Integumentary Outline

Nursing 304

I. Function of the Skin in General--varies in different parts of the body

A. Protection--First line of defense not easily penetrated; Also, sebaceous
glands secrete oily and slightly acid secretions that limit growth of many
organisms. Palms and soles are especially thick to absorb the constant
contact to these areas.
B. Homeostasis--Barrier that prevents excessive loss of water and electrolytes;
Prevents SQ tissues from drying out. Individuals with burns lose this
barrier and lose much fluid and electrolytes from areas of impaired skin.
C. Thermoregulation--adjusts heat production to heat loss to maintain temp
around 98.6 F. Skin is very vascular, thus surface temp of skin sets rate
of heat loss (regulated by CNS, local neural, and hormonal processes.)
D. Sensory Reception--senses temperature (hot and cold), pain, light touch, and
pressure. Next to sight and hearing, skin is major sensory apparatus.

II. Specific Structures and Functions of the Skin

A. Epidermis--thin outer layer that comes in contact with environment.
Five layers of epidermis each with varying degrees of differentiation
which takes 3 - 4 weeks for the entire process
Stratum Corneum (outer layer of dead keratinized cells)
Stratum Germinativum (basal cell layer)--cells migrate from basal layer
upward to corneum and sheds

B. Dermis--gives bulk to skin

1. Dense layer of tissue below the epidermis giving skin bulk.
2. Contains blood vessels for nourishment and temperature
regulation; also contains nerve endings (touch, temp, pain).

C. Subcutaneous Fat--adipose layer; a specialized layer of connective tissue.

Primary function of SQ fat:
1. insulation from extremes of hot and cold
2. cushion to trauma
3. source of energy and hormone metabolism
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D. Epidermal Appendages--downgrowths of epidermis into dermis
1. Eccrine Glands--sweat producing; play role in thermoregulation;
stimulated by heat, exercise and emotional stress.
2. Apocrine Glands (breast areolae, axillae, anogenital area, ear canals, and
eyelids--function unknown, thought to be part of evolutionary changes
from animal--function in sexual arousal; require sex hormones for
activity.
3. Sebaceous Glands--found everywhere except palms and soles; Secreted
onto skin surface along hair follicles; Androgen causes development of
these glands which secrete sebum--an oily/fatty substance
Sebum plays role in Vitamin D synthesis; Vitamin D needed for
Ca and Phos metabolism; Sun or ultraviolet light synthesizes Vit. D
in body. Ergosterol is a fat converted to Vit D by irradiation.
4. Hair and Hair Follicles--"dead" protein; ornamental; goes through growth
and resting phases; Melanocytes in the bulb of the hair follicle determine
the hair color.
5. Nails--horny scales of epidermis; keratinized "dead" cells; protect nail bed.

III. Effects of Aging on the Skin

A. Adolescence--surge of hormones (androgens) lead to maturation of hair
follicles, sebaceous glands, apocrine and eccrine units. Sweat, odor, acne.
Pigmented nevi (freckles)
B. Adulthood--male baldness, facial hair on women, sebaceous cysts, skin tags,
C. Older Adulthood: thinner skin; more sensitive to minor changes in
humidity, temperature; wrinkles due to weakened collagen;
Lentigines (liver spots--have nothing to do with liver) black or brown flat lesions can
appear anywhere, but on face and dorsum of hand from prolonged sun exposure.
("Aging" pigment--left over from broken-down cells.)
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IV. Assessment of the Integumentary System
A. History

B. Physical Exam

1. Hair/Scalp

2. Skin Assessment
a. Pallor

b. Jaundice

c. Temperature

d. Texture

e. Turgor

f. Edema

g. Tenderness

C. Diagnostic Tests
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1. KOH (potassium hydroxide) Examination--for fungal infection
2. Culture--for viral, fungal, bacterial infection
3. Tzanck Test--fluid and cells from lesion examined for herpes virus
4. Mineral oil slides--scrapings for infestations (local anesthesia not necess)
5. Wood's Light Examination--ultraviolet light causes some organisms to
glow (fluorescence); No pain involved
6. Patch Testing--used for determining allergies (usually on back)
7. Biopsy-- Removal of tissue specimen for histologic examination
(cellular assessment under microscope);
a. Shave Biopsy--tissue obtained by cutting or shaving; goes through
epidermis and upper portion of dermis; no need for sutures;
little or no scarring
b. Punch Biopsy--circular instrument cuts down into depidermis, dermis
and SQ tissues; the opening may need to be closed with sutures
c. Surgical Incision Biopsy—some removed, will need sutures
d. Surgical Excision Biopsy--Done when necessary to be sure to remove
entire lesion; Sutures needed

