The Integumentary System

Sasha Alexis Rarang, RN, MSNNURS 120 Instructor

The integument as an organ:

• Alternative name for skin.• The integumentary system includes the skin and the skin derivatives hair, nails, and glands. • The integument is the body’s largest organ and accounts for 15% of body weight.

The skin

The skin

Functions of the skin:

ThermoregulationVitamin D

production ProtectionAbsorption &

secretion Wound healing

The Two Layers of Skin:

Epidermis – The Epidermis is the thinner more superficial layer of the skin.

Dermis: is the deeper, thicker layer composed of connective tissue, blood vessels, nerves, glands and hair follicles.

Five distinct sub-layers of the Epidermis:

Stratum corneum: the outermost layer. replaced.

Stratum lucidum: Only found in the fingertips, palms of hands, & soles of feet. This layer is made up of 3-5 layers of flat dead keratinocytes.

Stratum granulosum: made up of 3-5 layers of keratinocytes, site of keratin formation,

Stratum spinosum: appears covered in thornlike spikes, provide strength & flexibility to the skin.

Stratum basale: The deepest layer, made up of a single layer of cuboidal or columnar cells. Cells produced here are constantly divide & move up to apical surface.

The Dermis

There are two main divisions of the dermal layer: ◦Papillary region - The superficial layer of the dermis,

made up of loose areolar connective tissue with elastic  fibers.

◦Dermal papillae - Fingerlike structures invade the epidermis, contain capillaries or Meissner corpuscles which respond to touch.

Reticular region of the Dermis – Made up of dense irregular connective & adipose tissue, contains sweat lands, sebaceous (oil) glands, & blood vessels.

Factors that influence Color

The outer layer is called the epidermis; it is a tough protective layer that contains melanin (which protects against the rays of the sun and gives the skin its color).

Dermal melanin is produced by melanocytes. which are found in the stratum basale of the epidermis.

Some individual animals and humans have very little or no melanin in their bodies, a condition known as albinism.

Because melanin is an aggregate of smaller component molecules, there are a number of different types of melanin with differing proportions and bonding patterns of these component molecules.

Both pheomelanin and eumelanin are found in human skin and hair, but eumelanin is the most abundant melanin in humans, as well as the form most likely to be deficient in albinism.

Techniques of assessing the integumentary system.

Assessing Clients with Integumentary Disorders

Functional HealthUse the following health history questions and

leading statements, categorized by functional health patterns, with a family member, friend, or client.

Identify areas for focused physical assessment based on findings from the health history.

Assessing the Integumentary System

Techniques of assessing the Integumentary system.

1. Health Perception-Health Management Have pt. describe any skin problems or injuries,

nail problems, and/or scalp problems you have had. How was pt. problem treated? Ask pt. to describe current problem. Ask pt. if taking any medications for this problem?

If so, what does he or she takes, and how often? Did pt. recently had any insect bites? Explain. Have pt. describe any food, drug, plant, or animal

allergies she/he have. Ask pt. to describe how he/she care for her skin.

Techniques of assessing the Integumentary system.

2. Nutritional-Metabolic Ask pt. to describe usual intake of fluids and food

over a 24-hour period. Ask pt. if pt. made any changes in her diet or have

recently introduced new foods into diet? What are they? When did he/she eat them?

How well do skin cuts or scratches heal? Has there been a recent change in the way pt. heal?

3. Elimination Is pt.’s skin and/or scalp dry or oily? Does the pt. perspire heavily?

Techniques of assessing the Integumentary system.

4. Activity-Exercise Ask pt. to describe her/his usual activities in a 24-hour period. How much sun exposure does pt. get? Does she or he use

sunscreen or sun-block products? Does he/she bruise easily? Ask pt. to explain.

5. Sleep-Rest How many hours of sleep does the pt. get each night? Does itching or sweating wake the pt. at night? Is pt. unable to rest because of a skin problem?

6. Cognitive-Perceptual Does the pt. have any skin pain, including itching, burning,

stinging, tingling, achiness, tenderness, or numbness? Ask pt. to explain.

