Assessing the Integumentary System 8/19/2015 1 Mrs. Mahdia Samaha Kony

Assessing the IntegumentarySystem

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Mrs. Mahdia Samaha Kony

Composition of the integumentary system•Skin•Hair•Nails•Is the largest organ of the body and the

easiest of all systems to assess

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Anatomy and Physiology Review

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Epidermis■ Covers, protects, and waterproofs.■ Contains four main layers: • Stratum corneum: Keratinized layer. Prevents

loss or entry of water; protects against pathogens and chemicals.

• Stratum lucidum: Found only on palms of hands and soles of feet; protects against UV sunrays to prevent sunburn.

1.Stratum granulosum2.Stratum germinativum. The innermost layer of

epidermis, is the only layer that undergoes cell division & contains melanin & keratin-forming cells.

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Epidermis• The epidermis, hair, nail, dental enamel, & horny tissues

are composed of keratin. • It is replaced every 3-4 weeks.• Skin colorSkin color depends on:1.The amount of melaninamount of melanin & carotene" yellow pigmentcarotene" yellow pigment"

contained in the skin 2.2.The volume of bloodThe volume of blood containing hemoglobin3.The oxygen-binding pigment that circulates in the dermis.

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Dermis■ Contains collagen, reticular, and elastic fibers.■ Adds strength and elasticity to skin. Contains

papillary layer, reticular layer, sweat glands, sebaceous glands, cholesterol, and arterioles.

Papillary Layer: Contains capillaries that supply the stratum germinativum; also contains nerve endings, touch receptors, and fingerprint pattern; double layer on hands and feet.

Reticular Layer: Contains connective tissue with collagen and elastic fibers, blood and lymphatic vessels, nerves, free nerve endings, fat cells, sebaceous glands and hair roots, deep pressure receptors, and smooth muscle fibers.

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DermisSweat Glands (Sudoriferous):Most numerous on

palms of hands and soles of feet. Two types are eccrine and apocrine glands.

Eccrine Glands: Respond to external temperature and psychological stress.

Found over most of body but most numerous on palms of hands and soles of feet; secrete sweat, which helps regulate body temperature and, to a lesser degree, excretes wastes such as urea.

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Dermis•Apocrine or Odoriferous Glands:■ Found in axilla and genital area.■ Respond to stress; secrete pheromones, a

substance with a barely perceptible odor; when apocrine secretions react with bacteria, body odor results.

■ Ceruminous glands are a type of apocrine gland found in the external ear canal.

•They secrete cerumen, which prevents drying of the ear drum and traps foreign substances.

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•Sebaceous Glands: Produce sebum, which lubricates and protects skin and hair.

•Cholesterol: Converts to vitamin D when exposed to UV lights.

•Arterioles: Dilate when hot to increase heat loss and constrict when cold to conserve heat.

•Constrict in response to stressful situations to shunt blood to vital organs.

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Hypodermis/Subcutaneous

•Connective Tissue: Connects skin to muscles; contains white blood cells.

•Adipose Tissue: Contains stored energy, cushions bony prominences, provides insulation.

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The HairThe hair is also made up of keratinized

cells.1. Vellus, which is short, pale,and fine hair, is

located over all of the body. 2. Terminal hairs, which are dark and

coarse, are found on the scalp, brows, and, after puberty, on the legs, axillae, and perineum.

• Hair provides protection by covering thescalp and filtering dust and debris away from the nose, ears, and eyes.

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The Nails• Nails are made up of hard, keratinized

cells and grow from a nail root under the cuticle.

• The nail bed, or epithelial layer of skin: vascular supply gives the nail a pink color

• The lunula, the proximal part of the nail. The nailbed’s .

• The purpose of the nails is to protect the distal portions of the digits and aid in picking up objects

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Relationship of the Integumentary System to Other Systems•ENDOCRINE•Thyroid affects growth and texture of

skin, hair and nails.•Hormones stimulate sebaceous glands.•Sex hormones affect hair growth and

distribution, fat and subcutaneous tissue distribution and activity of apocrine sweat glands.

