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III.

ANATOMY AND PHYSIOLOGY




The integumentary system is the organ system that protects the body from
various kinds of damage, such as loss of water or abrasion from outside. The
system comprises the skin and its appendages (including hair, scales, feathers,
hooves, and nails). The integumentary system has a variety of functions; it may
serve to waterproof, cushion, and protect the deeper tissues, excrete wastes,
and regulate temperature, and is the attachment site for sensory receptors to
detect pain, sensation, pressure, and temperature. In most terrestrial vertebrates
with significant exposure to sunlight, the integumentary system also provides for
vitamin D synthesis. The body stores about half its fat in the underlying
hypodermis.




Skin Layers Properties Function
Epidermis Outer layer of skin, composed of 5
zones of stratified epithelium
(keratinocytes); contains
melanocytes and Langerhans cells.
Responsible for the
continual replenishing of
skin, resists friction,
waterproof, prevents water
loss.
Stratum
corneum
(Horny layer)
15-25 layers of dead, flat, keratinized
squamous epithelial cells, without
nuclei. Normally thin but thick over
the soles of the feet and palms of
the hands.
Resists friction, waterproof,
prevents water loss.
Stratum
lucidum
(Clear layer)
Only found in thick skin (palms and
soles of the feet). Transition between
the corneum and lucidum layer.
Resists friction, waterproof,
prevents water loss.
Stratum
granulosum
(Granular
layer)
3-5 layers of
keratinocytes containing keratin
granules.
They form keratin and expel
lipids which stick the cells
together and form a
waterproof barrier.
Stratum
spinosum
(Prickly layer)
Usually the thickest layer of
keratinocyte cells, they are joined
together by desmosomal
connections. Also contains
Langerhans cells.
Langerhans cells are part of
the immune response.
Stratum
basale (Basal
cells)
A layer of cuboidal-shaped cells,
lined up on a basal
membrane. It contains stem cells,
keratinocytes, and melanocytes
(pigment cells).
Keratinocyte cell division
occurs here to replenish
skin. Melanocytes protect
the skin from UV.
Dermis Deep layer of skin, composed of
collagen and elastin rich
connective tissue. It contains hair
follicles, sebaceous glands, blood
vessels and sense receptors.
It is responsible for the
elasticity and mechanical
support of skin. Supplies the
epidermis with nutrients.
Important in
thermoregulation.
Papillary Projections push into the epidermis.
Highly vascular and innervated.
Forms finger prints, brings
capillaries closer to the
avascular epidermis.
Reticular Dense, interlacing connective tissue,
predominantly parallel to the skin's
surface.
Forms lines of skin tension,
cleavage lines.
Hypodermis Not part of skin layer. Subcutaneous
connective tissue, rich in fat and
vessels.
Protective cushion and
insulator.


Functions of the skin:

Thermoregulation - Evaporation of sweat & Regulation of blood flow to
the dermis.
Cutaneous sensation - Sensations like touch, pressure, vibration, pain,
warmth or coolness.
Vitamin D production - UV sunlight & precursor molecule in skin make
vitamin D.
Protection The sin acts as a physical barrier.
Absorption & secretion The skin is involved in the absorption of water-
soluble molecules and excretion of water and sweat.
Wound healing - When a minor burn or abrasion occurs basal cells of the
epidermis break away from the basement membrane and migrate across
the wound. They migrate as a sheet, when the sides meet the growth
stops and this is called contact inhibition.
In deep wound healing - A clot forms in the wound, blood flow increases
and many cells move to the wound. The clot becomes a scab;
granulation tissue fills the wound and intense growth of epithelial cells
beneath the scab. The scab falls off and the skin returns to normal
thickness.


Skin: Epidermal Layers
The skin is the largest organ of the body, with a surface area of 18 square feet. Its
two main layers are the epidermis (outer layer) and dermis (inner layer). The
epidermis has several strata (layers) that contain four cell types. Keratinocytes
produce keratin, a protein that gives skin its strength and flexibility and
waterproofs the skin surface. Melanocytes produce melanin, the dark pigment
that gives skin its color. Merkel's cells are probably involved with touch
reception. Langerhans' cells help the immune system by processing antigens
(foreign bodies).

