Integumentary System

Why is this a system?

What does it do for us?

Functional Review

• Protector and barrier between internal organs and external environment

• Barrier against foreign body intrusions – against invading bacteria and foreign matter

• Transmits sensation – nerve receptors– allows for feelings of temperature, pain, light

touch and pressure

Skin Functions

• Regulates body temperature– regulates heat loss

• Helps regulate fluid balance – prevents excessive water & electrolyte loss. – Slow loss up to 600 ml daily by evaporation

• Immune Response Function– inflammatory process

Skin Functions

• Vitamin production – exposure to UV light allows for the conversion

of substances necessary for synthesizing vitamin D

– Necessary to prevent osteoporosis, rickets

• Wound repair through cell replacement

• Allows excretion of metabolic wastes as

minerals

• Provides identity through skin color and facial

features

The skin is the body's largest

organ, covering the entire body.

Structure of the Integument • The skin is the largest organ of the body

comprising 15 percent of total body weight. • Layers of the skin A. Epidermis B. Dermis C. Subcutaneous tissue

Skin appendages• Hair• Nails• Glands: two types of skin glands:

1. Sweat Gland Eccrine sweat glands: are widely

distributed and open directly onto the skin surface

Apocrine sweat glands: open into hair follicle in axillary and genital areas

2. Sebaceous glands: Produce sebum(oily secretion)

• Epidermis: the most superficial layer, then,

devoid of blood vessels

• Epidermis depends on the underlying dermis

for its nutrition

• The dermis is well supplied with blood. It

contains connective tissue, sebaceous

glands, sweat glands and hair follicles.

• It merges below with subcutaneous or

adipose tissue, also known as fat.

15

The color of normal skin depends on four pigments:

• Melanin

• Carotene

• Oxyhemoglobin

• deoxyhemoglobin

• The amount of melanin, the brownish

pigment of the skin, is genetically

determined and is increased by exposure to

sunlight.

• Carotene is a golden yellow pigment that

exists in subcutaneous fat, palms and sole

• Oxyhemoglobin, a bright red pigment,

predominate in the arteries and capillaries. An

increase in blood flow through the arteries to the

capillaries causes a reddening of the skin, whereas

the opposite change usually produces pallor.

• The skin of light-colored people is normally redder

on the palms, soles, face, neck, and upper chest.

• Deoxyhemoglobin, a darker and somewhat

bluer pigment.

• An increased concentration of

deoxyhemoglobin in cutaneous blood

vessels gives the skin a bluish cast known as

cyanosis.

Hair

Adult have two types of hair:

• Vellus hair: short, fine, and relatively

unpigmented

• Terminal hair: thicker, and usually pigmented

( scalp, eyebrows)

Nails

• Nails protect the distal end of the fingers and toes.

• The firm and usually curving nail plate gets its pink

color from the vascular nail bed to which the plate

is firmly attached.

• One forth of the plate (nail root) is covered by the

proximal nail fold.

• The cuticle extends from the fold and functioning

as a seal, protects the space between the fold and

the plate from external moisture

• Lateral nail folds cover the sides of the nail plate

• Fingernails grow approximately 0.1mm daily;

toenails grow more slowly.

Sebaceous glands

• Sebaceous glands produce sebum, a fatty substance

secreted onto the skin surface through the hair

follicle.

• These glands are present on all the skin surfaces

except the palms and soles.

• The sebum lubricate hair and skin and reduces

water loss through the skin.

sweet glands

Are of two types:

• Eccrine glands: are widely distributed, open

directly onto the skin surface, and by their sweet

production help to control body temperature.

• Apocrine glands: are found chiefly in the auxiliary

and genital regions, usually open into hair follicles

Skin Assessment

1- The health history

The purpose of integumentary history is to identify the following:

• Disease of the skin• Systemic disease that have skin manifestations• Physical abuse• Risk for pressure ulcer• Need for health promotion education regarding skin• Promote wound healing

• Prevent skin breakdown and/or additional wounds

Past History• Are you having experience of skin problem, such as

rashes, lesion• Have you noticed any changed in your ability to feel

pain, pressure, light touch, or temperature changed? • Have you had any hair loss or change in the condition

of your hair?• Have you had any change in the condition or

appearance of your nails? • Describe any previous problem within the skin, hair

or nails ( past history)• Have you ever had any allergic skin reaction to food,

medication, plants?

Family history

• Has anyone in your family had a recent illness, rash, or other skin problem?