•Adrenal hormones affect dermal blood supply and mobilize lipids from adipocytes.

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Relationship of the Integumentary System to Other Systems•URINARY•Kidneys remove waste and maintain

normal pH.•Skin helps eliminate water and waste.•Skin prevents excess fluid loss.•DIGESTIVE•Skin synthesizes vitamin D for calcium

and phosphorous absorption.•Supplies nutrients while skin stores lipids.

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Relationship of the Integumentary System to Other Systems• CARDIOVASCULAR• Mast cell stimulation produces localized changes in

blood flow and capillary permeability.• CV system provides nutrients and removes wastes.• Delivers hormones and lymphocytes.• Provides heat for skin temperature.• SKELETAL• Skin synthesizes vitamin D needed for calcium and

phosphorus absorption.• Skeletal system provides a framework for skin.

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Relationship of the Integumentary System to Other Systems• LYMPHATIC/IMMUNE• Skin is first line of defense.• Langerhan cells and macrophages resist infection.• Mast cells trigger inflammatory responses.• Lymphatic system protects skin by sending more

macrophages and lymphocytes when needed.• RESPIRATORY• Provides oxygen to and removes carbon dioxide

from integumentary system.• Color of skin and nails can reflect changes in

respiratory system.

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Relationship of the Integumentary System to Other Systems• MUSCULAR• Skin synthesizes vitamin D needed for calcium

absorption for muscle contraction.• Gives shape to and supports skin.• Contraction of facial muscles allows

communication through expressions.• NEUROLOGICAL• Sensory receptors in dermis to touch, temperature,

pressure, vibration and pain.• Provides communication with external

environment.• Controls blood flow and sweating through

thermoregulation.

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Symptom Analysis04/21/23

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Change in Mole or Lesion

•Skin cancer is the most common type of cancer, and changes in a mole (nevus) or skin lesion can often evoke fear in the patient.

Types of skin cancer: •Basal cell •Squamous cell carcinomas, which affect

the epidermal keratinocytes•Melanoma which affects the melanocytes

of the basal layer of the epidermis.•Sun exposure is a risk factor in all types

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Nonhealing Sore or Chronic Ulceration• A nonhealing wound or chronic irritation is

often associated with an underlying disease. • The most common types of nonhealing wounds

or chronic skin ulcerations are caused by vascular disease or pressure or by diabetes.

Pruritus : is severe itching. • May be localized or generalized • Caused by a dermatologic problem or

underlying systemic problem.• Pruritus is often accompanied by a rash.

Itching, when not associated with a rash, may be indicative of significant systemic disease or simply dry skin.

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Causes of pruritis

•External stimuli, such as:• heat• dryness•Inflammation•Vasodilatation

•Psychological factors, such as depression, can influence the perception of itching, which explains the varied responses to it

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Rashes

•Like itching, may be localized or generalized, acute or chronic,

•Caused by an obvious dermatologic problem or an underlying systemic problem.

Seasonal Skin Disorders•Seasonal skin problems include those

caused by temperature fluctuations, air humidity, and exposure to contaminants.

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Seasonal Skin Disorders

•Spring: Chickenpox, Acne flare-ups•Summer: Contact dermatitis, Tinea,

Candida, Impetigo, Insect bites•Fall: Senile pruritus/winter itch,

Pityriasis rosea, Urticaria, Acne flare-ups•Winter: Contact dermatitis of hands,

Senile pruritus/winter itch, Psoriasis, Eczema

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Hair Changes• Hair loss (alopecia) is probably the most

distressing change in hair that can occur because of its cosmetic effect.

• Alopecia not only refers to scalp hair but also to body hair. Scalp hair grows about 0.25mm/d, and about 70- 100 strands of hair are lost per day.