The deepest layer of the epidermis, the stratum basale, is a single layer of cells
resting on a basement membrane (layer between the dermis and epidermis).
The stratum basale cells divide continuously. As new cells form, older ones are
pushed toward the skin surface.

The epidermis does not have a direct blood supply; all nutrients that feed these
cells come from the dermis. Only the deepest cells of the stratum basale receive
nourishment. The cells that are pushed away from this layer die. When the cells
reach the skin surface, they are sloughed off in a process called desquamation.

The next layer, the stratum spinosum, consists of spiny prickle cells that interlock
to support the skin. The stratum granulosum, the thin middle layer, initiates
keratinization (production of keratin). This process starts the death of epithelial
cells (the cell type that makes up skin).

During desquamation, keratinocytes are pushed toward the surface. These cells
begin to produce the keratin that eventually will dominate their contents. When
these cells reach the epidermis outer layer, they are little more than keratin-filled
sacs. Millions of these dead cells are worn off daily, creating a new epidermis
every 35 to 45 days.
The stratum lucidum protects against sun ultraviolet-ray damage. This thick layer
appears only in frequently used areas such as palms of the hands and soles of
the feet. Thick skin epidermis has all five strata. Thin skin covers thinner epidermal
areas such as eyelids. Thin skin has three or four of the five strata; it never has
stratum lucidum.
The stratum corneum, the fifth, outermost layer is thick with rows of dead cells.
These cells contain soft keratin, which keeps the skin elastic and protects
underlying cells from drying out.

Skin: Dermal Layer
The dermis, called "true skin," is the layer beneath the epidermis. Its major parts
are collagen (a protein that adds strength), reticular fibers (thin protein fibers
that add support), and elastic fibers (a protein that adds flexibility). The dermis
has two layers: the papillary layer, which has loose connective tissue, and the
reticular layer, which has dense connective tissue. These layers are so closely
associated that they are difficult to differentiate.

The papillary layer lies directly beneath the epidermis and connects to it via
papillae (finger-like projections). Some papillae contain capillaries that nourish
the epidermis; others contain Meissner's corpuscles, sensory touch receptors. A
double row of papillae in finger pads produces the ridged fingerprints on
fingertips. Similar patterns in the ridged fingerprints on fingertips are on palms of
the hands and soles of the feet. Fingerprints and footprints keep skin from tearing
and aid in gripping objects.

The reticular layer of the dermis contains criss-crossing collagen fibers that form
a strong elastic network. This network forms a pattern called cleavage (Langer's)
lines. Surgical incisions that are made
parallel to cleavage lines heal faster and
with less scarring than those made
perpendicular. Parallel incisions disrupt
collagen fibers less and require less scar
tissue (cells that aid in healing) to close
up a wound.

The reticular layer also contains Pacinian
corpuscles, sensory receptors for deep pressure. This layer contains sweat
glands, lymph vessels, smooth muscle, and hair follicles, described in the
discussion on hair follicles later in this overview.

The hypodermis (subcutaneous layer) lies beneath the dermis. Loose connective
tissue such as adipose tissue (fat) insulates the body, conserving heat. It also
contains blood vessels, lymph vessels, and the bases of hair follicles and sweat
glands. The fat distribution in this layer gives the female form its characteristic
curves.

Sudoriferous (sweat) and sebaceous (oil) glands
Skin produces associated structures such as sudoriferous (sweat) glands and
sebaceous (oil) glands. It also produces fingernails, hair, and sensory receptors
that enable humans to feel pressure, temperature, and pain.

Both groups of sudoriferous glands (sweat glands) are in most of the body:
eccrine glands are coiled ducts deep in the skin that connect to the surface;
apocrine glands are in armpits, areolae of nipples, and the genital region.
Eccrine glands secrete sweat, a mixture of 99 percent water and 1 percent salts
and fats. In warm conditions with low humidity, perspiration (secretion of sweat)
and evaporation cool the body.

