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ASSESSMENT

HISTORY
By obtaining a history of rash or other complaints related to dermatologic conditions, you will
understand characteristics of the problem and their effects on the patient that will help in
planning care.
Characteristics of Rash

When did the rash first occur? Was the onset sudden or gradual?

What site was first affected? Describe the spread and its severity.

What was the initial color and configuration of the rash? Has it changed?

Is there associated itching, burning, tingling, pain, or numbness?

Has it been constant or intermittent?

Associated Factors

What makes the rash worse or better? Is it seasonal? Is it affected by stress?

What medications are being taken? What topical products have been used? What effect
did they have?

What skin products are used? What chemicals have come into contact with the skin, such
as laundry detergent, cleaning products, insecticides?

Has there been pet contact?

What is the patient's occupation? Any hobbies, such as gardening or hiking?

What is the sexual history and chance of sexually transmitted disease exposure?

Medical History

Is there a history of hay fever, asthma, hives, eczema, or allergies?

Has the patient had this particular rash or had other skin disorders in the past?

What is the family history of skin disorders?

Are there any long-standing medical problems?

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PHYSICAL EXAMINATION

Focus your examination on the skin, hair, and nails. Some dermatologic conditions affect
other body systems; so, perform a general physical exam as indicated.

Ask the patient to show you the area of concern and examine the skin surface under good
lighting. You may have to examine the entire skin if the condition is generalized.

Note the distribution and configuration of skin lesions. Compare right and left sides of
the body.

Note the shape, border, texture, and surface of the lesions.

Palpate the lesions for texture, warmth, and tenderness.

Use a metric ruler to determine size of lesions to serve as a baseline for comparison with
subsequent measurements.

Examine the scalp, nails, and oral mucosa.

Perform diascopygently press a glass slide or Lucite rule over a skin lesion to detect
blanching (caused by dilated blood vessels).

Use a Wood's light to inspect for fluorescent changes with some fungal infections.

For dark-skinned persons, look for black, purple, or gray lesions; palpate carefully to
determine if rash is present.

DIAGNOSTIC TESTS
LABORATORY TESTS
Some dermatologic conditions can be evaluated by laboratory tests of microscopy and culture.
Microscopy

Sample taken by scraping, swabbing, or aspirating a lesion is transferred to a glass slide


for observation or staining.
o Direct visualization of scrapings mixed with mineral oil to detect scabies, mites,
or lice nits that cling to hair.
o A Tzanck smear is obtained from vesicular fluid or a moist ulcer and stained to
detect characteristics of herpes simplex virus, herpes zoster, and varicella.

o Potassium hydroxide may be added to skin scrapings on a glass slide and heated
to dissolve skin cells to detect hyphae and spores in fungal infections.
o Gram stain may be performed to tentatively identify bacteria in certain skin
infections.
Nursing and Patient Care Considerations

Use the side of a glass slide or a scalpel held at a 45-degree angle to gently scrape the
skin of a dry lesion or of an inflamed area; only mild discomfort and pinpoint bleeding
should occur.

For moist or semimoist ulcerations or crusted lesions, roll a saline-soaked cotton or


Dacron-tipped swab over the lesion; for weeping lesions, use a dry swab.

For intact vesicles, aspirate fluid from the edge with a 25-gauge sterile needle; if vesicle
is partially broken, gently unroof with forceps and obtain fluid on a swab.

Culture

Drainage from lesions may be cultured on specific media to detect causative organism
and sensitivity to antimicrobial therapy; also, portions of skin, hair, and nails may be
submitted for fungal culture.

Usually takes 24 to 48 hours for results; fungal cultures may take 4 to 5 weeks.

Nursing and Patient Care Considerations

Obtain specimen with cotton or Dacron-tipped swab and send to laboratory in culturette
or viral culture container; refrigerate viral culture if laboratory pickup is delayed.

To obtain specimen for fungal culture, scrape or clip the affected skin, hair, or nails.