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Integumentary system Integumentary system

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  • Integumentary system

    Integumentary system

  • The largest organ system of the body. It forms a barrier between the internal organs &

    the external environment. Composed of 3 layers: Epidermis Dermis Subcutaneous tissue

    Anatomy & physiologyAnatomy & physiology

  • Outermost layer of stratified epithelial cells composed of keratinocytes.

    It ranges in thickness from 0.1 mm on the eyelids to about 1 mm on the palms of hands & soles of the feet.

    It is composed of 4 distinct layers:o Stratum germinativumo Stratum granulosumo Stratum lucidumo Stratum corneum

    EpidermisEpidermis

  • Cells present in this layer are: Keratin Melanocytes Merkel cells Langerhens cells The junction of epidermis & dermis is called

    rete ridges, which permits the free exchange of nutrients between the two layers.

  • Makes up the largest portion of skin, provides strength & structure.

    It is composed of 2 layers: Papillary Reticular Dermis is also made up of blood & lymph vessels,

    nerves, sweat & sebaceous glands & hair roots. it is often referred to as true skin

    DermisDermis

  • The subcutaneous tissue or hypodermis is the innermost layer of the skin

    It is primarily adipose tissue which provides a cushion between the skin layers, muscles & bones.

    It promotes mobility, moulds body contours & insulates the body.

    Subcutaneous tissueSubcutaneous tissue

  • Protection Sensation Fluid balance Temperature regulation Vitamin production Immune response function

    Functions of skinFunctions of skin

  • Assessment of skin

  • Family & personal history of skin allergies. Allergic reactions to food, medications &

    chemicals. Previous skin conditions & skin cancers.. The names of cosmetics, soaps, shampoo & other

    products. Non-prescriptions or herbal preparations that are

    being used. Health history addresses the onset, signs &

    symptoms, location & duration of any pain, itching & rash.

    Health historyHealth history

  • Assessment of skin includes entire skin area including:

    Mucous membranes Scalp Hair Nails Inspection & palpation are common techniques in

    examining the skin Rooms must be well lighted & warm Gloves are worn in case of rash or lesions are to

    be palpated.

    Physical examinationPhysical examination

  • Mainly determined by genetics & described as light, medium and dark(Due to faster production of melanin)

    Buccal mucosa, tongue, nails & lips are normally pink.

    The skin of exposed portions may be more pigmented

    Hypo pigmentation may be caused by fungal infection, eczema or vitiligo.

    Hyper pigmentation may be caused by sun injury or as a result of ageing.

    Assessing the skin colorAssessing the skin color

  • Pallor skin can be seen in anemia(decreased hematocrit), shock(decreased perfusion & vasoconstriction),

    Albinism( total absence of melanin pigment) includes whitish pink skin changes

    Vitiligo(destruction of melanocytes in circumscribed areas of skin) includes patchy, milky white spots.

    Cyanosis is the increased amount of unoxygenated blood. It may be central & peripheral & includes dusky blue nail beds.

    Conti.Conti.

  • Erythema can be seen in Hyperemia(increased flow of blood through engorged arterial vessels as in inflammation, fever, alcohol intake & blushing).Red or bright pink skin changes.

    Polycythemia(increased red blood cells, capillary stasis), Venous stasis(decreased blood flow from the area, engorged venules. Skin changes includes ruddy face, oral mucosa, conjunctiva, hands & feet.

    Conti.Conti.

  • Jaundice is increased serum bilirubin concentration(>2-3mg/100ml) due to liver dysfunction or hemolytic disorders as after burns & infections. Skin changes includes yellowish discoloration firstly in sclera, mucosal membranes & hard palate and then over skin.

    ContiConti

  • Carotenemia is increased level of serum carotene from ingestion of large amounts of carotene rich foods. Skin changes includes yellow-orange tinge in forehead, palms and soles & nasolabial folds, but no yellowish in sclera or mucous membranes.

    Conti.Conti.