• Hair loss can occur for many reasons.Alopecia classification: • Alopecia scaring (resulting from injury such as burns,

radiation, or traction with irreversible damage to the hair follicles)

• Nonscarring (resulting from hormonal changes, medications, infectious diseases, or thyroid disease, in which the follicles remain intact with a potential to reverse the process).

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Nail Changes

•Changes in the nails also often reflect an underlying systemic problem

•Changes in color and texture are frequent complaints.

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Assessing Lesions

•Primary lesion is one that appears in response to some change in the internal or external environment of the skin and is not altered by trauma.

•Secondary lesions result from changes in primary lesions. They either add to or take away from an existing primary lesion.

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Pressure Ulcers

•Pressure ulcers are a type of secondary lesion caused by unrelieved pressure.

•Assessment begins with identifying those at risk for pressure ulcer development and developing a plan to prevent pressure ulcer formation.

•If a pressure ulcer develops, assessment focuses on staging pressure ulcers and developing and evaluating pressure ulcer treatment plans.

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Clinical Description of LesionsSize: Major determinant of correct category for

primary lesions.• Pigmented lesions are typically 0.5 cm. If larger,

consider potential for malignancy.• Depth of pressure ulcers is major determinant of

assigned gradShape■ Macules, wheals, and vesicles are circumscribed.■ Fissures are linear.■ Irregular borders are associated with melanoma.

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Clinical Description of Lesions

ColorVariegated-colored lesions may signal melanoma.■ Pustules are usually yellow-white.■ New scars are red and raised; old scars, white

or silver.■ Petechiae are red.■ Purpura are red to purplish.■ Vitiligo is whiteTexture ■ Macules are smooth.■ Warts are rough.■ Psoriasis is scaly.

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Clinical Description of Lesions

Surface Relationship■ Flat (nonpalpable): Macules, patches,

purpura, ecchymoses, spider angioma, venous spider.

■ Raised (palpable) solid: Papules, plaques, nodules, tumors, wheals, scale, crust.

■ Raised (palpable) cystic: Vesicles, pustules, bullae, cysts.

■ Depressed: Atrophy, erosion, ulcer, fissures.■ Pedunculated: Skin tags, cutaneous horn

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Exudate■ Clear or pale, straw-yellow exudate: Serous

oozing/weeping from noninfected lesion.■ Thicker, purulent discharge: Infected lesion.■ Clear serous exudates: Vesicles, as seen with

herpes simplex; or bullae, larger thanvesicles, as seen with second-degree burns.■ Yellow pus exudates: Pustules, as seen with

impetigo or acne.• Tenderness or Pain associated with a lesion

depends on the underlying cause. May be associated with bullae from a burn or ecchymoses (bruise).

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Clinical Description of LesionsPetechiae or Purpura■ Extravasations of blood into skin.■ Caused by steroids, vasculitis, systemic

diseases.■ Does not blanch.

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Vascular LesionsEcchymosis■ Extravasation of blood

into skin layer.■ Caused by trauma/injury.■ Does not blanch.

Petechiae or Purpura■ Extravasations of blood into skin.■ Caused by steroids, vasculitis, systemic diseases.■ Does not blanch.

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Vascular LesionsVenous Star■ Blue color.■ Irregular-shaped, linear,

spider.■ Does not blanch.■ Caused by increased

pressure onsuperficial veins.

Telangiectasia■ Red color.■ Very fine and irregular

vessels.■ Blanches.■ Seen with dilation of

capillaries.

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Vascular LesionsSpider Angioma■ Red color, type of

telangiectasis.■ Looks like a spider, with

central body and fine radiating legs.

■ Blanches; seen in liver disease,

vitamin B deficiencies, idiopathic

origin.

Capillary Hemangioma■ Red color.■ Irregular-shaped macula

patch.

