Integumentary OutlineNursing 304

I. Function of the Skin in General--varies in different parts of the body

A. Protection--First line of defense not easily penetrated; Also, sebaceous

glands secrete oily and slightly acid secretions that limit growth of many

organisms. Palms and soles are especially thick to absorb the constant

contact to these areas.

B. Homeostasis--Barrier that prevents excessive loss of water and electrolytes;

Prevents SQ tissues from drying out. Individuals with burns lose this

barrier and lose much fluid and electrolytes from areas of impaired skin.

C. Thermoregulation--adjusts heat production to heat loss to maintain temp

around 98.6 F. Skin is very vascular, thus surface temp of skin sets rate

of heat loss (regulated by CNS, local neural, and hormonal processes.)

D. Sensory Reception--senses temperature (hot and cold), pain, light touch, and

pressure. Next to sight and hearing, skin is major sensory apparatus.

II. Specific Structures and Functions of the Skin

A. Epidermis--thin outer layer that comes in contact with environment.

Five layers of epidermis each with varying degrees of differentiation

which takes 3 - 4 weeks for the entire process

Stratum Corneum (outer layer of dead keratinized cells)

Stratum Germinativum (basal cell layer)--cells migrate from basal layer

upward to corneum and sheds

B. Dermis--gives bulk to skin

1. Dense layer of tissue below the epidermis giving skin bulk.

2. Contains blood vessels for nourishment and temperature

regulation; also contains nerve endings (touch, temp, pain).

C. Subcutaneous Fat--adipose layer; a specialized layer of connective tissue.

Primary function of SQ fat:

1. insulation from extremes of hot and cold

2. cushion to trauma

3. source of energy and hormone metabolism

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D. Epidermal Appendages--downgrowths of epidermis into dermis

1. Eccrine Glands--sweat producing; play role in thermoregulation;

stimulated by heat, exercise and emotional stress.

2. Apocrine Glands (breast areolae, axillae, anogenital area, ear canals, and

eyelids--function unknown, thought to be part of evolutionary changes

from animal--function in sexual arousal; require sex hormones for

activity.

3. Sebaceous Glands--found everywhere except palms and soles; Secreted

onto skin surface along hair follicles; Androgen causes development of

these glands which secrete sebum--an oily/fatty substance

Sebum plays role in Vitamin D synthesis; Vitamin D needed for

Ca and Phos metabolism; Sun or ultraviolet light synthesizes Vit. D

in body. Ergosterol is a fat converted to Vit D by irradiation.

4. Hair and Hair Follicles--"dead" protein; ornamental; goes through growth

and resting phases; Melanocytes in the bulb of the hair follicle determine

the hair color.

5. Nails--horny scales of epidermis; keratinized "dead" cells; protect nail bed.

III. Effects of Aging on the Skin

A. Adolescence--surge of hormones (androgens) lead to maturation of hair

follicles, sebaceous glands, apocrine and eccrine units. Sweat, odor, acne.

Pigmented nevi (freckles)

B. Adulthood--male baldness, facial hair on women, sebaceous cysts, skin tags,

C. Older Adulthood: thinner skin; more sensitive to minor changes in

humidity, temperature; wrinkles due to weakened collagen;

Lentigines (liver spots--have nothing to do with liver) black or brown flat lesions can

appear anywhere, but on face and dorsum of hand from prolonged sun exposure.

("Aging" pigment--left over from broken-down cells.)

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IV. Assessment of the Integumentary System

A. History

B. Physical Exam

1. Hair/Scalp

2. Skin Assessment

a. Pallor

b. Jaundice

c. Temperature

d. Texture

e. Turgor

f. Edema

g. Tenderness

C. Diagnostic Tests

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1. KOH (potassium hydroxide) Examination--for fungal infection

2. Culture--for viral, fungal, bacterial infection

3. Tzanck Test--fluid and cells from lesion examined for herpes virus

4. Mineral oil slides--scrapings for infestations (local anesthesia not necess)

5. Wood's Light Examination--ultraviolet light causes some organisms to

glow (fluorescence); No pain involved

6. Patch Testing--used for determining allergies (usually on back)

7. Biopsy-- Removal of tissue specimen for histologic examination

(cellular assessment under microscope);

a. Shave Biopsy--tissue obtained by cutting or shaving; goes through

epidermis and upper portion of dermis; no need for sutures;

