to take?

a. Remove the splinter

b. Clean the wound area using aseptic technique

c. Bandage the area

d. B and C

e. All of the above


9. The configuration for individual skin lesions that are arranged in circles is:

a. Annular

b. Linear

c. Clustered

d. Grouped


10. You note a number of small, firm, round, raised lesions on a student’s arm. You would document these findings as:

a. Macules

b. Pustules

c. Papules

d. Plaques




Answers: 1. d; 2. a; 3. b; 4. a; 5. c; 6. b; 7. d; 8. d; 9. a; 10. c