• Do any family members have the same or similar symptoms?

• Does anyone have allergies?

Lifestyle and personal habits

• Describe your bathing• Have you changed product brands recently?• Do you wear false nails or wigs?• How much sun exposure do you receive daily?• Diet• Sunscreen

• For example, if the patient report a rash, the nurse can use the OLD CART mnemonic to ask follow-up questions in order to obtain a full description of the condition

• Onset: when did it start?• Location: where is it located?• Duration: how long have you had it?• Characteristic symptoms: describe your rash

• Associated manifestations: does it itch? Is there

any discharge?

• Relieving/ exacerbating factors: have you used

or done anything that seems to make it better:

• Treatment: have you put anything on it to treat

it?

2- Physical Assessment

• Adequate lighting• Good visualization• Explain assessment process to patient• Head-to-toe assessment• Remove necessary cloths while providing

respect, warmth and privacy• Appropriate client positions

Copyright 2002, Delmar, A division of Thomson Learning

Inspection of the Skin

• Follow head-to-toe approach• Supine position to inspect anterior surfaces• Special attention to skin folds• Side-lying position to inspect posterior

surfaces

Technique to examination of skin

• Inspection • Palpation • Olfactory senses

Equipment

• Magnifying glass• Good lighting, natural light preferred• Penlight• Clean gloves• Small centimeter rule

Inspections and palpation of skin Color Moisture Temperature Thickness Turgor Edema Lesions Skin odors are usually noted in the skin fold.

39

Color

• Skin color varies from body part to body part and

from person to person. • Pallor easily perceived in the mouth mucosa

particularly in individuals with dark skin. • Cyanosis readily seen in area of least

pigmentation e.g. lips, nail beds, conjunctiva, soles and palm.

40

• Central cyanosis: if the oxygen level in the arterial

blood is low and indicate decreased oxygenation

in the patient

• Central cyanosis is best identified in the lips, oral

mucosa and tongue

• Peripheral cyanosis: the oxygen level is normal.

occurs when cutaneous blood flow decreases and

slows and tissues extract more oxygen than usual

from the blood. May be a normal response to

anxiety or a cold environment

• Cyanosis of the nails, hand and feet may be

central or peripheral in origin

• Jaundice or Yellow seen in client’s sclera, skin and

conjunctiva.

• Erythema may indicate circulatory changes

44

moisture of skin

• Skin is normally smooth and dry to touch without flaking or

cracking. • Skin folds e.g. axillae are normally moist. • In presence of lesions or ooze fluid, nurse must wear gloves

to prevent exposure to infections • Carefully inspect skin folds where moisture may cause skin

breakdown

• Moisture indicates: Degree of client’s hydration Dryness: Vitamin A def., hypothyroidism Oily: Acne

45

Temperature• Temperature of skin depends on the amount of blood

circulating through dermis.

• Generalized warmth: (Fever, Hyperthyroidism)

• Local warmth: (Inflammation)

• Coolness: (Hypothyroidism, Hypothermia, Shock, Low

cardiac output)

• Palpation of skin with dorsum of the hand.

• Assessment of skin is critical point in some conditions

such as: after cast application, or after vascular surgery. 46

Texture• Note the roughness or smoothness of the skin• Texture of skin normally smooth, soft and flexible

• If any abnormalities in texture found you must ask

the client is he exposed to any recent injury to the

skin?

• Nurse determines whether the client’s skin is

smooth or rough, thin or thick, tight or flexible.

• Rough: (Hypothyroidism)47

Mobility and Turgor

• Turgor: is the skin elasticity diminished by edema or dehydration.

• Assessment of turgor done by lift a fold of skin between the thumb and forefinger and released.

• Note the ease with which it lifts up (mobility) and the speed with which it returns into place (turgor)

• Normally skin return immediately to its position. • Failure of this process means dehydration. • Decreased mobility in edema and Scleroderma • Decrease in turgor predisposes the client to skin

breakdown.

Edema• Edema : "Build up of fluid in the interstitial

spaces“• Inspected for location• may be localized due to injury Or systematic as in

heart failure• Systematic edema most often occurs in the

dependent portions of the body such as feet, legs and sacral area

• Edema may be pitting or nonpitting• The skin appears puffy and feels tight

Edema Scale

Lesions

• Normally skin free of lesions except common freckles.