Techniques of assessing the Integumentary system.

7. Self-Perception-Self-Concept

Describe the appearance of pt. skin, hair, and nails. Does the pt. have a rash or open area on her/his skin? If so, where is it

located? What size and shape is it? Is it flat or raised? Does it have any drainage from it? How long pt. had the rash or open area? What precipitates or relieves

it? Ask pt. to describe any changes she/he have recently noticed in the

appearance of a mole (such as changes in color and size, bleeding, or pain).

Had pt. recently lost any hair? From where, and how much? Had pt.’s nails changed in color or shape? Have they become more

brittle? Has a problem with pt. skin, scalp, or nails affected how the pt. feel

about her/himself? Has a problem with skin, scalp, or nails affected how he/she feel about

his/her normal life?

Techniques of assessing the Integumentary system.

8. Role-Relationship Is there a history of allergic disorders or skin problems in pt’s

family? Ask pt. to describe. Is pt’s problem with her/his skin affected her relationships with

others in her/his family? At work? In social activities? Ask pt. to explain.

Is a problem with pt.’s skin or scalp affected her/his ability to work? Explain.

9. Sexuality-Reproductive Has a health problem with pt. skin or scalp interfered with or

changed her/his usual sexual activities? Ask pt. to explain. Describe how problems with pt.’s skin, scalp, or nails have

made her/him feel about her/himself as a man or woman.

Techniques of assessing the Integumentary system.

10. Coping-Stress Does pt’s skin problem seems to become

worse when he/she experience increased stress? Explain.

Are health problems with pt. skin created stress for him/her? Explain.

Describe what pt. do to cope with stress. Who or what will be able to help pt. cope with

stress from this skin problem? 11. Value-Belief How will this health problem affect pt. future?

Integumentary Problems

Pressure Ulcers - Tissue necrosis commonly occurring

adjacent to bony prominences caused by unrelieved pressure blocking blood flow to the region.

- Most common sitesSacrumHeels

Pressure Ulcer – heel

Pressure Ulcer- sacrum

Risk Factors

Skin changes related to agingImmobilityIncontinence or excessive moistureSkin friction and shearingVascular DisordersObesity

Contributing Factors

Inadequate nutrition and/or hydration.AnemiaFeverImpaired circulationEdemaSensory deficitsLow diastolic blood pressureImpaired cognitive functioningNeurological disordersChronic Diseases – e.g. Diabetes Millitus, Chronic

Renal Failure, CHDs, CLD

Diagnostic Procedures

Wound Culture and SensitivityCBC with DifferentialBlood CulturesSerum albumin and Pre-albumin

Assessment

Monitor for s/s – assess stage of the wound

Wound Stages ( pressure ulcer)Some ulcers cannot be stagedAssess/monitor - Alteration in skin integrity- Skin Moisture status- Incontinence- Nutritional status- See Braden Scale assessment tool.

Stage I

Nonblanchable erythema of intact skin the heralding lesion of skin ulceration. In individuals with darker skin, discoloration, warmth, edema, induration, or hardness may be indicators.

Intact skin with some observable damage such as redness or a boggy feel.

Does not blanchRecersible if pressure is relieved.

Nursing Intervention

Relieve pressureFrequent turning repositioningUse pressure relieving devices such as air

fluidized bed.Utilize pressure reduction surfaces ( air

mattress, foam mattress)Keep the client dry, clean, and well-

nourished and hydrated.

Stage II

Partial thickness skin loss involving epidermis, dermis, or both. The lesion is superficial and presents clinically as an abrasion, blister, or shallow center.

Lesion present as an abrasion, shallow crater, or blister

May appear swollen and painfulTakes several weeks to heal after pressure

is relieve.

Nursing Interventions

Maintain a moist healing environment. (saline or occlusive dressing)Promote naturalhealing whilepreventing

formation of scar tissue.Provide nutritional supplement as needed Protein supplement PROSTAT,(vitamins

and mineral e.g. zinc sulfate, Vitamin C)Administer analgesics as needed.

Staqe III

Full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The sore presents clinically as a deep crater with or without undermining of adjacent tissue.

