Integumentary System: Skin Structure and Function

• Normal skin is warm, dry, and intact which provides protection, thermoregulation, sensory perception, metabolism, and Vitamin D synthesis.

Functions

• Protection: Skin acts as a barrier against microorganisms, parasites, chemical substances, and prevents water and electrolyte loss.
• Thermoregulation: Blood vessels dilate for heat loss and constrict to retain heat.
• Sensory perception: Skin allows for touch, temperature, pain, and pressure sensation.
• Metabolism: Skin aids in excretion of water and sodium and wound repair.
• Vitamin D synthesis: The liver converts cholecalciferol to calcidiol, then the kidneys convert it to calcitriol, the active form of Vitamin D.

Layers of Skin

• Epidermis: Avascular outermost layer.

Epidermis

• Keratinocytes: Produce keratin for hair and nail formation.
• Melanocytes: Produce melanin, which gives color to skin and hair.
• Dermis: Composed of connective tissue containing lymphatics, nerves, and blood vessels.
• Subcutaneous layer: Beneath the dermis, made of connective tissue and fat cells.

Hair

• Covers most body surfaces except palms, soles, lips, nipples, and parts of external genitalia.
• Functions to keep the body warm and protect from external elements and trauma.
• Hair follicles: Tube-like structures derived from the epidermis, from which hair grows.

Nails

• Dense layer of flat, dead cells filled with keratin.
• Clubbing: Enlargement of fingers and toes with convex nails, often caused by chronic obstructive pulmonary disease (COPD).

Glands

• Sweat glands: Located all over the body, participate in heat regulation.
• Sebaceous glands: Oil glands located everywhere except palms and soles, abundant on face, scalp, upper chest, and back, produce sebum.
• Sebum: Prevents drying and cracking of the skin and hair.

Skin Diseases

• Hives (urticaria): Skin rashes with reddened, raised, circular wheals (lumps).
• Angioedema: Swollen eyes, lips, tongue, face, with rapid edema beneath the skin or mucosa, indicating a severe allergic reaction or anaphylaxis. Respiratory distress is a high priority.
• Vitiligo: Depigmentation of areas of the skin.
• Filiform warts: Caused by human papillomavirus (HPV).
• Skin cancer: Characterized by non-uniform color, irregular borders, asymmetry, and growth. Immediate referral is needed for moles that change size, bleed, or cause sudden itching or burning.
• Port-wine stain: Capillary malformation present at birth with irregularly shaped, red macules and patches.
• Angioma: Benign vascular tumor involving underlying tissues and blood vessels.
• Spider angioma: Displays a network of dilated capillaries radiating from a central vessel, common in people with alcohol-related liver cirrhosis.

Types of Burns

• Thermal: Caused by hot liquid, steam, fire, etc.
• Chemical
• Electrical: May cause dysrhythmias; acute tubular necrosis can occur if the current causes muscles to release myoglobin and cells to release hemoglobin, blocking kidney tubules, leading to acute renal failure or acute kidney injury (AKI) due to hemoconcentration.
• Smoke inhalation: Causes respiratory tissue damage.

Classifications of Burns

• Partial thickness (First degree): Epidermis only, caused by sunburn or hot liquid splashes, painful with erythema and blanching on pressure, no vesicles.
• Partial thickness (Second degree): Epidermis and dermis, caused by flame burn or flash, very painful with fluid-filled vesicles (blisters); red, shiny, and wet after vesicles rupture.
• Full thickness (Third and Fourth degree): Epidermis and dermis destroyed, extending into subcutaneous tissue, muscles, tendons, and bones (Fourth degree), caused by flame, chemicals, or electric current, with little or no pain; dry, white wound, eschar formation (hard, leathery dead tissue), which is a source of infection and impairs healing and can impede respiratory movement.

Burns

• Fluid loss (water vapor and seepage).
• Decreased BP leading to shock.
• Serum potassium increases as ions move from burned cells into the bloodstream.
• Sodium decreases as ions leave the body with fluid loss.
• Protein is lost.
• Hemoconcentration (elevated hematocrit) due to plasma loss.
• Sluggish blood flow results in inadequate cell and organ nutrition.
• Renal failure due to hypovolemia.
• Lung tissue injury from heat and smoke inhalation may cause alveolar edema.
• Curling’s ulcer: Decreased perfusion causes changes in the gastric mucosa that impairs its integrity.
• Severe burns to extremities lead to compartment syndrome, and chest tightness can occur.
• Swelling from burn injuries may encircle a body part, causing constriction and shutting off circulation.
• Escharotomy: Surgical incision to release pressure and improve circulation in a deeply burned and swollen body part. On the chest, it improves breathing.
• Head and neck - 9/2
• Each arm - 9/2
• Each leg - 18/2
• Trunk - 36/4
• Genitalia - 1

Nursing Interventions for Burns

• Ensure airway patency.
• Implement reverse isolation and maintain strict handwashing; use sterile sheets.
• Change gloves between caring for wounds on different areas of the body.
• Apply antimicrobials, such as silver sulfadiazine (Silvadene), using a sterile glove. May cause leukopenia; check WBC.
• Provide nutritional support: high caloric, high carbohydrate, vitamin A, C, and iron, and high protein for wound healing (meat, fish, beans, and legumes).
• Use elasticized pressure garments to cover burned areas to reduce scar formation.

