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Components of the Integumentary System
- Sebaceous glands
Functions of Skin
- Protection from foreign substances & trauma
- Retains body fluids & electrolytes
- Primary contact with outside world; sensory input
- Temperature regulation
- Production of vitamin D.
- Express emotions/blushing.
- Excretion sweat, urea, and lactic acid.
- Repair of surface wounds by cell replacement.
3 Layers of Skin
- Epidermis-outermost layer.
- ¨Stratified squamous epithelium
- ¨Contains hair & nails
- ¨Keratinization = Stratum germintavium
- Dermis-middle layer.
- Highly vascular connective tissue
- Blood vessels dilate/constrict; response to external/internal stimuli – regulating temp/BP
- Nourishes epidermis/supports outer layer
- Sensory nerve fibers-touch, pain, temperature.
- Stretch/contracts with body movement.
- Variable thickness (1-4 mm).
- Hypodermis layer/ Subcutaneous (inner layer)
- Made up of loose connective tissue and subcutaneous fat.
- Retains heat, cushions, & calorie storage
- ¨Epidermal cells (dermis) produce hair
- ¨Papilla (base of hair follicle) provides nourishment for growth
- ¨Melanocytes in hair shaft give color
: epidermal cells converted to keratin (protect fingertips; tissue under nail highly vascular with clue to O2 status
- Eccrine Sweat Glands: Regulate body temperature.
- Appocrine Sweat Gland: larger and deeper. Produce sweat in response to emotional stimuli.
- Sebaceous Glands: Secretes sebum that lubricates skin and hair.
Skin, Hair, Nails Risk Factors
- Systemic disease - liver, kidney, autoimmue
- Family history - dermatitis, exzema
- Excessive sun exposure
- Chemical exposure
- Allergen exposure
Problem-Based History - Skin
- Pruritus (most common) - itching (many causes - medications to bug bites, soap, etc)
- Pain /discomfort
- Lesions/changes in moles
- Changes in skin color - vitiligo
- Skin texture change
- ¨Xerosis - excessive dry - thyroid disorders
- ¨Seborrhea - excessive oily
- Wounds - ask about what happened, how long they have been there
- siver or white - been there a year or longer
- Keliod formers - get overabundance of scar tissue
Assessment - Hair & Nails
Hair: experience change (dry, brittle, hair loss), when, contributing factors: hair products & diet change (low protein), distribution change on extremities (poor circulation)- skin discoroation will accompany?
Nails: problems, chemical exposure, brittle, pitting, chew, infection, keeping clean, appear dirty?
Health Promotion with Integumentary System
- Screening is important to prevent problems with skin.
- Skin cancer is the most important common cancer.
- Older people tend to be diagnosed later with more deadly results.
- One of the goals of Healthy People 2010 is to reduce number melanoma deaths and to increase the number of people who use protection.
American Cancer Society Primary Prevention
- Avoid sun exposure-especially between 10am-4pm
- Avoid sunlamps and tanning booths.
- Wear protective clothing and wide brimmed hats.
- Wear sunglasses with 99%-100% UV protection.
- Apply suncreen protection of 15 or higher every two hours while in the sun.
- Apply suncreen even on overcast days
- Screening-Cancer related skin checkup every 3 years for people 20-40.
- Screening-Cancer related skin checkup every year for people over 40.
- Monthly self-exam of skin starting at age 20
- Use: ABCDEF mnemonic to help remember warning
- signs of melanoma.
Early Signs of Melanoma
- A---- Asymmetry (not round or oval).
- B---- Border (poorly defined or irregular border).
- C---- Color (uneven, variegated).
- D---- Diameter (usually > 6 mm).
- E---- Elevation (recent change from flat to raised lesion).
- F ----Feeling (sensation of itching, tingling, stinging
Skin Cancer Warning Signs
- A–Asymmetry (not round or oval)
- B– Border poorly defined
- C– Color uneven, variegated
- D– Diameter > 6 mm
- E– Elevation/raised
- F– Feeling (itch, tingle, sting)
Examining the Integumentary System
- Inspect skin for general color & localized variations in skin color.