Shallow or deep.May have deep crater with or without undermining

of adjacent tissue and maybe foul smelling purulent drainage if locally infected.

Yellow slough/and or necrotic tissue in wound bedMay require several months to heal after pressure is

relieved.

Nursing Interventions

Clean and/or debride – 1. wet to dry dressing2. surgical intervention3. Proteolytic enzymes – e.g. accuzyme. Provide nutritional supplement prn. Administer analgesics prn Administer antimicrobials ( topical or

systemic)

Stage IV

Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, tendon, bone, or supporting structures.

Deep. Lesion may appear small in the surface but can

have extensive tunneling out of sight beneath superficial tissues and usually includes a foul smelling discharge.

Local infection can easily spread causing sepsisMay take months or several years to heal.

Nursing Interventions

Perform non-adherent dressing chage q 12 hours

May require skin grafts.Provide nutritional supplement as needed.Administer analgesics as needed.Administer antimicrobials ( topical or

systemic)

Prevention of Pressure Ulcers

Maintain clean, dry skin and wrinkle free linens.

Repositions clients in bed at least every 2 hours and every 1 hour if sitting in chair.

Provide adequate hydration (2000 to 3000 ml/day) and meet protein and calorie needs

Complications and Nursing considerations

DeteriorationSystemic InfectionsNursing ConsiderationsWhen planning interventions to promote wound

healing, the nurse understands that elevated blood glucose will impact on multiple factors.

Full thickness wounds heal by secondary intention and much of the skin and skeletal muscle will be replaced by connective tissue, some scar tissue will form.

Nursing considerations

Applying of antimicrobials ointment is not included in wet-to-dry dressing.

Client should get pain medication prior to starting dressing change.

Wet-to-dry dressing is used when there is minimal eschar to be removed.

A full thickness wound filled with eschar will require interventions such as surgical debridement to remove necrotic tissues.

In full thickness skin destruction, the area is painless because of the associated nerve destruction.

Chronic corticosteroid use will interfere with wound healing.

Therapeutic Procedures

Vacuum-Assisted Wound ClosureHyperbaric oxygen TherapySurgical debridement and/or wound

grafting.

Care of Clients with Burn

Burns are 6th leading cause of accidental death in the U.S.

Causes – thermal, chemical, electrical, radioactive agents.

Results to loss of temperature regulation.Loss of sensory function.Evaluating extent of damage: need to

know;1. Type of burning agent2. Duration of contact3. Site of injury

Areas most vulnerable to burns

EyelidsEarsNoseGenitaliaAnd the tops of the hands and feets

( including fingers and toes).

Classifications

Superficial PartialThickness

Deep Partial Thickness

Full Thickness

Deep Full Thickness

Tissue layer damage

Epedermis Entire epedermis to some of dermis

Extend to deeper layer of the dermis

Ertire Dermis Entire dermis and subq skin Can not heal on its own.

Color Pink to red Pink to red Red to white Black, brown, yellow

Black

Blister No yes rare No No

Edema Mild Mild to moderate

Moderate Severe Absent

Pain Yes Yes yes Yes and No Absent

Eschar No No No Yes, soft and dry

Yes, hard and inelastic

Yes, hard and elastic

Tx No emergency care needed

No emergency care needed

Depending on the area, a local ED

ER at the scene and transfer to burn center

Care and nearest ED and transfer to burn center

Healing 3-5 days 2 weeks 2-6 weeks Weeks to months

Weeks to months

Risk for Death from Burns

Age more than 60 yearsBurn involves > 40 % total body surfaceInhalation Injury

Diagnostic Procedures

Lab values: CBC, serum electrolyes, BUN, arterial

blood gas (ABGs) fasting blood glucose, liver enzymes, urinalysis, and clotting studies.

Initial fluid shift ( first 24 hours after injuryFluid mobilization ( 48-72 hours after injury

Assessment

Assess/monitor:Head to toe assessmentAirway patency ( esp. burn in the face and in

close door spaces.Signed hair in the nostrils – inhalation injuryOxygenation statusV/S, heart rhythm esp. electrical burnsFluid status

Circulatory status – hypovolemiaSize and depth of burns (BSA) rule of nine, lund

browder.