Psoriasis

• Noninfectious disorder causing silvery white scales (plaque).
• Cells of the epidermis proliferate at a faster rate than normal.
• Signs and symptoms: Silvery white scales, not contagious, nail pitting (tiny dents in fingernails or toenails).
• Treatment: Corticosteroids like triamcinolone acetonide (Kenalog) to reduce inflammation and pruritus, sunlight in moderate doses or ultraviolet light therapy to slow epithelial cell proliferation, tar preparations to impede proliferation of skin cells, calcipotriene (Dovonex), vitamin D cream to slow skin cell development, and biological drugs (-mab).
• Nursing interventions: Assist the client with identifying ways to reduce stress. Place the client in a room with other clients because this is a noninfectious inflammatory disorder.

Atopic Dermatitis (Eczema)

• Pruritic lesions.
• Allergic reaction mediated by IgE.
• It can be associated with a higher risk for the development of asthma and allergic rhinitis.
• Pruritus is a primary feature.
• Rash with thickening of the skin.
• Nursing interventions: Avoid exposure to skin irritants such as soaps, detergents, fabric softeners, diaper wipes, and powder, apply cool, wet compresses, colloidal oatmeal baths to soothe the skin (Aveeno) or starch bath daily, antihistamines (diphenhydramine, fexofenadine) which can cause drowsiness, avoid driving or alcohol, lightly slap the itching area, rinse clothes in clear water, Biological- mab.

Tinea (Ringworm)

• Fungal infection.
• Tinea capitis: Ringworm of the scalp.
• Tinea corporis: Ringworm of the body.
• Tinea pedis: Ringworm of the feet.
• May spread to other parts of the body.
• Signs and symptoms: Pedis (athlete’s foot) with vesicular eruptions (blisters) in interdigital webs; scaling, redness, and cracking between the toes. Wood’s lamp examination can determine if the rash is fungal using ultraviolet light.
• Nursing interventions: Wear clean cotton socks everyday, ciclopirox olamine 1% cream (Loprox), butenafine 1% cream (Mentax), systemic azoles.

Herpes Zoster (Shingles)

• Initially produces chickenpox.
• Reactivation of a dormant virus.
• The lesions usually affect only one side of the body or face.
• Risk factors: Stress or trauma.
• Tzanck test (Tzanck smear): Scraping of an ulcer base to look for Tzanck cells, also called the chickenpox skin test and the herpes skin test
• Signs and symptoms: The rash and lesions occur on the skin area innervated by the infected nerve), Painful vesicles following a nerve pathway = herpes zoster or shingles.
• Nursing interventions: Contact isolation, antiviral agents (-clovir), anticonvulsants (gaba), and TCA antidepressants.

Acne Vulgaris

• The exact cause is unknown.
• Increase in sebum production (over production of sebum).
• Signs and symptoms: Closed comedones are whiteheads and noninflamed lesions, open comedones are blackheads, and pustules and papules.
• Nursing interventions: Address stress management with the client (stress can affect the client physiologically), isotretinoin (Accutane), instruct the client not to squeeze, prick, or pick at lesions, and limit exposure to the sun.

Impetigo

• Highly contagious bacterial infection of the skin caused by beta-hemolytic streptococci.
• The most common sites of infection are the face, around the mouth, the hands, the neck, and the extremities.
• Honey-colored crust.
• Signs and symptoms: Contact isolation, antibiotic ointments (mupirocin (bactroban), penicillin, cephalosprins (Cef), macrolides (azithromycin).
• Inform the parents that the child needs to use separate towels, linens, and dishes, and that all linen and clothing should be washed separately with detergent in hot water.
• Monitor for acute glomerulonephritis (complication of untreated impetigo).

Pediculosis (Lice)

• Signs and symptoms: Nits are visible and firmly attached to the hair shaft near the scalp; they appear as tiny silver, gray specks, or white particles that resemble dandruff.
• Pediculocide shampoo - repeated in 7 days

Wound Dehiscence/Evisceration

• Wound dehiscence: Separation of the wound edges at the incision line.
• Wound evisceration: Protrusion.
• Risk factors: Obesity, poor nutrition, wound infection.
• Diagnostic procedures: Wound and tissue culture - cleanse the wound with 0.9% sodium chloride irrigation before obtaining the specimen, remove all wound exudate and any residual antimicrobial ointment or cream to avoid altering the culture results.
• Signs and symptoms: Sudden increase in the flow of serosanguineous fluid on the wound dressings. The client stating that “something just popped in my stomach”.
• Nursing interventions: Emergency Treatment: Cover the wound and any protruding organs with sterile towels or dressings that have been soaked in saline solution. Place the client in a supine position with hips and knees bent. Prepare the client for surgery (keep the client NPO for impending surgery to repair the wound dehiscence).