Skin

• Stage 1 Pressure Injury: Non-blanchable erythema of intact skin - intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin

  
• Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis - The wound bed is viable bed is not visible and deeper tissues are not visible

  
• Stage 3 Pressure Injury: Full thickness skin loss -adipose and granulation is visible; slough or eschar may be present but does not obscure the extent of damage to underlying structures

  
• Stage 4 Pressure Injury: Full thickness skin and tissue loss - directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough or eschar may be visible

  
• Unstageable Pressure injury: Obscured full-thickness skin and tissue loss - full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar

  
• Pustule - puss-filled vesicle or bulla
• Cyst - encapsulated fluid-filled or semisolid mass that is located in the subcutaneous tissue or dermis
• Erosion - loss of superficial epidermis that does not extend to the dermis. It is depressed, moist area
• Scar (cicatrix) - skin mark left after healing of wound or lesion that represents placement by connective tissue of the injured tissue
• Ulcer - skin loss extending past the epidermis, with necrotic tissue loss. Bleeding and scarring are possible

  
• Fissure - linear crack in the skin that may extend to the dermis and may be painful

  
• Petechia (Pl. Petechiae) - round red or purple macule that is 1 to 2 mm in size. It is secondary to blood extravasation and associated with bleeding tendencies or emboli to skin

  
• Spider angioma - red arteriole lesion with a central body with radiating branches. It is usually noted on the face, neck, arms and trunk.

  
• Ecchymosis - round or irregular muscular lesion that is larger than petechial lesion. Secondary to blood extravasation and associated with trauma and bleeding tendencies

  
• Hematoma - a localized collection of blood creating an elevated ecchymosis. It is associated with trauma.

  
• Telangiectasias (Venous star) - bluish or red lesion with varying shape (spider-like or linear) found on the legs and anterior chest. It does not blanch when pressure is applied. It is secondary to superficial dilation of venous vessels

  
• Cherry angioma - papular and round, red or purple lesion found on the trunk or extremities
• Basal Cell Carcinoma is the most common type of skin cancer and is usually found on the face, neck, and scalp

  
• Squamous cell carcinoma is less common but more aggressive compared to basal cell carcinoma. It can be found anywhere on the body.

  
• Melanoma - a type of skin cancer that is caused by the accumulation of melanin in the skin

  
• Linear configuration - straight line, as in scratch or streak

  
• Annular Configuration - Circular lesion. (Corporis)

  
• Clustered configuration - lesion grouped together. (Herpes simplex)

  
• Discrete configuration - individual and distinct lesions. (Multiple nevi)

  
• Nummular configuration - coin-shaped lesions. (Nummular eczema)

  
• Confluent Configuration - smaller lesion run together to form larger lesion. (Tinea versicolor)

  
• Changes in sensation or temperature may indicate vascular or neurologic problems such as peripheral neuropathy related to diabetes mellitus or arterial occlusive disease.
• Decreased sensation may put the client at risk for developing pressure injuries, impaired skin integrity, and skin infections.
• Pruritus may be seen with dry skin, aging, drug reactions, allergies, lice, tinea, insect bites, uremia, or obstructive jaundice.
• Paresthesia - Abnormal sensations of tingling, pricking, or burning
• Diabetic peripheral neuropathy - numbness or dulling of the sensations of pain, temperature, and touch to the feet
• Patchy hair loss (alopecia) - may accompany infections, stress, hairstyles that put stress on hair roots, and some types of chemotherapy.
• Bacterial infections cause green, black, or brown nail discoloration.
• Yellow, thick, crumbling nails are seen in fungal infections.
• Yeast infections cause a white color and separation of the nail plate from the nail bed
• Self-injury - associated with cutting, burning, scratching, piercing, carving, inserting objects under the skin, or hitting and pinching oneself, and is an unhealthy way to cope with emotional pain, intense anger, and frustration.
• Keloids - are more common in skin of color (African, African-American, Asian descent) and in persons with a family history
• Traumatic - caused by debris embedded in skin, as after a motorcycle accident
• Amateur - placed by nonprofessionals using India ink with a pin
• Professional - applied by a professional or skilled tattoo artist