Calculcation of Burned BSA

Estimation of Surface AreaUse a Burn diagram (LUND-BROWDER)  to

accurately calculate the area burnt, however do not count skin with isolated erythema (no blistering)

As a rough measure, the child's palm represents about 1% of total body surface.

Rule of Nine

Assessment

Size and depth of burnsRenal function – urine output decreased

first 24 hours.Bowel sound – commonly reduced/absent.Stool and emesis for evidence of bleeding

(ulcer risk)

Nursing Interventions

Ensure airway patency – intubation , trach provide O2 if prnMaintain thermodynamics ( warm room,

cover with blanket)Monitor V/s pulses, cap refill ( check for

evidence of shock.Administer fluid ionotropic agents ,

osmotic diureticsas needed to maintain adequate cardiac output and tissue perfusion.

Begin IV and electrolyte replacement .

Burn resuscitation Formula

Parkland Formula for Treating Burn Victims. For burn victims, fluid resuscitation is critical within the first

24 hours. The amount of fluid resuscitation can be determined from the percentage of body surface area (%BSA) involved. "Rule of 9's" can estimate the %BSA.

The Parkland Formula is as follows.Fluid for first 24 hours (ml) = 4 * Patient's weight in kg * %BSAAfterwards, the first half of this amount is delivered in the first 8 hours, and the remaining half is delivered in the remaining 16 hours.

The "Rule of 9's" is as follows.Head and each arm = 9%Back and chest each = 18%Each leg = 18%Perineum = 1%

Nursing Interventions

Keep the client NPO. Administer H2 Antagonists. Elevate client’s extremities Encourage client to cough and deep breathe and to utilize

incentive spirometry. Administer tetanus prophylaxis per hospital protocol. Implement infection control measures. Apply topical

antimicrobials such as Silver Sulfadiazine ( Silvadene Creame). Wound care and dressing changes to prevent scarring and

edema. Monitor and assess for pain. Provide nutrition support as ordered. Dietician consult is

important for proper caloric and protein needs. ( High protein intake is needed for wound healing) Encourage ROM – to prevent immobility and use of splints to

correct positioning. Collaborative care. Initiate referrals as appropriate.

Complications

Airway Injury – progressive hoarseness of voice, brassy cough, drooling and expiratory sounds that include audible wheeze, crowing and stridor. Rapid obstruction in short time. Carbon Monoxide poisoning

Thermal heat injuries such as steam inhalation.Chemical Inhalation. Inadequate Tissue Perfusion – circumferential

burns ( extremities, thorax). Escharotomy and or fasciotomy to relieve

compartment pressure and/or to facilitate breathing.

Care of Client with Burn

With chemical burrns, the initial action is to remove the chemical from contact with the skin as quick as possible.

Electrical burns should be considered at risk for cervical spinal injury and assessment of extremity movement will provide baseline data.

Urine output during emergent phase should be at least 30-50 ml/hr, when the client is at greater risk for hypovolemic shock.

Care of Client with Burn

See parklands formula:Blood pressure of a burn patient during

the emergent phase should be > 90 SBP and the pulse should be < 120.

Hydrotherapy leads to loss of sodium from open burns into the bath water, which is hypotonic.

Clients with large burn surface requires a room temperature of 85 degrees Fahrenheit during dressing.

Care of Client with Burns

At the end of emergent phase, capillary permeability normalizes and the client begins to diures large amount of urine with low specific gravity.

Burn patients ( upper body) should be placed in fowler’s position to make ventilation easier.

No pillows under the head with neck burns.

Arms and hands should be extended to avoid flexure contractures.

Care of Client with Burns

Systemic antibiotics are not well absorbed into deep burns because of lack of circulation.

Enteral feeding can usually be initiated during emergent phase at low rate and increase over 24 to 48 hours to goal rate.

Parenteral nutrition increases the infection risk, does not help preserve GI function, and is not routinely used in burn patients.