MEDSURG 7

Assessment: Integumentary System

STRUCTURES AND FUNCTIONS

• The epidermis is the outermost skin layer. The dermis is the second skin layer; it contains
the collagen bundles while it supports the nerve and vascular network.

• The subcutaneous layer is composed of fat and loose connective tissue.

• The primary function of skin is to protect underlying body tissues by serving as a surface
barrier to the external environment. Skin also is a barrier against bacteria, viruses, and
excessive water loss. Fat in the subcutaneous layer insulates the body and provides
protection from trauma.

• Two major types of epidermal cells include melanocytes (5%) and keratinocytes (90%).
o Melanocytes contain melanin, a pigment giving color to skin and hair and protecting
the body from damaging ultraviolet (UV) sunlight. More melanin results in darker
skin color.
o Keratinocytes produce fibrous protein, keratin, which is vital to protective barrier
function of skin.

• The dermis is the connective tissue below the epidermis. It is highly vascular and assists in
the regulation of body temperature and blood pressure.

• The dermis is divided into two layers: upper thin papillary layer and deeper, thicker reticular
layer.

• Collagen forms the largest part of the dermis and is responsible for the mechanical strength
of the skin.

• Skin appendages include hair, nails, and glands (sebaceous, apocrine, and eccrine). These
structures develop from the epidermal layer and receive nutrients, electrolytes, and fluids
from the dermis. Hair and nails form from specialized keratin that becomes hardened.

• Nail color ranges from pink to yellow or brown, depending on the skin color. Pigmented
longitudinal bands (melanonychea striata) may occur in the nail bed in most people with
dark skin.

• Sebaceous glands secrete sebum, which is emptied into hair follicles. Sebum prevents skin
and hair from becoming dry.

• Apocrine sweat glands are located in the axillae, breast areolae, umbilical and anogenital
areas, external auditory canals, and eyelids. They secrete a thick, milky substance that
becomes odoriferous when altered by skin surface bacteria.

• Eccrine sweat glands are widely distributed over the body, except in a few areas such as
lips. These glands cool the body by evaporation, excrete waste products through skin pores,
and moisturize surface cells.

• With aging, the following changes occur in the skin: fewer melanocytes (gray and white
 hair), less volume in the dermis, nail plate thinning, nails become brittle and prone to
splitting and yellowing, skin wrinkling, decreased subcutaneous fat, hypothermia, and skin
shearing.

ASSESSMENT
• Specific skin areas should be assessed during the examination of other body sites, unless the
chief complaint is of dermatologic nature.

• Information related to sensitivities should be obtained. History of chronic or unprotected

exposure to UV light, including tanning bed use and radiation treatments, should be noted.

• The patient should be questioned about skin-related problems occurring as result of taking
medications, self-care habits related to daily hygiene, family history of any skin disease, and
feelings related to altered body image in relation to skin condition.

• Primary skin lesions develop on previously unaltered skin. These include macule, papule,
vesicle, plaque, wheal, and pustule.

• Secondary skin lesions change with time or occur because of factors such as scratching or
infection and include fissure, scale, scar, ulcer, and excoriation.

• The skin should be inspected for general color and pigmentation, vascularity, bruising, and
presence of lesions or discolorations, and palpated for information about temperature, turgor
and mobility, moisture, and texture.

• Structures of dark skin are often more difficult to assess. Assessment is easier where the
epidermis is thin and pigmentation is not influenced by sun exposure such as lips, mucous
membranes, nail beds, and protected areas such as buttocks.

• Palmar and plantar surfaces are lighter than other skin areas in darker-skinned individuals.
Rashes are often difficult to observe and may need palpation.

• Individuals with dark skin are predisposed to pseudofolliculitis, keloids, and mongolian
spots. Cyanosis may be difficult to determine because normal bluish hue occurs in dark-
skinned persons.

DIAGNOSTIC STUDIES
• Biopsy is one of most common diagnostic tests in evaluation of skin lesions. Techniques
include punch, incisional, excisional, and shave biopsies.

