The Integumentary System: Skin Structure and Function

• The integumentary system includes the skin and its accessory structures.
• Skin functioning includes protection, temperature regulation, Vitamin D synthesis, waste excretion, preventing dehydration, insulation/cushioning, and sensation.
• Vasoconstriction (shivering) conserves and produces heat.
• Vasodilation (sweating) results in heat loss.

Epidermis

• Outer skin layer.
• The inner layer, stratum germinativum, undergoes cell division and reproduces itself.
• The outermost layer, stratum corneum, contains keratin and prevents pathogen entry.
• Melanocytes produce melanin, responsible for skin color.
• Tanning occurs on the hair root and iris of the eye.

Dermis

• Also known as corium or true skin.
• Thickest on palms and soles.
• Contains blood vessels, nerves, oil glands, sweat glands, and hair follicles.
• Elastin and collagen are present.
• Connective tissues contain collagen and papillae.

Subcutaneous Layer

• Stores water and fat, and insulates/protects organs.
• Located directly beneath the dermis.
• Connects skin to muscles and consists of adipose tissue.

Sudoriferous Glands

• These are sweat glands.
• Excrete sweat, which cools the body’s surface.
• Sweat consists of water, salt, urea, uric acid, ammonia, sugar, lactic acid, and ascorbic acid.

Ceruminous Glands

• Secrete cerumen (earwax).
• Located in the external ear canal, protecting it from foreign body invasion.

Sebaceous Glands

• Oil glands associated with blackhead formation.
• Secrete sebum, lubricating the skin and hair.
• Hair and nails are composed of modified dead epidermal tissue, mainly keratin.
• Keratin is a protein and the major component in skin, hair, and nails.
• The base of the hair is enclosed in a follicle in the dermis.
• Arrector pili muscles cause goosebumps.

Inspection and Palpation

• Ask about recent skin lesions, rashes, and color changes.
• Assess for rashes, ecchymosis, and decubitus/pressure ulcers.
• Check for family history of skin cancer.
• Assess the risk of developing pressure ulcers.
• Inspect skin under natural lighting.
• Inspect lips and mucous membranes for pallor or cyanosis.
• Assess ceruminous and sebaceous gland activity.
• Clubbing of fingers indicates decreased blood oxygen (hypoxemia).
• Woods light is used to assess tinea capitis in a darkened room.
• Diascopy test is performed by applying pressure to observe color changes, indicating vascular, nonvascular, or hemorrhagic conditions.
• A Tzanck smear is used to detect viral lesions.
• A scar is fibrous tissue replacing normal skin.

Lesion Types

• Macule: Flat moles, freckles

• Patch: Vitiligo, Mongolian spots

• Wheal: Insect bites, allergic reaction

• Tumor: Neoplasm, benign tumor

• Bulla: Blister

• Cyst: Elevated, encapsulated lesion

• Scale: Flaking skin

• Keloid: Irregularly shaped, elevated scar

• Fissure: Linear crack or break

• Ulcer: Loss of epidermis and dermis

• Atrophy: Thinning of skin

• Papule: Wart, elevated moles

• Plaque: Psoriasis

• Nodule: Lipomas, elevated firm lesion

• Vesicle: Varicella (chicken pox) with serous fluid; Shingles

• Pustule: Impetigo, acne (skin filled w/ pus)

• Telangiectasia: Fine, irregular red lines

• Lichenification: Rough, thickened epidermis

• Excoriation: Loss of epidermis

• Erosion: Follows rupture of a vesicle

• Crust: Dried serum, blood or purulent exudate

• Vitiligo: Unpigmented skin patches

• Melanocytes account for skin color related to tanning.

• Lips and mucous membranes are easier to assess for cyanosis due to thinner skin.

Chief Complaint Assessment Tool

• P: Provocative and Palliative factors
• Q: Quality and Quantity
• R: Region
• S: Severity of the signs and symptoms
• T: Time the patient has had the disorder
• Explore how body condition affects self-image, especially with acne.