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Primary Lesions• Flat, Nonpalpable• Macule:< 1 cm• Patch: >1 cm

Vitiligo

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Primary Lesions• Palpable, Raised, but

Superficial• Papule: <1 cm

• Kaposi’s sarcoma• Psoriasis

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Primary LesionsRaised, Superficial,

TemporaryExamples:■ Allergic reaction■ Hives (urticaria)■ Insect bite

Palpable, Solid WithDepth Into DermisExamples:■ Bartholin’s cyst■ Erythema nodosum■ Lipoma Nodule:<2 cm If fluid filled and

encapsulated, called a cyst• Cyst• ■ Tumor: >2 cm

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Primary LesionsVesicle (serous):<1 cm• Palpable, Fluid FilledExamples:■ Blister■ Contact dermatitis■ Herpes simplex

Bulla (serous):> 1 cmExamples:■ Blister■ Burn■ Contact dermatitis

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Primary Lesions• Pustule(pus filled)Examples:■ Acne vulgaris■ Impetigo

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Secondary Lesions

Lichenification: Thickening and Scaling With Increased Skin Markings

Examples:■ Contact dermatitis■ Eczema■ Lipoma■ Psoriasis

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Secondary Lesions• Scales: Shedding, Dead

SkinCells; Scales Can Be Either

Dry or Oily, Adherent or Loose,

Variable in ColorExamples:■ Psoriasis

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Secondary Lesions• Crust: Dried ExudatesExamples:■ Dried herpes simplex■ Impetigo

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Secondary Lesions• Scar: Replacement

Connective Tissue Formations

Examples:■ Surgical site■ Trauma site

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Secondary Lesions• Keloid: Hypertrophic

scarring because of excess collagen formation; raised and irregular

Examples:■ Surgical site■ Tattoo

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Secondary Lesions: Secondary lesions that take away• Excoriation:

Abrasion or other loss that Does not extend beyond the superficial epidermis

Examples:■ Atopic dermatitis■ scratch marks■ Insect bite■ Scabies■ Vascular rupture site

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Secondary lesions that take away• Erosion: Loss of

superficial epidermisExamples:■ Abrasion■ Candidiasis erosion■ Fragile skin■ Impetigo

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Secondary lesions that take away

Fissure: Linear breaks in the skin with well-defined borders, may extend to the Dermis

Examples:■ Athlete’s foot■ Cheilitis■ Hand dermatitis (chapped

hands)■ Syphilis

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Secondary lesions that take away• Ulcer: Irregularly

shaped loss extending to or through the dermis; may be Necrotic

Examples:■ Pressure ulcer

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Secondary lesions that take away• Atrophy: Thinning of

skin with transparent appearance and loss of markings

Examples: ■ Aging■ Arterial insufficiency■ Topical

corticosteroids

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Common Abnormalities04/21/23

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Acne Vulgaris■ Caused by sebaceous gland overactivity with

plugging of hair follicles and retention of sebum,resulting in comedones, papules, and pustules.

Onset is typically at puberty, but acne may last into advanced age.

Greater incidence in males.■ Aggravated by:1.Emotional distress2.Greasy topical applications (cosmetics) 3.Medications (oral contraceptives, lithium,

phenobarbital).

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ASSESSMENT FINDINGS■ Pimples present as

papules or pustules.■ Cysts may develop and

leave extensive scarring.■ Most common on face,

back, and shoulders.■ Bacillus is cause.■ Lesions may be sore and

painful.

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Basal Cell Carcinoma■ An epidermoid cancer, one of the most common

malignant skin diseases, but rarely metastatic.■ Typically has pearly, flesh-colored or transparent

“rolled” border.■ Central area develops telangiectasia and may

ulcerate.■ Variations can present with nodular, sclerotic,

and/or pigmented appearance.■ Usually occurs on sun-exposed surfaces, especially

the face.

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Contact Dermatitis■ Localized skin irritation, inflammation, and

pruritus from contact with an irritating substance.

1.Additive effect of multiple irritants (soaps, detergents, or chemicals)

2.Allergy to a specific agent (topical to a specific agent, topical medication, plant oils, or metals).

3.Secondary infections may occur at the site.