little or no scarring

b. Punch Biopsy--circular instrument cuts down into depidermis, dermis

and SQ tissues; the opening may need to be closed with sutures

c. Surgical Incision Biopsy—some removed, will need sutures

d. Surgical Excision Biopsy--Done when necessary to be sure to remove

entire lesion; Sutures needed

V. Types of Lesions

1. Primary--first to appear and has visually recognizable structure and

specific characteristics

a. Macule and Patch

Flat, non-palpable color change (brown, red, purple, white, tan)

due to change in melanocytes or a change in vascularity

Macule < 1 cm and has circumscribed border

Patch > 1 cm, may have irregular border

Ex: freckles, petechiae, flat moles, vitiligo, bruises, rubella

b. Papule and Plaque

Elevated, palpable, solid mass, color may vary

Papule < 0.5 cm

Plaque > 0.5 cm (merged papules)

Ex: Papules: warts or elevated nevus (moles), drug related rash

Plaques: Psoriasis, actinic keratosis

c. Vesicle (also called blister) and Bulla(e)

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Elevated, circumscribed mass containing free serous fluid

Vesicle < 0. 5 cm (ex: blister, chicken pox, herpes simplex)

Bulla(e) > 0.5 cm (ex: blister, pemphigus vulgaris, poison

ivy, large burn blisters)

d. Pustule—pus-filled vesicle or bulla (ex: acne, impetigo)

Boils, Furuncles--pustule larger than 1 cm

Carbuncle--collection of furuncles

e. Nodule and Tumor

Elevated, palpable, solid mass deeper than papule

Nodule: 0.5 – 2 cm ( ex: lipomas, squamous cell ca)

Tumor: > 1 – 2 cm not always be easily marked border;

Can be benign or malignant;

f. Cyst—encapsulated, containing fluid or semi-solid material;

Similar to nodule but not solid; Material from sebaceous

glands and hair follicles; (Ex: sebaceous cyst)

g. Wheal (also called hive, urticaria--due to allergic reaction)--

vascular reaction causes vasodilation which leads to

erythema in which fluid leaks out of vessels into tissue

causing edema in dermis; No free fluid; elevated, irregular-

shaped areas of cutaneous edema; solid, transient (fleeting),

changing, variable diameter; pale pink with lighter center;

(Ex: mosquito bites, urticaria, nerves)

2. Secondary--once changes have occurred to primary lesion either by

progresison of the lesion or physical changes such as from scratching,

irritation or secondary infection

a. Scale--dried fragments of sloughed epidermal cells, irregular in shape and size,

and colors are white, tan, yellow, or silver ; Due to increased proliferation of

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epidermal cells; Outer layer does not shed fast enough to keep up with

proliferation, thus scales on top of scales;

Ex: dandruff, dry skin, or psoriasis

b. Crust--dried serum, blood, or pus on skin surface producing a temporary barrier

to the environment; Brown or honey colored = bacterial; dark = blood;

Ex: impetigo, eczema, scab on abrasion

c. Fissure—cracked skin (athlete’s foot, chapped hands)

d. Ulcer—skin loss past epidermis (ex: pressure sore, stasis ulcer)

e. Lichenification—thick, roughening due to repeated irritation (ex: contact

dermatitis)

VI. Nursing Care of Clients with Integumentary Disorders

A. Pruritus

Medication Vehicles

a. Powders

b. Lotions and Creams

d. Ointments

e. Emollients

B. Eczematous Disorders

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Contact and stasis dermatitis are in this category

1. Intertrigo

2. Psoriasis Vulgaris

C. Infections

1 Bacterial

a. Cellulitis

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b. Erysipelas

c. Impetigo (Im-pe-TI-go)

2. Viral Infections of Skin---- Herpes Zoster (Shingles)

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3. Fungal infections

a. Candidiasis

b. Tinea--fungal infection

Types of tinea infections

1. Tinea corporis

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2. Tinea capitis

3. Tinea cruris

4. Tinea pedis

Treatment of Tinea infections

4. Parasitic Infestations

a. Lice (Pediculosis)

b. Scabies

D. Blistering Conditions

1. Phemphigus

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2. Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis

E. Tumors

1. Actinic Keratosis

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Treatment of actinic keratosis

1. Topical antimetabolite

2. Surgery for Actinic Keratosis

a. Cryotherapy

b. Curettage and Electrodesiccation and (C&D)--

c. Shave or Excisional Biopsy

d. Moh’s Micrographic surgery

e. Deep Chemical Peel

2. Basal Cell Carcinoma

3. Squamous Cell Carcinoma

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4. Malignant Melanoma

ABCDs of melanoma