Herpes Simplex

• Transmitted through direct contact with an open lesion.
• Type 1: Common cold sore
• Vesicle at the corner of the mouth, lips, or nose
• Type 2: Genital Herpes
• Various types of vesicles on cervix or penis
• Flu-like symptoms may occur 3-4 days after vesicle eruption.

Diagnostic Skin Tests.

• To obtain a skin specimen:
• Puncture crusted area with sterile needle.
• Place cotton-tipped application in culturette tube.
• Place culturette tube in ice.

Medical Management (Herpes Simplex)

• Acyclovir (Zovirax): Delays herpetic disease progression, decreases pain; can cause nausea and vomiting.
• Patient education:
• Avoid kissing.
• Focus on treating symptoms and preventing the spread of the virus.
• Keep lesions dry, and practice good hygiene.

Medications for the Integumentary System

• Acvir (Zovirax): Antiviral (Herpes zoster)
• Aluminum acetate solution (Burow’s solution): Therapeutic bath for severe pruritus.
• Antihistamine/Diphenhydramine (Benadryl): Blocks allergic reactions (urinary retention).
• Isotretinoin (Accutane): Anti-acne medication (contraindicated in pregnant women, take with food, don’t crush).
• Salicylic Acid: Can cause tinnitus (toxicity).
• Tinactin: Antifungal agent.
• Griseofulvin (Fulvicin): Common oral antifungal drug.
• Clotrimazole topical cream: Apply for up to 2 weeks after lesions are gone.

Herpes Zoster (Shingles)

• Airborne precaution.
• Inflammation of the spinal ganglia (nerve pathway).
• Same virus as varicella (chicken pox).
• Acyclovir (Zovirax) reduces pain and duration of the virus, administered orally and IV.
• Priority Nursing diagnosis: Acute Pain
• Patient teaching: Decrease in pain
• Someone lacking varicella immunity can acquire chickenpox from someone with shingles.
• Pain described as burning and knifelike.
• S/S:
• Painful, erythematous rash along the spinal nerve pathway
• Clustered skin vesicles.
• Vesicles are usually preceded by pain; usually in thoracic region.
• Extreme tenderness and pruritus; caused by reactivation of dormant virus.

Pityriasis Rosea

• Single pink, scaly patch resembling a large ringworm.
• Appears mainly on the chest, abdomen, back, groin, and axillae.
• Usually requires no treatment.
• Can use 1% hydrocortisone cream for pruritus.

Cellulitis

• Infection usually occurs on lower extremities.
• Can spread and become life-threatening, leading to blood poisoning.
• Staphylococcus aureus can cause sepsis and meningitis complication
• Symptoms include erythema, pain, and tenderness.
• Erysipelas- streptococcal cellulitis makes the skin bright red.
• Diagnostic test: CBC and gram stain to determine ABT therapy.
• Antibiotic therapy for 10 days.
• Apply warm, moist compress at least twice a day (no heat lamp or heating pad).
• Elevate above the level of the heart to reduce swelling.

Impetigo Contagiosa

• Caused by Staphylococcus aureus or streptococci (bacterial infection).
• Common in children.
• Pustules rupture and form honey-colored exudate.
• Highly contagious through direct or indirect contact.
• Separate washing of clothes and toys for household members, wash with soap and hot water.
• Antibiotic therapy is a treatment option.

Bacterial Disorders of the Skin

• Folliculitis: Infected hair follicle.

• Furuncle (boil): Infection deep in the hair follicle, involves surrounding tissue.

• Carbuncle: Cluster of furuncles.

• Felons: Infected soft tissue under and around an area.

• Clinical manifestations:

  • Pustule.
  • Pain.
  • Edema
  • Pruritus
  • Erythema

• M/M: Warm soaks two to three times a day promote suppuration.

• A boil is referred to as a skin abscess, collection of pus that forms in the body, localized deep in the skin.

• Starts as a reddened, tender area and, over time, becomes firm and hard, filling with pus.

• Treatment: hot packs and draining(lancing) the abscess, only if soft and ready to drain.