Apocrine glands, which become active at puberty, are larger, deeper, and
produce thicker secretions than eccrine glands. The apocrine glands secretions
contain pheromones, substances that enable olfactory (sense of smell)
communication with other members of the species. This communication
provokes certain behavioral responses such as sexual arousal. Unlike eccrine
glands that respond to heat, apocrine glands respond to stress and sexual
activity by secreting sweat with a characteristic odor. This odor differs from body
odor that results from bacteria decomposing skin secretions on the skin.

Ceruminous glands are modified apocrine glands in the external ear canal
lining. They secrete cerumen (earwax), a sticky substance that is thought to
repel foreign material.
Mammary glands in female
breasts are modified apocrine
glands. These glands are adapted to
secrete milk instead of sweat.

Sebaceous glands (oil glands) are all over the body except on the palms of
hands and soles of feet. The glands empty via ducts into the bases of hair
follicles and secrete sebum (a mixture of fats, waxes, and hydrocarbons). Sebum
keeps hair moist and prevents skin from drying. Sebaceous glands are numerous
on the face and scalp. During puberty, increased sex hormone levels in the
blood may produce excessive sebum. This over secretion plugs the gland and
hair follicle, producing a skin disorder called acne.

Hair and nails
Hair is composed of cornified threads of cells that develop from the epidermis
and cover most of the body. Each hair has a medulla, cortex, and cuticle. The
medulla in the center contains soft keratin and air. The cortex, the innermost
thickest layer, has the pigment that gives hair color. The cuticle, the outermost
layer, has cells that overlap like scales. Both the cuticle and cortex have hard
keratin.

The hair root in a hair follicle is embedded beneath the skin. The hair shaft
protrudes from the skin. Hair sheds and is replaced constantly during growth and
rest phases. Hair has a protective function: eyebrows keep sweat from running
into the eyes, nose and ear hairs filter dust from the air, and scalp hairs protect
against abrasion and overexposure to sun rays.

Hair follicles extend into the dermis; the deep ends expanded parts are called
hair bulbs. A papilla (connective tissue protrusion that contains capillaries)
protrudes into the hair bulb and provides nutrients for the growing hair. The hair
follicle walls have an inner epithelial root sheath and an outer dermal root
sheath. The epithelial root sheath has an inner and an outer layer that thins as it
approaches the hair bulb. It becomes the matrix, the actively growing part of
the hair bulb that produces the hair.

Arrector pili muscles are smooth muscle cells attached to hair follicles. When
they contract, they pull the hair into an upright position, causing skin dimples
(goose bumps). The nervous system regulates these muscles; cold temperatures
or fright can activate them.

Hair development begins in the third fetal
month. By the fifth month, lanugo (thin hair)
covers the fetus. At 5 months, lanugo
disappears from every area except the scalp
and eyebrows where coarser hair replaces it.
Vellus (a film of delicate hair) eventually
covers the rest of the body. Terminal hair is
the early coarse scalp and eyebrow hair
and later armpit and genital hair that grow during puberty. No new hair follicles
develop after birth.

Like hair, nails develop from the epidermis. These hard plates of keratinized cells
are at the ends of fingers and toes. Nails appear pink because their
translucency reveals the vascular tissue beneath. They aid in grasping objects,
scratching, and protecting fingers and toes.

The components of the nail are the lunula, body, root, and free edge. The lunula
is the white half-moon shaped part at the nail base. Both the body and free
edge region that overhangs the end of the finger or toe are visible. The nail rests
on the thick layer of epithelial skin called the nail bed. The root is hidden under
skin folds. Under the root lies the matrix (thick layer of skin). Eponychium (thin
layer of epithelium) covers the nail during development; in the adult, it remains
at the nail base only and is called the cuticle. The hyponychium is the epithelium
of the nail bed.
Skin color
Skin color results from the presence of
melanin, carotene (yellow to orange
pigment), and underlying blood
reflected through skin. Melanin keeps
excessive ultraviolet rays from burning the
skin. Exposure to sunlight causes the skin
to produce more melanin, causing
suntan, a temporary change in skin color. Melanin-rich cells continually move
toward the surface, where they are sloughed. Too much sun is dangerous to
skin; it increases the risk of cancer by affecting the genetic material of cells.

