WHA Skin Assessment

cyanosis

light skin: bluish

dark skin: ashen gray

pallor paleness

light skin: loss of rosy glow

dark skin: ashen gray, yellowish brown

erythema redness

light skin: visible redness

dark skin: rely on palpation or warmth, edema

petechiae small pinpoint

light skin: purplish pinpoints

dark skin: usually invisible, check oral mucosa, conjunctiva, eyelids

malignant skin lesions

• basal cell carcinoma

• squamous cell carcinoma

• malignant melanomas

macules

solely a color change, flat & circumscribes, less than 1cm

patches

macules larger than 1cm

papule

felt & caused by superficial thickening of the epidermis

plaques

papules coalescing by superficial thickening of the epidermis

wheal

superficial, raised, transient, and erythematous; irregular in shape due to edema

urticaria (hives)

wheals coalesce to form extensive pruritic reaction

vesicles

elevated cavity containing fluid up to 1cm (blister)

bulla

larger than 1cm, usually single chamber, superficial in dermis & ruptures easily

cysts

encapsulated fluid dilled cavity

pustules

pus in cavity that is circumscribed & elevated

nodule

solid elevated, hard or soft, greater than 1cm, may extend deeper into dermis than papule

tumor

larger in diameter, firm or soft, deeper into dermis, benign or malignant

telangiectases

spider star or spider angioma, rosacea

crust

thickened dried out exudate

scale

compact flakes of desiccated skin from shedding dead excess keratin cells

fissures

linear crack w/ abrupt edges extending into dermis

erosions

scooped out but shallow depression

ulcers

deeper depression extending into dermis w/ irregular shape, may bleed, leaves scar

scar

permanent fibrotic change after healing

atrophic scares

resulting skin level is depressed w/ loss of tissue & thinning

lichenification

prolonged intense scratching leading to thickened skin producing tightly packed set of papules

keloids

benign excess of scar tissue beyond original injury

excoriations

self-inflicted abrasion that is superficial

hemangiomas

• port win stain (nevus flammeus)

• strawberry mark (immature)

• cavernous hemangioma (mature)

purpuric legions

petichae, ecchymosis, purpura

annular or circular

begins in center & spreads to periphery

confluent

lesions run together

discrete

distinct & separate

grouped

cluster of lesions

gyrate

twisted, coiled, or snakelike

target or iris

resembles iris of eyes, concentric rings

linear

scratch, streak, line, or stripe

polycyclic

annular lesions grow together

zosteriform

linear arrangement following a unilateral nerve route

stage 1 pressure ulcer

• intact skin w/ localized are of non-blanchable erythema

stage 2 pressure ulcer

• partial thickness loss of skin w/ exposed dermis

• adipose not visible

stage 3 pressure ulcer

• full thickness loss of skin

• adipose is visible

• granulation tissue and epibole (rolled wound edges) often present

stage 4 pressure ulcer

• full thicken skin & tissue loss w/ exposed fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer

• epibole, slough, and eschar often visible-

unstageable pressure ulcer

• full thickness skin & tissue loss to extent that damage cannot be confirmed due to slough or eschar obscuring it

Braden scale

predicts pressure sore risks from

• sensory perception

• moisture

• activity

• mobility

• nutrition

• friction & shear