• If lesion present, inspection must done for their anatomic location and distribution, arrangement, morphology, color and size

• Palpation for lesion’s mobility, contour (flat, raised or depressed) and consistency (soft or hard).

• Cancerous lesions frequently undergo changes in color and size.

Assessment of Lesions

• Color• Shape• Size in cm• Elevation (flat or raised)• Location and distribution on body• Exudate (color, odor)

skin color changes

• Cyanosis• Jaundice• Carotenemia: is the presence in blood of the

orange pigment carotene from excessive intake of carrots or other yellow fruits or vegetables . unlike jaundice it does not affect the sclera, which remain white

• Vitiligo: s a condition that causes depigmentation of parts of the skin. It occurs when skin pigment cells die or are unable to function

Skin lesions- anatomic location and distribution

• Psoriasis: meaning "itching condition" or "being itchy. Appears mainly on extensor surfaces

• atopic eczema or eczema is a type of dermatitis,, relapsing, non-contagious and itchy skin disorder. Appears mainly on flexor surfaces

Skin lesions- pattern and shapes

• Linear : e.g. linear epidermal nevus

• Clustered: herpes simplex

• Annular, arciform: annular lesion of tinea facial

Flat, non palpable lesion with change in skin color

• Macule: small flat spots up to 1 cm.

• Patch: flat spot. 1cm or larger

Mongolian Spot Birthmark: A dense collections of melanocytes

(not a bruise)

Palpable elevations: solid masses

• Papule : up to 1 cm. A papule is a circumscribed, solid elevation of skin with no visible fluid

• Plaque: elevated superficial lesion 1cm or larger, often formed by coalescence of papules

• Nodules: are solid, raised areas in or under the skin that are larger than 0.5 centimeters. Firmer than papule

• Cyst: nodule field with expressible material, either liquid or semisolid

•

• Wheal: somewhat irregular, relatively transient superficial area of localized skin edema

Palpable elevations with fluid-filled cavities

• Vesicle: up to 1 cm, filled with serous fluid

• Bulla: 1cm or larger, filled with serous fluid

• Pustule: filled with pus

Secondary skin lesion

• Scale: a thin flake of dead exfoliated epidermis

• Crust: Crusting is the result of the drying of plasma or exudates (pus or blood) on the skin

• Scars: connective tissue that arises from injury or disease

• Fissure: a linear crack in the skin, often resulting from excessive dryness

• Ulcer: a deeper loss of epidermis and dermis

• Petechia: is a small (1-3 mm) red or purple spot on the skin, caused by a minor hemorrhage (broken capillary blood vessels)

• ecchymosis: is the escape of blood into the tissues from ruptured blood vessels. The term also applies to the subcutaneous discoloration resulting from seepage of blood within the contused tissue. (> 3mm)

Hair and Scalp• Assessment done for distribution, thickness,

texture, and lubrication of the hair.

• Some events which affect the distribution of hair

over the body e.g. client with hormone disorders,

woman with hirsutism

• Amount of hair covering extremities may be

reduced as a result of aging and arterial

insufficiency especially in lower limbs. 79

• Scaliness or dryness of the scalp is frequently

caused by dandruff or psoriasis.

• Color of hair depends on the amount of melanin

present and varies from pale blond to black

• Inspect the scalp for lesions and parasites by

separating the hair

Nails Assessment

• Nails reflect an individual's general state of

health, state of nutrition, and occupation.

• Nails are normally transparent, smooth, and

convex, with a 160 degrees angle between nail

base and skin.

• The surrounding cuticles are smooth, intact and without inflammation.

• Nail bed is normally firm on palpation.

• Nails normally grow at a constant rate.

• Note their color and shape and any lesions

Assessment of Nails

• Shape and contour: slightly curved or flat and smooth, 160 degrees.

• Consistency- surface smooth and regular, not brittle or splitting, uniform thickness.

• Capillary Refill- depress nailbed color blanches , color should return <1-2 seconds

Abnormal condition of nail

84

Anonychia: complete absence of nails

Platunychia: flatting nails

Onycholysis: separation of nail form nail bed (thyrotoxicosis)

Koilonychia : nails like spoon shape (iron deficiencies anemia)

• It refers to abnormally thin nails (usually of the hand) which have lost their convexity, becoming flat or even concave in shape. In a sense, koilonychia is the opposite of nail clubbing.

89

Melanoychia: presence of brown color in nails plate

Leukonychia ( white nails) :white discoloration appearing on nails

• Paronychia: inflammation of tissue surrounding the nail

•

Considerations as the nurse…

•Is the patient nutritionally challenged?