Variety of skin color is caused mainly by the number and distribution of
melanocytes. Darker skin has more melanin that is produced by more
melanocytes. However, the different skin colors among individuals and races do
not reflect different numbers of melanocytes; instead, they show different kinds
and amounts of melanin production by melanocytes. Oriental skin has a greater
amount of carotene in the stratum corneum, producing a yellowish tinge.
Albinism is a condition where skin does not produce melanin.












IV PATIENT AND HIS ILLNESS

A Schematic Diagram

Pathophysiology (Book Centered)









































Mast cells release histamine,
chemotactic factors,
leukotrienes, and prostaglandin
Kinin system release bradykinin
Phagocytosis begins
Clotting system
builds a fibrin
meshwork
Cell Injury: Pathogens, surgery, hypoxia, trauma, toxins, extreme temperature, or chemicals.
Inflammatory Response
Spasm of the arterioles constriction vasodilation of the
arterioles, venules increased capillary permeability
leukocytes line vessel walls migration of leukocytes into
interstitial spaces phagocytosis exudates and fibrin
meshwork wall of area
Platelet release serotonin
Complement system
releases histamine and
alters cell membrane
Exudate serous (plasma), sanguineous (bloody), purulent (pus)
Pain exudates and edema stimulate nerve endings
Edema increased blood supply and capillary permeability
Heat blood vessel dilation and increased metabolic rate
Pathophysiology (Client Centered)

































CC











Modifiable Factors:
- Lifestyle
- Environmental
- Socio Economic
Non Modifiable Factors:
- Age (13 years old)
- Sex (Male)
- Immune system
GABHS enters the body

Enzyme breaks down the skin and
allows the bacteria to spread

Produce toxin from the bacteria

Inflammatory
response

Immunosuppression of the body

Cytokine and
prostaglandin release

Presence of Infection

Decrease tissue
perfusion

Presence of erythema
on Right Thigh

Injury/ Trauma to
the skin

WBC: 11.3 x 10
9
/L
(Normal: 5-10 x 10
9
/L)
Extravasation of fluid
in the thigh
(fluid buildup)
Swelling Right thigh

C-Reactive Protein:
120 mg/L
(Normal: >6 mg/L)
B SYNTHESIS OF THE DISEASE

The Non modifiable and Modifiable Factors presented have put the
patient into his current disease condition, which is Cellulitis. Trauma of the leg
was the onset of the disease, which GAHBS invade the body. After the invasion,
enzyme begins to break the skin and allows the bacteria to enter the body,
which the body produce toxin from the bacteria that lead to
immunosuppression of the body. The invasion of bacteria stimulated an
inflammatory response which PATIENT X manifested fever. After the
immunosuppresion, cytokines and prostaglandin were released that resulted to
presence of infection, were the patients WBC is 11.3 x 10
9
/L. This resulted to
extravasion of fluid in the lower leg, which resulted to presence of edema. Due
to presence of infection, tissue perfusion decreased which resulted to erythema
on the right leg.

B.1 Definition of the Disease

Cellulitis is a skin infection caused by bacteria. Normally, your skin helps protect
you from infection. But if you have a cut, sore, or insect bite, bacteria can get
into the skin and spread to deeper tissues. If it is not treated with antibiotics, the
infection can spread to the blood or lymph nodes. This can be deadly.

Cellulitis is a common infection of the skin and the soft tissues underneath the
skin. It occurs when bacteria invade broken or normal skin and start to spread
under the skin and into the soft tissues. This results in infection and inflammation.
Inflammation is a process in which the body reacts to the bacteria.
Inflammation may cause swelling, redness, pain, and/or warmth.

B.2 Predisposing and Precipitating Factors

Predisposing Factor



Precipitating Factor



B.3 Signs and Symptoms