• MRSA stands for Methicillin-resistant Staphylococcus aureus.

• Most MRSA infections are skin infections that produce cellulitis, bumps on the skin, boils, and abscesses.

Fungal Infections

• Also known as dermatophytosis/mycoses, or ringworm.
• Tinea capitis affects the scalp, and infected hair fluoresces blue-green under ultraviolet light. Darken the room during the exam.
• Tinea corporis affects the body.
• Tinea cruris affects the groin.
• Tinea pedis is Athlete's foot.
• Scaling and redness are present between toes.
• Griseofulvin is a common oral drug.
• Treatment includes Tinactin or Desenex (powder on feet).
• Can use Burow’s solution (tinea pedis) for antipruritic/healing.

Contact Dermatitis

• Direct contact/exposure with agents of hypersensitivity.
• Detergents, soaps, industrial chemicals, and plants.
• CM: Pruritus, redness, papules, fluid-filled vesicles.
• Can use Burow’s solution and/or colloidal oatmeal treatment.
• Prednisone (corticosteroid) to lesions (don’t stop abruptly, taper off).
• Cool Compresses, wet dressings, and cool baths.
• Antihistamines, such as diphenhydramine/Benadryl, cause drowsiness, so it's better to take it at bedtime. They also might cause urinary retention.

Inflammatory disorders of the skin

• Dermatitis venenata: Contact with certain plants, e.g., poison ivy.
• Thoroughly wash affected area, and use cool, wet dressings and baths to promote vasoconstriction for severe pruritus.
• Exfoliative dermatitis: Infestation of heavy metals, antibiotics, aspirin, codeine, gold, or iodine.
• Dermatitis medicamentosa: Hypersensitivity to a medication. Check the pt history for changes in meds, and hold meds if erythema, pruritus, and rash develop.
• Discontinue use of the drug.
• Respiratory distress with medicamentosa.

Seborrheic Dermatitis

• Dandruff
• Urticaria (hives)): Allergic reaction (release of histamine by drugs, food, insect bites, inhalants, emotional stress, or exposure to heat or cold.
• Pruritus; pale, red, elevated wheals.
• Use antihistamine/Benadryl for treatment.
• Diagnostic test: Allergy skin test.
• Skin patch test: A small amount of allergens is applied to adhesive patches, placed on skin and left on skin for two days.
• Discontinue prescribed antihistamine two days before the test.
• Angioedema causes respiratory distress (larynx).
• Manage with antihistamines, epinephrine, or corticosteroids.

Eczema (Atopic dermatitis)

• Primarily occurs in infants.
• Papules and vesicles on scalp, forehead, cheeks, neck, and extremities.
• Hydration of skin: If dry, soak affected area in warm or cool water for 15-20 min then occlusive dressing to retain water.
• Lotions: Eucerin, alpha-keri, lubriderm, or curel.
• Avoid fabric softeners and dress in cool clothing.

Acne Vulgaris

• Occluded oil (sebaceous) glands.
• Overactive hormones, oily and shiny skin, and comedones (blackheads).
• Topical therapies include benzoyl peroxide (can cause excessive drying) -(tetracycline, erythromycin).
• Use isotretinoin/Accutane (form of vitamin A), but it can cause birth defects.
• Assess self-image and life style, disturbed body image.
• Requires monthly liver function test to determine hepatotoxicity.
• Use a new cosmetic pad each time makeup is applied.

Psoriasis

• Chronic, proliferative skin disorder with thick, scaly patches and inflammation Aggravated by stress.
• Silvering plagues
• Tar preparations, corticosteroids, and exposure to photochemotherapy (administer psoralen UV therapy.
• Identify effective stress reduction techniques.

Topical Creams

• Apply on occlusive dressing after application, wear gloves, and avoid applying on skin folds to avoid skin thinning.
• Expect a stinging sensation upon application, Apply to the scalp, Obtain a pregnancy test, Limit application to skin folds

Systemic Lupus Erythematosus (SLE)

• Autoimmune disorder.
• Inflammation of almost any body part
• Erythema butterfly rash over nose and cheeks
• Alopecia, photosensitivity, Polyarthralgia and polyarthritis.
• No cure, treat symptoms, induce remission, alleviate exacerbations, Avoid direct sunlight.

