ASSESSMENTHISTORYBy 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?P.1095

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 TESTSLABORATORY TESTSSome 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. Direct visualization of scrapings mixed with mineral oil to detect scabies, mites, or lice nits that cling to hair. 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. 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. 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.