• Other diagnostic procedures include stains and cultures for fungal, bacterial, and viral
infections.

****Chapter 24: Nursing Management: Integumentary Problems

• Health promotion activities for good skin health include asvoidance of environmental
hazards, adequate rest and exercise, and proper hygiene and nutrition.

• Sun safety includes sun avoidance, especially during midday hours, protective clothing, and
sunscreen.
• Actinic keratoses, basal cell carcinoma, squamous cell carcinoma, and malignant melanoma
are problems associated with sun exposure.

• Actinic keratosis:
o Is a premalignant form of squamous cell carcinoma affecting nearly all the older
white population.
o A typical lesion is an irregularly shaped, flat, slightly erythematous papule with
indistinct borders and an overlying hard keratotic scale or horn.
o Treatment includes cryosurgery, fluorouracil (5-FU), surgical removal, tretinoin
(Retin-A), chemical peeling agents, and dermabrasion.

• Skin cancer is the most common malignant condition. Patients should be taught to self-
examine their skin monthly.

• The cornerstone of self-skin examination is the ABCD rule. Examine skin lesions for
Asymmetry, Border irregularity, Color change/variation, and Diameter of 6 mm or more.

• Risk factors for skin cancer include fair skin type (blonde or red hair and blue or green
eyes), history of chronic sun exposure, family history of skin cancer, and exposure to tar and
systemic arsenicals.

• Nonmelanoma skin cancers do not develop from melanocytes, as melanoma skin cancers do.
Instead, they are a neoplasm of the epidermis. Most common sites are in sun-exposed areas.

• Basal cell carcinoma (BCC):

o Is a locally invasive malignancy from epidermal basal cells.
o Is the most common type of skin cancer and the least deadly.
o Tissue biopsy is needed to confirm the diagnosis.
o Treatments of electrodessication and curettage, cryosurgery, and excision all have
cure rate of more than 90%.

• Squamous cell carcinoma (SCC):

o Is a malignant neoplasm of keratinizing epidermal cells.
o Is less common than BCC.
o Can be very aggressive, has the potential to metastasize, and may lead to death if not
treated early.
o Pipe, cigar, and cigarette smoking area are also risk factors for SCC; therefore SCC
is also found on mouth and lips.
o Biopsy is performed when a lesion is suspected of being SCC.
o Treatment includes electrodesiccation and curettage, excision, radiation therapy,
intralesional injection of 5-FU or methotrexate, and Mohs’ surgery.

• Malignant melanoma:
o Is a tumor arising in melanocytes.
o Melanomas can metastasize to any organ.
o Is the most deadly skin cancer, and its incidence is increasing faster than that of any
other cancer.
o Individuals should consult health care provider if moles or lesions show any clinical
signs (ABCDs) of melanoma.
o Melanoma can also occur in eyes, meninges, and lymph nodes.
 o Suspicious lesions should be biopsied using excisional biopsy.
o Important prognostic factor of melanoma is tumor thickness at time of diagnosis.
o Initial treatment for melanoma is surgery.
o Melanoma spread to lymph nodes or nearby sites often requires chemotherapy,
biologic therapy (e.g., α-interferon, interleukin-2), and/or radiation therapy.
o Stage I is 100% curable with stage IV being mostly palliative care.

• Abnormal nevus pattern called dysplastic nevus syndrome identifies individual at increased
risk of melanoma. Dysplastic nevi (DN), or atypical moles, are nevi >5 mm across with
irregular borders and varying color.

• Staphylococcus aureus and group A β-hemolytic streptococci are major types of bacteria
responsible for primary and secondary skin infections. Herpes simplex, herpes zoster, and
warts are the most common viral infections affecting the skin.

• Ultraviolet light, or a combination of two types (UVA and UVB), is used to treat many
conditions. UV wavelengths cause erythema, desquamation, and pigmentation and may
cause temporary suppression of basal cell mitosis followed by rebound increase in cell
turnover.

• Radiation use for treatment of cutaneous malignancies varies greatly. Lasers are used for
many dermatologic problems.