Pediculosis

• Lice infestation.
• Types are head lice (Capitis), Body lice (Corporis) and pubic lice (Crabs)
• Nits or lice in involved area.
• Lindane
• use at last 2x; shampoo/ lotion on dry hair for 4 min then rinse
• Wash bed linens, clothes and bath articles in hot water.

Scabies

• Itch mite
• Mite penetrates the skin and makes a burrow, lays eggs under skin that mature and rise to surface.
• Treat with Lindane (Kwell), Pyrethrins (RID), Crotamiton (Eurax), , Administer antihistamine to relieve pruritus andwash bed linens, clothes and bath articles in hot water.

Keloid

• Overgrowth of collagenous scar tissue, which may be raised, hard and shiny.
• Angiomas: Port-wine birthmark, Group of dilated blood vessels and form a tumor- like mass
• Spider angioma is associated with liver disease (having three or more)
• Verruca (Wart): Foot (plantar wart).
• Nevi (moles).

Basal Cell Carcinoma

• Type of skin cancer. Small translucent nodule (pearly or shiny nodule)
• Fair skinned people are more likely to develop this skin cancer

Squamous Cell Carcinoma

• Rapid invasion with metastasis via the lymphatic system, which leads to firm, nodular lesion; ulceration and indurated margins

• Early detection is important

• Malignant Melanoma: The most deadly cancerous neoplasm, which is purplish in color.

• Greatest risk is fair complexion, blue eyes, red or blonde hair, freckles, regular sun exposure Diagnostic test

• Skin biopsy: Apply antibiotic after skin surgery with sutures

Cancer Prevention

• Apply broad spectrum sunscreen SPF 15 or greater.
• Most effective when applied 30 min prior
• Avoid exposure to sun or avoid tanning under direct sun from 10am to 4pm.

Alopecia

• Loss of hair
• Vitiligo: pigmentation disorder in which melanocytes in the skin are destroyed, resulting in white patches.
• Hypertrichosis (hirsutism): Excessive growth of hair in masculine distribution
• Burns may result from electricity (Cardiac arrest is the main concern)
• The greatest fluid loss is with the 12 hours after burns; urinary output should be 30 ml per hour)
• Degrees range from Superficial (First degree), Deep Partial-thickness (second degree) and full-thickness (third degree).

Rule Of Nines

• Determines the TBSA (total body surface area) burned (may not be accurate for children)
• First determine the burned areas, then use the rule of nines to estimate the percentage of body surface area burned.

Burn management

• Tetanus injection
• Fluid Management- IV route
• Lactated Ringers solution
• Burn on upper chest assess for respiratory distress
• Stop, Drop, and Roll
• Remove any clothing
• Most electrical burns result in cardiac arrest
• Emergent phase (First 48 hours)
• The acute phase (48 to 72 hours) and is used to assess Curling Ulcer.
• Infection most common of death after 72 hours.
• Skin grafts are used ASAP to cover full thickness burns.
• Limit noise in room.

Stages of pressure Ulcers and what to ifnetvene

• Stage 1: Intact w/ nonblanchable erythema of the skin
• Stage 2: Blisters, Partial thickness skin loss
• Stage 3: Full thickness skin loss w/ crater, damage or necrosis of subcutaneous tissue
• Stage 4: Damage to muscle, bone or supporting structures, Full thickness skin loss w/ extensive damage Identify patients as risk, reposition every two hours, provide clients diet high in Vitamin C Edema and tenderness indicate wound infection.

Skin issues

• Atopic Dermatitis - Allergic response
• Acne Vulgaris Inflammatory process of skin
• Herpes Simplex Virus Type 1: Common
• Tinea Infections: and common fungal of the skin.
• Pediculosis and scabies

Skin disorders

• Meningococcal Septicemia- Fever
• Scarlet Fever; Flushed face