V. Types of Lesions
1. Primary--first to appear and has visually recognizable structure and
specific characteristics
a. Macule and Patch
Flat, non-palpable color change (brown, red, purple, white, tan)
due to change in melanocytes or a change in vascularity
Macule < 1 cm and has circumscribed border
Patch > 1 cm, may have irregular border

Ex: freckles, petechiae, flat moles, vitiligo, bruises, rubella

b. Papule and Plaque

Elevated, palpable, solid mass, color may vary
Papule < 0.5 cm
Plaque > 0.5 cm (merged papules)
Ex: Papules: warts or elevated nevus (moles), drug related rash
Plaques: Psoriasis, actinic keratosis
c. Vesicle (also called blister) and Bulla(e)
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Elevated, circumscribed mass containing free serous fluid
Vesicle < 0. 5 cm (ex: blister, chicken pox, herpes simplex)
Bulla(e) > 0.5 cm (ex: blister, pemphigus vulgaris, poison
ivy, large burn blisters)

d. Pustule—pus-filled vesicle or bulla (ex: acne, impetigo)

Boils, Furuncles--pustule larger than 1 cm
Carbuncle--collection of furuncles

e. Nodule and Tumor

Elevated, palpable, solid mass deeper than papule
Nodule: 0.5 – 2 cm ( ex: lipomas, squamous cell ca)
Tumor: > 1 – 2 cm not always be easily marked border;
Can be benign or malignant;

f. Cyst—encapsulated, containing fluid or semi-solid material;

Similar to nodule but not solid; Material from sebaceous
glands and hair follicles; (Ex: sebaceous cyst)

g. Wheal (also called hive, urticaria--due to allergic reaction)--

vascular reaction causes vasodilation which leads to
erythema in which fluid leaks out of vessels into tissue
causing edema in dermis; No free fluid; elevated, irregular-
shaped areas of cutaneous edema; solid, transient (fleeting),
changing, variable diameter; pale pink with lighter center;
(Ex: mosquito bites, urticaria, nerves)

2. Secondary--once changes have occurred to primary lesion either by

progresison of the lesion or physical changes such as from scratching,
irritation or secondary infection

a. Scale--dried fragments of sloughed epidermal cells, irregular in shape and size,

and colors are white, tan, yellow, or silver ; Due to increased proliferation of
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epidermal cells; Outer layer does not shed fast enough to keep up with
proliferation, thus scales on top of scales;
Ex: dandruff, dry skin, or psoriasis

b. Crust--dried serum, blood, or pus on skin surface producing a temporary barrier to

the environment; Brown or honey colored = bacterial; dark = blood;
Ex: impetigo, eczema, scab on abrasion

c. Fissure—cracked skin (athlete’s foot, chapped hands)

d. Ulcer—skin loss past epidermis (ex: pressure sore, stasis ulcer)

e. Lichenification—thick, roughening due to repeated irritation (ex: contact

dermatitis)

VI. Nursing Care of Clients with Integumentary Disorders

A. Pruritus

Medication Vehicles
a. Powders

b. Lotions and Creams

d. Ointments

e. Emollients

B. Eczematous Disorders
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Contact and stasis dermatitis are in this category

1. Intertrigo

2. Psoriasis Vulgaris

C. Infections
1 Bacterial

a. Cellulitis
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b. Erysipelas

c. Impetigo (Im-pe-TI-go)

2. Viral Infections of Skin---- Herpes Zoster (Shingles)

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3. Fungal infections
a. Candidiasis

b. Tinea--fungal infection

Types of tinea infections

1. Tinea corporis
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2. Tinea capitis

3. Tinea cruris

4. Tinea pedis

Treatment of Tinea infections

4. Parasitic Infestations

a. Lice (Pediculosis)

b. Scabies

D. Blistering Conditions
1. Phemphigus
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2. Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis

E. Tumors
1. Actinic Keratosis
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Treatment of actinic keratosis
1. Topical antimetabolite

2. Surgery for Actinic Keratosis

a. Cryotherapy

b. Curettage and Electrodesiccation and (C&D)--

c. Shave or Excisional Biopsy

d. Moh’s Micrographic surgery

e. Deep Chemical Peel

2. Basal Cell Carcinoma

3. Squamous Cell Carcinoma

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4. Malignant Melanoma

ABCDs of melanoma