•Is the patient immobile?

•Does the skin appear paper-like or fragile?

Diabetics are at high risk for slow healing wounds due to vascular changes leading to arteriosclerosis (thickening,

loss of elasticity, and calcification of arterial

walls).

Skin Ulcer

Necrotic Toes

What causes this? Decreased/impaired tissue perfusion.

Dry, Scaly Skin

Age Spots:(Liver Spots)

Age Spots:(Liver Spots) Part of the skin’s

normal aging process. Appear as flat gray, brown or black spots. They vary in size and usually appear on the face, hands,

shoulders and arms; areas most exposed to the sun.

Wound Types

Contusions: Bleeding under or within layers of skin

Abrasion:Surface scrape, open wound

Laceration:Tissues torn apart, open wound; edges

often jagged

Puncture or Penetrating: Penetration of skin and underlying tissues; open wound

Copyright 2002, Delmar, A division of Thomson Learning

Wound Evaluation

• Location• Color• Drainage• Odor• Size• Depth• Measure the borders

Copyright 2002, Delmar, A division of Thomson Learning

Safety Tips for the Elderly

• Identify environmental hazards and minimize risk

• Interventions to decrease risk for thermal injuries

• Interventions to maintain skin integrity and prevent damage

Risk factors for pressure sores

People are at risk of developing pressure sores if they have difficulty moving and are unable to easily change position while seated or in bed. Immobility may be due to:

• Generally poor health or weakness• Paralysis• Injury or illness that requires bed rest or wheelchair use• Sedation• Coma

Age. The skin of older adults is generally more

fragile, thinner, less elastic and drier than the

skin of younger adults. Also, older adults usually

produce new skin cells more slowly. These

factors make skin vulnerable to damage.

• Lack of sensory perception. Spinal cord injuries,

neurological disorders and other conditions can

result in a loss of sensation. An inability to feel

pain or discomfort can result in not being aware

of bedsores or the need to change position.

• Weight loss. Weight loss is common during

prolonged illnesses, and muscle atrophy and

wasting are common in people with paralysis.

• Poor nutrition and hydration. People need

enough fluids, calories, protein, vitamins and

minerals in their daily diet to maintain healthy

skin and prevent the breakdown of tissues.

• Excess moisture or dryness. Skin that is moist

from sweat or lack of bladder control is more

likely to be injured and increases the friction

between the skin and clothing or bedding. Very

dry skin increases friction as well

• Bowel incontinence. Bacteria from fecal

matter can cause serious local infections and

lead to life-threatening infections affecting the

whole body.

• Medical conditions affecting blood flow. Health

problems that can affect blood flow, such as

diabetes and vascular disease, increase the risk

of tissue damage.

Assessment using the Braden Scale

The Braden scale assesses a patient's

risk of developing a pressure ulcer by

examining six criteria:

1-Sensory perception

This parameter measures a patient's ability to

detect and respond to discomfort or pain

that is related to pressure on parts of their

body.

2- Moisture

• Excessive and continuous skin moisture can

pose a risk to compromise the integrity of the

skin by causing the skin tissue to become

macerated and therefore be at risk for

epidermal erosion. So this category assesses

the degree of moisture the skin is exposed

to.

3- Activity

This category looks at a clients level of physical

activity since very little or no activity can

encourage atrophy of

4- Mobility

This category looks at the capability of a

client to adjust their body position

independently. This assesses the physical

competency to move and can involve the

clients willingness to move.

5- Nutrition

The assessment of a clients nutritional status

looks at their normal patterns of daily

nutrition. Eating only portions of meals or

having imbalanced nutrition can indicate a

high risk in this category.

6- Friction

Friction looks at the amount of assistance a client needs

to move and the degree of sliding on beds or chairs

that they experience. This category is assessed because

the sliding motion can cause shear which means the

skin and bone are moving in opposite directions

causing breakdown of cell walls and capillaries.[5]

• Each category is rated on a scale of 1 to 4, excluding the 'friction category which is rated on a 1-3 scale. This combines for a possible total of 23 points, with a higher score meaning a lower risk of developing a pressure ulcer and vice-versa. The Braden Scale assessment score scale:

• Very High Risk: Total Score 9 or less• High Risk: Total Score 10-12• Moderate Risk: Total Score 13-14• Mild Risk: Total Score 15-18• No Risk: Total Score 19-23