- Palpate skin for texture, temperature, moisture, mobility, turgor & thickness.
- Inspect facial & body hair for distribution, color, quantity & hygiene.
- Inspect & palpate the nails for shape, contour, consistency, color, thickness & cleanliness.
- General survey (color, pigmentation, vascularity, bruising, lesions, discolorations, odors)
- ¨Systematic examination (head, neck, trunk, arms & legs)
- ¨Adequate lighting
- Inspect for color: uniformity (consistent over body
- surface) except vascular areas
- Inspect for localized variation in skin color
- ¨Intentional: tattoos, coining or cupping patterns
- ¨Normal localized variations
- Moles, freckles, patches, striae
Examination Techniques: Skin
- Palpate for:
- ¨Temperature and moisture
- ¨Mobility and turgor
- ¨Thickness: varies with age/area
- Inspect/palpate for skin lesions/ observable change in
- ¨Location/distribution, color, size (cm), shape/border,
- elevation (flat/raised), pattern, & characteristics (hard, soft, fluid, exudate)
- Primary lesions: previously normal
- Secondary lesions: change in primary
- Vascular lesions: with bleeding, aging, circulatory problems (ecchymosis, telangiectasia, angioma)
Terms Related to Color Variation
- Cyanosis-bluish tone.
- Jaundice-yellowish color.
- Petechiae-pinpoint purplish areas on skin
Primary Skin Lesions
- Macule-flat, circumscribed (round with definite borders), <1cm.
- Ex. Freckles, nevi, petechiae, measles.
-elevated, firm, circumscribed, <1cm. Ex. Wart (verruca), skin tag, cherry angioma.
-flat, irregular shaped macule > 1cm. Ex. Vitiligo, port wine stains (birth marks), mongolian spots.
-elevated firm, rough, flat surface >1cm. Ex. Psoriasis, exzema.
-elevated irregular, solid, variable diameter. Ex. Insect bites, allergic reactions. TB test.
-elevated, firm, circumscribed, deeper in the dermis than a papule 1-2 cm. Ex. Melanoma, neurofibroma, hemagioma.
-elevated, solid. > 2cm. Ex. Neoplasms, hemangioma.
-elevaed circumscribed, superficial, fluid filled, <1 cm. Ex. Varicella, sherpers zoster, impetigo.
-elevated, similar to vesicle but filled with purulent fluid. Ex.acne, herpes simplex.
-vesicle > 1cm. Ex. Blister.
- Cyst-elevated circumscribed, encapsulated in dermis, semisolid, filled with fluid.
- Ex: cystic acne, sebaceous cyst.
Secondary Skin Lesions
-flaky skin, irregular, thick or thin, dry or oily, size varies. Ex. Seborrheic dermatitis, drug reactions.
-rough, thick, epidermis. Comes from rubbing or irritation. (bra line)Ex: chronic dermatitis.
- Keloid-irregular-shaped, elevated, grows larger
- than the scar.
- Scar-thin to thick fibrous tissue. Follows surgery
- or injury.
- Excoriation-loss of epidermis, hollow-out in appearance. also called denuded
- Ex: abrasion, scratch, scabies.
-linear, crack through epidermis to dermis. Moist or dry. Ex: Athelete’s foot, cracks at corner of mouth.
-dried drainage or blood, slightly elevated, size varies, may be red, back, tan. Ex: scab on abrasion, eczema.
-loss of part of epidermis, depressed, moist. Ex: varicella, herpes simplex.
- Ulcer-loss of epidermis and dermis, concave.
- Ex: pressure ulcer, stasis ulcer
- Atrophy-thinning of skin surface. Skin will
- seem translucent. Ex: aged skin, striae.
