Integumentary System: Skin Structure and Function

• Skin, hair, and nails are external structures with a variety of functions.
• Sebaceous and sweat glands originate within the skin and have vital functions.
• Melanin is the major determinant of skin color.
• Significant determinants that affect skin color include: capillary blood flow, chromophores (carotene and lycopene), and collagen.
• Skin, hair, and nails function is protection.

Structure of Skin

• The epidermis is the outermost layer, and is replaced every 3-4 weeks.
• The layers of the epidermis include the stratum corneum (keratinized, dead cells), stratum lucidum, stratum granulosum, and stratum germinativum.
• The dermis is the inner layer, and it is connected to the epidermis by means of papillae.
• The dermis consists of highly vascularized connective tissue.
• Collagen, elastic fibers, nerve endings, and lymph vessels are present in the dermis
• The dermis is the origin of sweat glands, sebaceous glands and hair follicles
• Subcutaneous tissue is a loose connective tissue containing fat cells, nerves, and blood vessels.
• Subcutaneous tissue assists with heat regulation
• Vascular pathways for nutrient supply and waste removal are in the subcutaneous tissue

Structure of Hair

• The structure of hair consists of the follicle, bulb, shaft, and root.
• The hair follicle is a sheath of epidermal cells, where hair develops.
• Hair growth occurs at the base of the follicle, where cells of the hair bulb are nourished.
• The hair root is surrounded by the hair follicle.

Structure of Nails

• The structure of nails consists of the cuticle, body, and lunula.

Collecting Subjective Data

• Collection of subjective data includes areas like history of current health problem, past and family histories, and lifestyle and health practices.
• Important past history questions: previous problems with skin, hair, or nails, treatment or surgery and its effectiveness, and any allergic skin reactions to food, medications, plants, or other environmental substances
• Subjective data includes questions like: fever, nausea, vomiting, gastrointestinal (GI), or respiratory problems, pregnancy and menstrual regularity for female clients, recent family illness, rash, skin problem or allergy, and family history of skin cancer
• Further lifestyle and practice question examples: sunbathing and use of protection, regular exposure to chemicals harmful to the skin (e.g., paint, bleach, cleaning products, weed killers, insect repellents, petroleum), long periods of time sitting or lying in one position, and exposure to extreme temperatures.
• Additional data to collect examples: kinds of foods consumed, daily fluid intake, daily routine for skin, hair, and nail care, and products used (e.g., soaps, lotions, oils, cosmetics, self-tanning products, razor type, hair spray, shampoo, coloring, nail enamel) and method of nail cutting

Collecting Objective Data

• During the collection of objective data implement an interview approach (COLDSPA) for nursing assessment
• Physical examination (PE) includes client preparation.
• Necessary equipment and supplies: Examination light and penlight, and a mirror for client's self exam of skin
• Magnifying glass, Wood’s light, centimeter ruler, gloves and examination gown
• Perform inspection and palpation as physical assessment strategy.
• Assess skin color, temperature, moisture, texture, integrity, and lesions
• Assess hair condition, loss, or unusual growth
• Assess nail bed condition and capillary refill

Inspect Skin

• Inspect for general skin coloration, color variations and integrity
• Inspect lesions.
• Non-life-threatening skin variations include freckles, vitiligo, and striae.
• Other skin variations include seborrhic keratosis (warty pigmented lesions), scar, mole, cutaneous tags, cutaneous horns, and cherry angiomas.
• Freckles are flat, small macules that are pigmented and appear following exposure to the sun.
• Skin integrity includes checking for breaks in the skin especially in pressure point areas such as the sacrum, hips, and elbow; skin breakdown is initially noted as reddened area in the skin.
• When inspecting lesions note color, size, shape and location, pattern, distribution and configuration.
• Lift breast of obese patients.
• A Wood's light can be used on the lesion to indicate if it’s a fungal infection
• Fungal infection is indicated by blue green fluorescence while using a Wood's light

Classifications of Lesions

• Palpable and non-palpable, and primary and secondary
• Macule is < 1 cm, with circumscribed border.
• Patch > 1 cm, may have irregular border; flat, nonpalpable skin color change.
• Papule: < 0.5 cm; Palpable
• Plaque: > 0.5 cm
• Wheal is an elevated mass with transient borders, often irregular with varying size and color, and caused by movement of serous fluid into the dermis.
• Palpable lesions contains fluid.
• A cyst is an encapsulated fluid-filled or semisolid mass in the subcutaneous tissue or dermis.
• Nodule size: 0.5 – 2cm
• Tumor size: >1-2 cm
• A nodule/tumor is elevated, palpable, and is a solid mass.
• Tumors do not always have sharp borders, whereas nodules are circumscribed.
• A vesicle is < 0.5 cm. and a bulla is >0.5 cm mass containing serous fluid that is circumscribed, elevated, and palpable (ex: Pemphigus, contact dermatitis, impetigo).
• Pustule: Pus-filled vesicle or bulla

Palpate Skin

• While palpating skin, observe for texture, thickness, temperature, moisture, mobility, turgor, and lesions

Scalp and Hair Assessment

• During physical examination, condition, cleanliness and texture should be noted
• Amount, distribution, dryness, oiliness, parasites, and lesions should be noted during scalp and hair assessment

Nail Assessment

• The nail assessments consists of assessing grooming, cleanliness, and consistency
• Inspect for color, markings, shape, texture, nail plate attachment to nailbed, and capillary refill

Nail Disorders

• Beau’s lines (Acute illness)
• Early clubbing (Hypoxia)
• Spoon nails (Iron deficiency anemia)
• Pitting (Psoriasis)
• Paronychia (local infection)
• Late clubbing (Hypoxia)
• Inspect the shape of nails and note there should be a 160 degree angle between nail base and the skin.
• Palpate nail to assess texture and consistency and noting whether nail plate is attached to nail bed.
• Capillary refill should happen quickly
• Nail base should be hard and immobile

Analysis of Data

• Analysis can lead to Wellness nursing diagnosis examples like health-seeking behavior
• It also helps determine validation and documentation of findings with subjective and objective data
• Data examples: requests information on skin reactions and effects of using a sun-tanning booth
• Risk nursing diagnosis example: Risk for impaired skin integrity related to excessive exposure to cleaning solutions and chemicals.
• Actual nursing diagnosis example: Impaired skin integrity related to immobility and decreased circulation.
• Collaborative problem example: potential complication of skin infection.