  • Brown tan includes Addison's disease( Cortisol deficiency stimulates increased melanin production. Skin changes includes bronzed appearance an external tan most apparent around the nipples, perineum, genitelia & pressure points(inner thighs, buttocks, elbows, axilla)

    Conti.Conti.

  • In instance of pruritis patient is asked to indicate the areas of body involved.

    Skin is then gently stretched to decrease the reddish tone & make the rash more visible.

    Highlight the rash with penlight & assess the differences in skin texture by running the tips of fingers lightly over the skin. T he border of rash may be palpable.

    Assess temperature and palpate lymph nodes

    Assessing rashAssessing rash

  • Skin lesions are the most prominent characteristics of dermatologic conditions.

    They vary in size, shape & cause and are classified according to their appearance and origin.

    Skin lesions can be described as primary & secondary.

    Assessing skin lesionsAssessing skin lesions

  • Macule, Patch Papule, Plaque Nodule, Tumor Vesicle, Bulla Wheal Pustule Cyst

    Primary lesionsPrimary lesions

  • Erosion Ulcer Fissure Scales Crust Scar Keloid Atrophy Lichenification

    Secondary lesionsSecondary lesions

  • Skin lesions are described clearly & in detail on patients health record, using precise terminology:

    Color of lesion Any redness, heat, pain or swelling Size & location Pattern of eruption Distribution of lesion

    Conti.Conti.

  • If open wound or lesion is found on inspection, a comprehensive assessment should be made & documented including following points:

    Wound bed: Inspect for granulation & necrosis of tissues, epithelium, color and odour of exudates.

    Wound edges & margins: observe for undermining i.e. extension of the wound under the wound skin.

    ContiConti

  • Wound size: measure in mm or cm as appropriate to determine diameter & depth of the wound & surrounding erythema.

    Surrounding skin: Asses for color, suppleness, moisture, irritation & scaling.

  • A description of vascular changes includes location, distribution, color, size and the presence of pulsations.

    Common vascular changes includes petechiae, ecchymoses, telangiectases(venous stars) and angiomas.

    Skin moisture, temperature and texture are assessed primarily by palpation.

    The turgor i.e. elasticity of skin which decreases in normal ageing may be a factor in assessing the hydration status of the client.

    Assessing vascularity & hydrationAssessing vascularity & hydration

  • A brief inspection of nails includes observation of configuration, color & consistency.

    Transverse depression in nail known as beaus line may reflect the retarded growth of the nail matrix because of the severe illness or local trauma.

    Ridging, hypertrophy and other changes may also be visible because of local trauma.

    Paronchia an inflammation of the skin around the nails is usually accompanied by tenderness and erythema.

    Assessing the nailsAssessing the nails

  • Pitted surface of nail is a definite indication of psoriasis.

    Spoon shaped nails can indicate a severe iron deficiency anemia.

    The angle between nail and its base is 160 degree and when palpated nail base is usually firm.

    Clubbing of nails which can occur from hypoxia and is manifested by a straightening of normal angle to 180 degree or greater and softening of nail base. The softened area feels sponge like when palpated.

  • The assessment of hair is carried out by inspection and observation.

    Any abnormal lesions, evidence of itching, inflammation, scaling or sign of infestation(lice or mites) are documented.

    Assessing the hairAssessing the hair

  • Natural hair color ranges from black to white. Hair begins to turn gray with age initially during

    third decade of life when the loss of melanin pigment is usually apparent.

    The texture of hair ranges from fine to coarse, silky to brittle, oily to dry, shiny to dull & hair can be straight, curly or kinky.

    Color and textureColor and texture

  • Dry, brittle hairs may results from overuse of hair dyes, hair dryers, curling irons or due to endocrine system disorders.

    Oily hair is usually due to increased secretions from sebaceous glands close to the scalp.

  • Body hair distribution varies with location. Men tend to have more hair on chest and face

    than women. Hair over the most of the body is fine except

    axillae and pubic area where it is coarse. Regrowth may be erratic and distribution may

    never attain the previous thickness.

