Nursing care
Basal and Squamous Cell Carcinoma nursing care: what to assess and what to do first
Written and reviewed by Dana Whitfield, RN, MSN · 6 min read · Updated September 2026
Short answer
A pearly papule that bleeds and does not heal is basal cell carcinoma, the commonest cancer there is and one that almost never kills. A scaly, crusted plaque on sun-exposed skin that grows and ulcerates is more likely squamous cell, which can spread to nodes and beyond. Both are diagnosed by biopsy, not by appearance alone.
Recognising it at the bedside
Basal cell carcinoma usually starts as a small, pearly or waxy papule, often with visible fine blood vessels across its surface. It grows slowly over months. A patient may report a spot that bled after shaving or scratching and then scabbed over rather than healing properly. Sun-exposed skin is the usual site: the nose, the ear, the upper lip, the back of the neck.
Squamous cell carcinoma tends to look rougher: a firm, scaly, red or pink plaque, sometimes with a central crust or ulcer and raised, indurated edges. It can arise on sun-damaged skin, in a chronic wound or scar, or on the lip in a smoker. Growth is faster than basal cell, and the lesion is more likely to feel tender. Ask about duration, change in size or colour, bleeding, and any new numbness at the site, which can signal perineural spread.
Why the classic presentation misleads
Students are taught to picture a textbook pearly nodule, but real lesions are often mixed in appearance, pigmented, or partly healed from repeated picking. A basal cell lesion on darker skin can look brown or black and be mistaken for a benign mole. A squamous lesion on a lower leg wound can be dismissed as a stubborn ulcer that simply will not close, delaying biopsy for months.
The label 'skin cancer' also invites false reassurance. Basal cell carcinoma almost never metastasises, so patients and even some staff can underestimate squamous cell, which does have real metastatic potential, particularly on the lip, ear, or in an immunosuppressed patient. Nursing assessment has to separate the two by feature and history, not by treating every scaly patch as low risk. Any lesion that has changed, bled without an obvious cause, or failed to heal within four weeks needs a dermatology referral, not a watch-and-wait plan.
Priority nursing actions
First, get an accurate description and photograph, with a ruler in shot if your facility allows it, so change over time can be measured rather than recalled. Document size, colour, border, surface texture and exact anatomical location. Ask directly about pain, bleeding, and how long the lesion has been present.
Facilitate biopsy referral promptly rather than deferring to a routine follow-up slot, since diagnosis rests on histology, not inspection. Assess regional lymph nodes, particularly for suspected squamous lesions on the lip, ear, or scalp, since these sites carry higher metastatic risk. Screen for risk factors: cumulative sun exposure, tanning bed use, immunosuppression, prior radiotherapy, and organ transplant history, all of which raise squamous cell risk specifically. If the lesion is on the face, prepare the patient for the likely referral to Mohs surgery or plastics, and address the emotional impact of a facial excision before it becomes a surprise on the day.
Labs and diagnostics to expect
Shave, punch, or excisional biopsy confirms the diagnosis and subtype; this is the definitive test, and no blood panel replaces it. Pathology will report tumour thickness and margin status for squamous lesions, both of which drive the decision on wider excision or adjuvant treatment.
For suspected squamous cell carcinoma with palpable nodes or high-risk features, expect imaging such as CT or ultrasound of the regional nodal basin and possibly a sentinel node biopsy. Immunosuppressed patients, including transplant recipients on long-term immunosuppression, are assessed more aggressively because their squamous cell carcinomas behave more like high-risk tumours even when they look unremarkable. There is no routine tumour marker blood test for either cancer, so do not expect one.
Complications and their early signs
Local tissue destruction is the main risk with untreated basal cell carcinoma: it can erode into cartilage or bone around the nose or ear over years if ignored, causing disfigurement rather than death. Watch for a lesion that has become fixed to underlying structures or that has ulcerated deeply.
Squamous cell carcinoma carries the added risk of regional and distant metastasis, most often to lymph nodes, then lung. New, painless neck or preauricular swelling in a patient with a known lip or ear lesion is a red flag and warrants urgent review. Perineural invasion presents as new numbness, tingling, or weakness near the tumour site and should prompt escalation, since it changes both prognosis and treatment planning.
Teaching that changes outcomes
Teach daily sun protection as the single most modifiable factor: broad-spectrum SPF 30 or higher, reapplied every two hours outdoors, protective clothing, and avoidance of peak UV hours. This matters as much for prevention of new lesions as for treatment of the current one, since both cancer types are strongly linked to cumulative UV exposure.
Give the patient a simple self-check routine: look monthly for any sore that bleeds and does not heal within four weeks, any new pearly bump, or any scaly patch that grows or changes colour. Explain that a healed-looking scab that keeps reopening on the same spot is the sign to report, not reassurance that it is resolving. For those who have had one skin cancer, stress that annual full-body skin checks are lifelong, since risk of a second lesion is significantly higher, and set the expectation before discharge rather than leaving it for the next visit to raise.
The next step on this is the same as on everything else here: answer questions and read the rationales. Our med-surg practice questions are the closest set to what this page covers.
One question from the med-surg set
A client with chronic obstructive pulmonary disease has an oxygen saturation of 88% on 2 L/min via nasal cannula and is alert with no distress. What should the nurse do first?
Rationale
In COPD a saturation of 88–92% is the therapeutic target, not an emergency, and this client is alert with no distress. The first action is the independent nursing intervention that is least invasive and most likely to help: sit them up and reassess. Turning the oxygen up to 6 L/min risks blunting the hypoxic drive, and calling rapid response or drawing an ABG escalates ahead of an assessment you have not finished.
Answer: B
Common questions
Can basal cell carcinoma spread like squamous cell can?
Basal cell carcinoma very rarely metastasises; it grows locally and can damage nearby tissue if left untreated, but distant spread is exceptionally uncommon. Squamous cell carcinoma has a meaningfully higher metastatic potential, especially on the lip, ear, or in an immunosuppressed patient. This difference is why staging and follow-up intensity differ between the two.
What is the priority nursing diagnosis for a patient with suspected skin cancer?
Disturbed body image and deficient knowledge are common early priorities, alongside risk for infection once a lesion is excised. If nodes are palpable or the lesion shows signs of perineural invasion, risk for ineffective tissue perfusion related to potential metastasis moves up the list. Always individualise to the assessment findings rather than applying a fixed list.
How is basal or squamous cell carcinoma typically treated?
Surgical excision, including Mohs micrographic surgery for facial or high-risk sites, is the mainstay for both. Options for select superficial lesions include curettage and electrodesiccation, topical chemotherapy, or radiotherapy, chosen based on size, location, and patient fitness for surgery. Advanced or metastatic squamous cell carcinoma may need systemic therapy, including immunotherapy.
What NCLEX-style scenario commonly appears for this topic?
Expect a case describing a non-healing, bleeding facial lesion in an older adult with a long sun exposure history, asking you to identify the priority action, which is nearly always to facilitate biopsy referral rather than reassure or treat symptomatically. Distractor options often include treating the lesion as a simple skin tear or minor infection.
Who is at highest risk and does skin tone change that risk?
Fair skin, high cumulative UV exposure, older age, immunosuppression, and a personal or family history of skin cancer all raise risk substantially. People with darker skin tones can still develop both cancers, often on less sun-exposed areas such as the soles, palms, or under nails, and diagnosis is frequently delayed because clinicians underestimate the risk in this group.
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