Wound Care

Skin Assessment and Documentation 337
• General assessment questions
— Always ask about changes in moles, birthmarks, or other
body spots.
— Assess for color changes, irregular growth, pain, scaling,
or bleeding.
— Are there any red, scaly, or crusted areas of the skin that
do not heal?
— Ask if the patient has ever had skin cancer?
— Ask about the location of the cancer and treatment?
— Any recent growth of a flat, pigmented lesion is relevant
information.
PHYSICAL EXAMINATION
When arranging the visit by telephone, request that the patient
wear loose clothing that is easy to remove. For the examination
have the patient seated in a comfortable position and
wearing loose clothing. Be certain there is a good light source.
This may be the closest window during daylight hours with
window treatments open. Tangential lighting will assist with
assessing contour (e.g., from a flashlight). Generally, the skin
is inspected during the assessment of other body systems;
however, be certain that the skin assessment and evaluation
are thorough.
• Inspect
— All areas not usually exposed such as axillae, buttocks,
perineum, backs of thighs, inner upper thighs, feet, and
intertriginous surfaces.
— In the individual with a darker complexion the best areas
to determine actual color are sclera, conjunctiva, buccal
mucosa, tongue, lips, nail beds, and palms.
— Normal variation may include opaque yellow color in
heavily calloused palms or soles, lighter palms and soles,
hyperpigmented macules on soles, and freckling in the
buccal cavity, gums, and tongue.