Integumentary System: Skin Layers

• The integumentary system consists of the skin, subcutaneous tissue, hair, and nails
• It protects the body, provides temperature regulation, sensory reception, vitamin D synthesis, and immunological defense
• The skin has three layers: epidermis, dermis, and subcutaneous tissue.

Epidermis

• The epidermis is the outermost layer of the skin
• It's avascular, meaning it contains no blood vessels
• The epidermis is composed of stratified squamous epithelium
• Its primary cell type is keratinocytes, which produce keratin for protection
• Melanocytes in the epidermis produce melanin, providing skin color and UV protection
• Langerhans cells provide immune defense.
• The epidermis has five layers: stratum basale, stratum spinosum, stratum granulosum, stratum lucidum, and stratum corneum

Dermis

• The dermis is the second layer of skin, located beneath the epidermis
• It's thicker than the epidermis and contains blood vessels, nerves, hair follicles, and glands
• The dermis is composed of connective tissue containing collagen and elastin fibers
• Collagen provides strength, while elastin allows for flexibility
• Sensory receptors in the dermis detect touch, pressure, pain, and temperature

Subcutaneous Tissue

• The subcutaneous tissue (hypodermis) is the innermost layer of skin, located beneath the dermis
• It consists of adipose tissue (fat) and connective tissue
• The subcutaneous tissue provides insulation, cushioning, and energy storage
• It also anchors the skin to underlying structures

Hair

• Hair is composed of keratinized cells and grows from hair follicles in the dermis
• Hair provides protection, insulation, and sensory input
• Hair color is determined by melanin production
• Arrector pili muscles cause hair to stand up, resulting in "goosebumps"

Nails

• Nails are composed of hard, keratinized cells and protect the tips of fingers and toes
• The nail matrix is where nail growth occurs
• The nail bed is the skin beneath the nail plate
• The cuticle is the skin that covers the nail matrix

Glands

• Sebaceous Glands: Secrete sebum (oil) to lubricate skin and hair
• Sweat Glands: Eccrine glands regulate body temperature through perspiration; apocrine glands in axillae and groin secrete sweat in response to emotional stimuli
• Ceruminous Glands: Produce cerumen (earwax) in the ear canal for protection

Functions of the Integumentary System

• Protection: Acts as a barrier against pathogens, UV radiation, and physical injury
• Temperature Regulation: Controls heat exchange through sweating, vasodilation, and vasoconstriction
• Sensory Reception: Detects touch, pressure, pain, and temperature through nerve endings
• Vitamin D Synthesis: Synthesizes vitamin D when exposed to sunlight, essential for calcium absorption
• Immunological Defense: Contains Langerhans cells for immune response

Data Collection - Assessment of the Integumentary System

• Patient History: Gather information on skin conditions, allergies, medications, and family history
• Physical Examination: Inspect skin color, temperature, moisture, lesions, and palpate for texture, turgor, and edema

Skin Color

• Pallor (paleness) may indicate anemia or decreased blood flow
• Erythema (redness) may indicate inflammation, infection, or sunburn
• Cyanosis (blueness) may indicate hypoxia
• Jaundice (yellowing) may indicate liver dysfunction
• Hyperpigmentation (darkening) or hypopigmentation (lightening) may indicate various conditions

Skin Lesions

• Macule: Flat, distinct, discolored area of skin, usually < 1 cm (e.g., freckle)
• Papule: Raised, solid area of skin, usually < 1 cm (e.g., mole)
• Vesicle: Small, fluid-filled blister (e.g., chickenpox)
• Pustule: Pus-filled vesicle (e.g., acne)
• Ulcer: Open sore or lesion extending into the dermis
• Wheal: Raised, itchy area of skin, often with an irregular shape (e.g., hives)

Palpation

• Temperature: Assess for warmth (inflammation, infection) or coolness (poor circulation)
• Moisture: Assess for dryness (dehydration) or diaphoresis (excessive sweating)
• Texture: Assess for smoothness, roughness, or induration (hardening)
• Turgor: Assess skin elasticity by pinching and releasing skin (decreased turgor indicates dehydration)
• Edema: Assess for swelling by pressing on skin (pitting or non-pitting)

Diagnostic Tests for Integumentary Disorders

• Skin Biopsy: Removal of skin tissue for microscopic examination to diagnose skin conditions (e.g., cancer, infection)
• Culture and Sensitivity: Identifies bacteria or fungi in skin infections and determines antibiotic sensitivity
• Allergy Testing: Identifies allergens causing allergic skin reactions (e.g., patch testing, prick testing)
• Wood's Lamp Examination: Uses UV light to detect fungal or bacterial skin infections