• Antibiotics are used topically and systemically to treat dermatologic problems, and are often
used in combination. Common OTC topical antibiotics include bacitracin and polymyxin B.

• Corticosteroids are particularly effective in treating a wide variety of dermatologic

conditions and are used topically, intralesionally, or systemically. High-potency
corticosteroids may produce side effects when use is prolonged, including skin atrophy,
rosacea eruptions, severe exacerbations of acne vulgaris, and dermatophyte infections.

• Oral antihistamines are used to treat conditions that exhibit urticaria, angioedema, and
pruritus. Topical immune response modifiers such as pimecrolimus (Elidel) and tacrolimus
(Protopic) are newer nonsteroidal medications used in atopic dermatitis.

• Diagnostic and surgical therapy techniques include skin scraping, electrodesiccation and
electrocoagulation, curettage, punch biopsy, cryosurgery, and excision.

• Wet dressings are commonly used when skin is oozing from infection and/or inflammation,
and to relieve itching, suppress inflammation, and debride a wound.

• Baths are used when large body areas need to be treated. They also have sedative and
antipruritic effects.

• Careful hand washing and safe disposal of soiled dressings are the best means of preventing
spread of skin problems.

• Cosmetic procedures include chemical peels, toxin injections, collagen fillers, laser surgery,
breast enlargement and reduction, laser surgery, face-lift, eyelid-lift, and liposuction.
Preoperative management includes informed consent and realistic expectations of what
cosmetic surgery can accomplish.
 • Skin grafts may be necessary to provide protection to underlying structures or to reconstruct
areas for cosmetic or functional purposes. Ideally, wounds heal by primary intention.

• Two types of grafts are free grafts and skin flaps. Soft tissue expansion is a technique for
resurfacing a defect, such as a burn scar, removing a disfiguring mark, such as a tattoo, or as
a preliminary step in breast reconstruction.

****Chapter 25: Nursing Management: Burns

• Burns are body tissue injuries due to heat, cold, chemicals, electrical current, or radiation.

• Smoke and inhalation injuries result from inhalation of hot air or noxious chemicals.

• The resulting effect of burns is influenced by the temperature of the burning agent,
the duration of contact time, and the tissue type injured.

• Burn prevention programs focus on child-resistant lighters; nonflammable children’s

clothing; stricter building codes; smoke detectors/alarms; and fire sprinklers.

• Nurses need to advocate for scald- and fire risk–reduction strategies in the home.
Occupational health nurses need to educate workers to reduce scald, chemical, electrical,
and thermal injuries in the work setting.

• Burn treatment is related to injury severity determined by depth. The extent is calculated by
the percent of the total body surface area (TBSA), location, and patient risk factors.

• Burns are defined by degrees: first degree (same as sunburn), second degree, and third
degree. A more precise definition of second- and third-degree burns includes the depth of
skin destruction: partial-thickness and full-thickness.

• Second- and third-degree burn extent can be determined using total body surface area based
on two guides: Lund-Browder chart and Rule of Nines. Burn extent is often revised after
edema subsides and demarcation of injury zones occurs.

• Face, neck, and circumferential burns to the chest/back area may inhibit respiratory function
with mechanical obstruction secondary to edema or leathery, devitalized tissue (eschar)
formation. These injuries may cause inhalation injury and respiratory mucosal damage.

• Hands, feet, and eye burns may make self-care difficult and jeopardize future function.
Buttocks or genitalia burns are susceptible to infection. Circumferential burns to extremities
can cause circulatory compromise distal to the burn.

• Burn management is organized chronologically into three phases: emergent (resuscitative),

acute (wound healing), and rehabilitation (restorative). Overlaps in care exist from one
phase to another.

EMERGENT PHASE
• Period of time required to resolve immediate, life-threatening problems. Phase may last
from time of burn to 3 or more days, but it usually lasts 24 to 48 hours.
 • A primary concern is the onset of hypovolemic shock and edema formation. Toward the end
of the phase, if fluid replacement is adequate, the capillary membrane permeability is
restored. Fluid loss and edema formation cease. The interstitial fluid gradually returns to the
vascular space. Diuresis occurs with low urine specific gravities.

