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 germinativum

o Stratum granulosum

o Stratum lucidum

o 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.

Conti…Conti…

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

patient’s 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.

Conti…Conti…

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 beau’s 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.

Wood’s 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