Common Integumentary Disorders

• Infections: Bacterial (cellulitis, impetigo), fungal (tinea, candidiasis), viral (herpes simplex, varicella-zoster)
• Inflammatory Conditions: Eczema (atopic dermatitis), psoriasis, contact dermatitis
• Skin Cancer: Basal cell carcinoma, squamous cell carcinoma, melanoma
• Pressure Ulcers: Tissue damage from prolonged pressure, shear, or friction
• Burns: Thermal, chemical, or electrical injuries to the skin

Therapeutic Measures for Integumentary Disorders

• Topical Medications: Corticosteroids, antibiotics, antifungals, emollients
• Systemic Medications: Oral antibiotics, antifungals, corticosteroids, antihistamines
• Wound Care: Cleansing, debridement, dressing changes
• Phototherapy: Use of UV light to treat skin conditions (e.g., psoriasis)
• Surgery: Excision of skin lesions, skin grafts, laser therapy

Nursing Interventions for Integumentary Disorders

• Skin Care: Maintaining skin hygiene, moisturizing, preventing skin breakdown
• Wound Care: Assessing wounds, performing dressing changes, preventing infection
• Medication Administration: Administering topical and systemic medications as prescribed
• Patient Education: Teaching patients about skin care, medication use, and prevention of complications
• Pain Management: Assessing and managing pain associated with skin conditions or procedures
• Infection Control: Implementing measures to prevent the spread of infection

Pressure Ulcers

• Pressure ulcers are localized injuries to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction
• Risk factors include immobility, incontinence, malnutrition, and decreased sensory perception
• Prevention involves frequent position changes, pressure-reducing devices, and proper skin care

Staging of Pressure Ulcers

• Stage I: Non-blanchable erythema of intact skin
• Stage II: Partial-thickness skin loss involving epidermis or dermis
• Stage III: Full-thickness skin loss involving damage or necrosis of subcutaneous tissue
• Stage IV: Full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures
• Unstageable: Full-thickness tissue loss with the base of the ulcer covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed
• Deep Tissue Injury (DTI): Persistent non-blanchable deep red, maroon, or purple discoloration

Prevention of Pressure Ulcers

• Identify at-risk patients using risk assessment tools (e.g., Braden Scale)
• Implement pressure-reducing support surfaces (e.g., specialty mattresses)
• Reposition patients frequently (every 2 hours)
• Keep skin clean and dry
• Provide adequate nutrition and hydration
• Protect bony prominences with padding
• Educate patients and caregivers about pressure ulcer prevention

Treatment of Pressure Ulcers

• Debridement: Removal of necrotic tissue
• Wound Cleansing: Use of appropriate solutions (e.g., normal saline)
• Dressings: Selection of appropriate dressings based on wound characteristics (e.g., hydrocolloids, alginates, foams)
• Nutrition: Ensuring adequate protein, vitamins, and minerals for wound healing
• Pain Management: Addressing pain associated with pressure ulcers
• Infection Control: Monitoring for and treating wound infections

Burns

• Burns are injuries caused by thermal, chemical, electrical, or radiation exposure leading to tissue damage
• Severity depends on depth, extent, and location of the burn
• Complications include infection, fluid loss, hypothermia, and scarring

Classification of Burns

• Superficial (First-Degree): Affects epidermis, causes redness and pain
• Partial-Thickness (Second-Degree): Affects epidermis and dermis, causes blisters and pain
• Full-Thickness (Third-Degree): Destroys epidermis, dermis, and subcutaneous tissue, appears dry and leathery
• Fourth-Degree: Extends into muscle, bone, or tendons

Rule of Nines

• A method of estimating the total body surface area (TBSA) affected by burns in adults
• Each arm is 9%, each leg is 18%, the anterior trunk is 18%, the posterior trunk is 18%, the head is 9%, and the perineum is 1%

Treatment of Burns

• Fluid Resuscitation: Administer intravenous fluids to maintain adequate tissue perfusion
• Wound Care: Cleansing, debridement, and application of topical antibiotics
• Pain Management: Administering analgesics for pain relief
• Nutritional Support: Providing high-protein, high-calorie diet to promote healing
• Infection Control: Preventing and treating infections with antibiotics
• Skin Grafting: Surgical transplantation of skin to cover large burns

Nursing Management of Burns

• Assess and monitor respiratory status, circulation, and fluid balance
• Administer medications as prescribed
• Provide wound care and prevent infection
• Manage pain and promote comfort
• Provide emotional support and education to patients and families
• Monitor for complications such as infection, contractures, and scarring.