• Manifestations include shock from the pain and hypovolemia. Areas of full-thickness and
deep partial-thickness burns are initially anesthetic because the nerve endings are destroyed.
Superficial to moderate partial-thickness burns are painful.

• Shivering occurs as a result of chilling, and most patients are alert. Unconsciousness or
altered mental status is usually a result of hypoxia associated with smoke inhalation, head
trauma, or excessive sedation or pain medication.

• Complications:
o Cardiovascular system: dysrhythmias and hypovolemic shock
o Respiratory system: vulnerable to upper airway injury causing edema formation and
obstruction of airway, and inhalation injury
o Renal system: if patient is hypovolemic, kidney blood flow may decrease, causing
renal ischemia. If it continues, acute renal failure may develop. With full-thickness
and electrical burns, myoglobin and hemoglobin are released into the bloodstream
and occlude the renal tubules.

• Management includes a rapid and thorough assessment and intervention of airway

management, fluid therapy, and wound care. Analgesics are ordered to promote patient
comfort. Early in the postburn period, IV pain medications are given.

• Early and aggressive nutritional support decreases mortality and complications, optimizes
healing of burn, and minimizes negative effects of hypermetabolism and catabolism.

ACUTE PHASE
• Begins with the mobilization of extracellular fluid and subsequent diuresis. Phase concludes
when burned area is completely covered by skin grafts or when wounds are healed. This
may take weeks or many months.

• Manifestations include eschar from partial-thickness wounds. Once removed, re-

epithelialization appears as red or pink scar tissue.

• Margins of full-thickness eschar take longer to separate. As a result, they require surgical
debridement and skin grafting for healing.

• Because the body is trying to reestablish fluid and electrolyte homeostasis, it is important for
the nurse to follow the patient’s serum electrolyte levels closely (hypo- or hypernatremia,
hypo- or hyperkalemia).

• Complications include wound infection progressing to transient bacteremia as result of

manipulation (e.g., after hydrotherapy and debridement). Same cardiovascular and
respiratory system complications as in emergent phase may continue.

• Patient can become extremely disoriented, withdraw, or be combative.

• This is a transient state, lasting from a day to several weeks. Range of motion may be
 limited and contractures can occur. Paralytic ileus results from sepsis. Diarrhea and
constipation may also occur.

• Management involves wound care with daily observation, assessment, cleansing,

debridement, and dressing reapplication.

• Individualized and consistent pain assessment and care are essential. Note two kinds of pain:
continuous, background pain existing throughout day and night, and treatment pain
associated with dressing changes, ambulation, and rehabilitation activities.

• First line of treatment is pharmacologic. Then use nonpharmacologic strategies, such as

relaxation tapes, visualization, hypnosis, guided imagery, and biofeedback. Rigorous
physical therapy throughout recovery is imperative to maintain joint function. Nutritional
therapy provides adequate calories and protein to promote healing.

REHABILITATION PHASE
• Begins when wounds have healed and patient is able to resume self-care activity. Phase
occurs as early as 2 weeks or as long as 7 to 8 months after the burn.

• Goals are to assist the patient in resuming a functional role in society and accomplish
functional and cosmetic reconstructive surgery.

• Manifestations include new skin appearing flat and pink, then raised and hyperemic; itching
occurs with healing. Complications are skin and joint contractures and hypertrophic
scarring.

• Management includes positioning, splinting, and exercise to minimize contracture. Burned

legs may be wrapped with elastic (e.g., tensor/Ace) bandages to assist the circulation to the
leg graft and donor sites. Patient education and “hands-on” instruction need to be provided
in dressing changes and wound care.

• Continuous exercise and physical/occupational therapy cannot be overemphasized.

Encouragement and reassurance are necessary for patient morale, attaining independence,
and returning to preburn activities.

• For patient with emotional needs, it is important that the nurse have understanding of
circumstances of burn, family relationships, and prior coping experiences with stressful
situations. Patient may experience fear, anxiety, anger, guilt, and depression.