Vascular Skin Lesions
- Petechiae-tiny flat, reddish purple, nonblanchable.
- <0.5 cm.
-flat, reddish >0.5 cm.
-bruise, reddish purple.
benign tumor, consisting of small mass of small blood vessels. Ex. Cherry or strawberry angioma.
Examination Procedures: Hair
- Inspect hair; head, face, body
- ¨Shiny, soft
- Inspect and palpate
- ¨Quantity (alopecia v. hirsutism)
- ¨Distribution esp. lower extremities
- ¨Texture (fine/vellus v. coarse/terminal)
- -hypothyroid - course dry hair
- -hyperthyroid - fine thin hair
- ¨Nail base
- ¨Capillary refill < 2 sec.
Abnormal Nail Findings
- Abnormal nail findings:
- ¨Clubbing > 180 degrees
- - - long term oxygen deficit
- ¨Koilonychia (spoon nail) - iron deficinecy
- ¨Beau’s lines - horizontal - due to chronic illness
- - vertical - dosent really mean anything
Age related changes
- drier skin
- from decreased perspiration & decreased sebaceous/sweat gland activity
- Appearance: thin, parchment skin due to decreased dermal vascularity
- ¨Folding/wrinkled appearance: loss of dermal elasticity, collagen, mass
- ¨Sharp/angular appearance over joints/bones, deepening of hollows: decreased cutaneous & SQ tissue
¨Nails get thicker, brittle, hard, yellow; ridges & split
- nExamination: extra care to correlate
- history with lesions (normal aging vs. cancer or systemic illness)
- pigmentation due to sun exposure
- areas of hypopigmentation
- ¨↑ sun
- exposure - ruddy,
- thickened skin
- ¨Solar lentigo
- (liver spots)
- ¨Seborrheic keratoses
- (wart-like lesions on trunk)
- hyperplasia (yellow, flat papules)
- due to loss of adipose tissue & elasticity
Age Related Changes: Examination
- Examination: extra care to correlate history with lesions (normal aging vs. cancer or systemic illness)
- ¨↑ pigmentation due to sun exposure
- ¨Isolated areas of hypopigmentation
- ¨↑ sun exposure - ruddy, thickened skin
- ¨Solar lentigo (liver spots)
- ¨Seborrheic keratoses (wart-like lesions on trunk)
- ¨Acrochordons (skin tags)
- ¨Sebaceous hyperplasia (yellow, flat papules)
- ¨Tenting due to loss of adipose tissue & elasticity
- - - test skin turger over scapula or other firmer skin site
Age Related Variation
- ¨Decreased melanin causes graying
- ¨Thinning of scalp, axillary & pubic hair
- ¨Follicles change size; terminal hair to vellus (fine) hair (age-associated baldness, symmetrical)
- ¨Men with (coarse) hair in nares, ears, & eyebrows
- ¨Females develop facial hair (increased androgen> estrogen ratio)
- ¨Loss of hair from trunk, extremities, axillary,
- pubic area in both sexes
Integumentary Nursing Diagnoses
- Risk for hypothermia RT thinning skin.
- Risk for infection RT scratching at rash.
- Altered nutrition, less than body requires RT malnutrition.
- Impaired skin integrity RT leg ulcers.
- Disturbed body image RT scarring.
- Risk for injury RT sun exposure.
Pediculosis (Lice) – parasites lay eggs/ nits that attach to hair shafts with underlying skin red & excoriated
Alopecia Areata– chronic autoimmune inflammatory disease with loss of hair in round patches while eyebrows & eyelashes remain
Hirsutism – increase growth in facial hair in women associated with menopause, endocrine disorders, or steroids
– fungal infection of nail plate due to tinea unguium affecting 18% population; nail plate turns yellow/white and separates from bed
- Paronychia – acute or chronic infection of cuticle usually due to staph, strep, or candida & associated with moisture; rapid onset painful inflammation at base of nail with possible abscess
- - - frequest in nail biters