    Distribution Distribution

  • The most common cause of hair loss is male pattern baldness which affects more than half of the male population and is believed to be related to hereditary, ageing and androgen levels.

    Women tend to retain some of the hair on the crown of the scalp and never go completely bald.

    Hair loss Hair loss

  • Male pattern hair distribution may be seen in women at the time of menopause due to reduced levels of estrogen.

    In women with hirsutism excessive hair growth can be seen on face, chest, shoulders & pubic area.

    Other changesOther changes

  • Skin consequences of selected

    systemic diseases

  • Diabetic dermopathy: shin spots occurs in about 50% of people with diabetes.

    These lesions are found on the lower legs, forearm, thigh and other bony prominences.

    They are caused by breakdown of small vessels that supply skin.

    Each spot starts as dull red bump smaller than a pencil eraser.

    Diabetes mellitus

  • Statis dermatitis: Large vessels are damaged that results in compromising blood supply to lower arms and legs.

    The skin suffers from lack of nutrients becoming dry and fragile.

    Skin infections: bacterial infection appear as small as pimple around the hair follicles.

    Fungal infections appears mostly on moist areas as beefy red and have small pustules around the border.

  • Leg & foot ulcers: Because of changes in peripheral nerves patient with diabetes do not always sense minor injuries to the lower legs & foot.

    Infections begins and if left untreated leads to ulcerations.

  • Cutaneous signs are the first manifestation of HIV disease appearing in 90% of the patients.

    These skin signs correlate with CD4 counts and may become very typical.

    HIV Disease

  • Diagnostic Evaluation

  • Performed to obtain tissue for microscopic examination.

    It may be performed by scalpel excision or by a skin punch instrument that removes a small amount of tissue.

    It is performed on skin nodules, plaques, blisters and other lesions to rule out malignancy.

    Skin biopsy

  • It is designed to rule out the site of an immune reaction.

    It combines antigen or antibody with a fluorescent dye.

    It may be direct and indirect.

    Immunofluorescence

  • Performed to identify the substances to which the patient has developed allergy.

    It includes applying the suspected allergen to normal skin under occlusive patches.

    The development of redness, fine elevations or itching is considered as weak positive reaction.

    Fine blisters, papules and severe itching indicate moderately positive reaction.

    Blisters, pain and ulcerations indicates strong positive reaction.

    Patch testing

  • Tissue samples are scraped from suspected fungal lesions with a scalpel blade moistened with oil.

    The scrapped tissues are placed on glass slide and examined microscopically e.g. for scabies.

    Skin scrapings

  • It is a test used to examine cells from blistering skin conditions such as herpes zoster, varicella and all forms of pemphigus.

    The secretions are applied to glass slide, stained and examined microscopically.

    Tzanck smear

  • It is a special lamp that produces long wave Uv rays which results in a dark purple fluorescence.

    The lesions that still contain melanin almost disappear under UV light where as lesions that are devoid of melanin increase in whiteness with UV light.

    Woods light examination

  • Photographs are taken to document the nature and extent of the skin condition& are used to determine the progress or improvement resulting from treatment.

    They are sometimes used to track the status of moles to document if the characteristics of the mole are changing.

    Clinical photographs

    Slide 1Anatomy & physiologyEpidermisSlide 4DermisSubcutaneous tissueFunctions of skinSlide 8Health historyPhysical examinationAssessing the skin colorConti.Conti.ContiConti.Conti.Assessing rashAssessing skin lesionsPrimary lesionsSecondary lesionsConti.ContiSlide 23Assessing vascularity & hydrationAssessing the nailsSlide 26Assessing the hairColor and textureSlide 29DistributionHair lossOther changesSlide 33Diabetes mellitusSlide 35Slide 36HIV DiseaseSlide 38Skin biopsyImmunofluorescencePatch testingSkin scrapingsTzanck smearWoods light examinationClinical photographs