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ASSESSMENT FINDINGS■ Edema may occur, with development of vesicles

and bullae.■ Vesicles or bullae may rupture, causing

crusting.■ Edema may be very significant, particularly

when face or genitalia are involved.■ Person may have history of previous reaction to

agent and recent exposure.

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Eczema/Atopic Dermatitis

Signs and symptoms:RednessPruritusScratching Skin lesions in a person with a

predisposition to skin irritations

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ASSESSMENT FINDINGS■ Red to red-brown, slightly scaly lesions.■ Skin markings common.■ Exudative■ As sites resolve, skin pigmentation is often

permanently altered.■ Common sites include: Face and NeckUpper trunkWrists and HandsFlexor surfaces (folds) of knees and elbows.

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ASSESSMENT FINDINGS

■ Person also often has asthma or allergic rhinitis; family history is often positive for asthma, rhinitis, eczema, or other allergy problems.

■ Itching can be quite severe.■ Sites may develop secondary infection.■ May be triggered by changes in

temperature, emotional stress, or food allergies.

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Herpes Simplex

■ A common, contagious disease caused by the herpes simplex virus type 1.

More prevalent in women than in men.

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ASSESSMENT FINDINGS■ Recurrent clusters of small vesicles on

erythematous base.■ Sites burn and sting; neuralgia often occurs.■ Typically found on perineal and genital areas.■ May initially follow a minor infection.■ Later recurrences may be triggered by

trauma, stress, or sun exposure.■ Often associated with lymphadenopathy of

regional nodes.

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Herpes Zoster

■ Also called shingles; an acute, infectious disease caused by the varicella zoster virus.

Postzoster neuralgia discomfort can last formonths. Ocular involvement can lead to blindness.

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■ Pain along a nerve dermatome is often the first symptom.

■ Discomfort followed in 2 to 4 days by erythematous area that develops papules or plaques followed by painful grouped vesicles unilaterally along the dermatome.

■ Vesicles or bullae rupture with crusting.■ Most common sites are face and trunk.■ Most common in people over age 60 and those with

impaired immunity.

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Psoriasis

■ A common dermatitis that has genetic causes and may begin at any age.

■ Silvery scales on bright red papules.■ Scales generally thick; area beneath bleeds if

scale isremoved.■ Usually occurs on extensor surfaces of knees,

elbows, and scalp.■ Can occur elsewhere, including between

buttocks.

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Psoriasis

■ Nails may develop a stippled, “pitted” appearance and separations.

■ Itching may be mild or severe.■ A genetic predisposition is suggested by

family history.■ May occur with arthritis.

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Tinea

Tinea Capitis■ A fungal infection of the scalp.■ Scaling, itching.■ Dry, brittle hair.

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Tinea Corporis

■ Ringworm, a fungal skin disease occurring anywhere on the body.

■ Ring-shaped erythematous lesions on body.

■ Central clearing.■ Advancing border with small vesicles.■ Pruritic.■ Most often on exposed surfaces.

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Tinea Cruris

■ Jock itch, a fungal skin disease occurring in the genital and anal areas in males.

■ reddened areas.■ Central clearing.■ Severe pruritus.■ Intertriginous area in groin.■ When it occurs on scalp, proper term is

tinea capitis.

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Tinea Pedis■ Athlete’s foot, a fungal skin disease occurring in

the foot. Tinea manum occurs on the palms.■ Exfoliating, fissuring, macerated area of

erythema.■ Sites itch, burn, and/or sting.■ Tinea manum occurs in interdigital folds of

fingers or on palms.■ Tinea pedis occurs in interdigital folds between

toes or on soles of feet.

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Vitiligo

■ Characterized by white patches of skin surrounded by areas of normal pigmentation. Progresses slowly and is more common in dark-skinned people.

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■ Irregular areas of depigmentation.■ May have hyperpigmented border.■ Flat, nonraised, with smooth surface.■ Most common sites are face, hands, and feet.■ Probably autoimmune cause; also associated

with various endocrine disorders.

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Assessing the Integumentary System 8/19/2015 1 Mrs. Mahdia Samaha Kony