Integumentary

• Integument


  Includes the skin, hair, and nails
• Epidermis


  • Outermost portion composed of stratum corneum plus cellular stratum
  • Protective layer, waterproofing layer
  • Provides pigment or color to skin
  • Forms nails and hair
• Dermis


  • Vascular connective layer that separates epidermis from adipose tissue
  • Sensory nerves and autonomic motor nerves are found here
  • Sweat glands and hair follicles originate in dermis
• Hypodermis


  • Dermis connected to underlying organs by the hypodermis, a loosely connective tissue filled with fatty cells
  • Adipose tissue generates heat, provides insulation, shock absorption, and a reserve of calories
• Glands found in skin

  • Eccrine Sweat Glands
  • Apocrine Glands
  • Sebaceous glands
• Eccrine Sweat Glands


  Sweat glands to regulate body temperature
• Apocrine Glands


  Secrete odorless fluid in response to emotional or sexual stimuli. Found in the axillae, nipples, anogenital area, eyelids, and ears. Bacterial growth causes odor.
• Sebaceous glands


  Secrete sebum to keep skin and hair lubricated. Secretion varies in response to sex hormones (primarily testosterone)
• Roles of the skin

  • Protection from microbial invasion and minor trauma
  • Retards body fluid loss
  • Regulates body temperature
  • Provides sensory perception
  • Produces vitamin D from precursors
  • Contributes to blood pressure regulation
  • Repairs surface wounds - scar formation
  • Excretes sweat, urea, and lactic acid
  • Expresses emotions

  
• Equipment for assessing the skin

  • Millimeter ruler - measuring skin lesions
  • Clean gloves
  • Magnifying glass

  
• Implementation of skin assessment

  1. Introduce self, verify client's identity and explain what you are going to do

  2. Perform hand hygiene and observe appropriate infection control procedures

  3. Provide client privacy

  4. Inquire about patient history

  5. Inspect skin color

  6. Inspect uniformity of skin color

  7. Assess edema

  8. Inspect, palpate and describe skin lesions

  9. Observe and palpate skin moisture

  10. Palpate skin temperature

  11. Note skin turgor by lifting and pinching the skin

  12. Document findings in the client record

  
• Scale for describing edema

  • 1+ (2mm depression, barely detectable, immediate rebound)
  • 2+ (4mm deep pit, a few seconds to rebound)
  • 3+ (6mm deep pit, 10-12 seconds to rebound)
  • 4+ (8mm, very deep pit, >20 seconds to rebound)
• Primary skin lesions


  • Macule
  • Patch
  • Papule
  • Plaque
  • Nodule
  • Tumor
  • Vesicle, bulla
  • Pustule
  • Wheal

  
• Secondary skin lesions


  • Atrophy, erosion, lichenification, scales, crust, ulcer, fissure, scar, keloid, excoriation

  
• Acanthosis Nigricans


  Dry thickened hyperpigmented skin with linear fissures across posterior neck, commonly in obese patients

  
• Lichenification


  Symmetrical pattern of lesion on flexor surfaces of knees and elbows, intense itching
• Lifespan considerations for skin

  • Infants (physiologic jaundice, milia, vernix caseosa, lanugo, Mongolian spots)
  • Children (normally have minor lesions, secondary lesions may frequently occur, oil glands become more productive with puberty)
  • Elders (skin loses elasticity, thin and translucent, loss of dermis and subcutaneous fat, dry and flaky, senile lentigines or melatonin freckles, vitiligo)
• Nail assessment


  • Color
  • Shape
  • Lesions
  • Capillary refill (blanch test)
• Clubbing


  Dorsal phalanx rounder and bulbous, convexity of nail plate increased, angle between plate and proximal fold increased to 180deg or more, proximal fold feel spongy. Many causes including chronic hypoxia and lung cancer.

  
• Paronychia


  Inflammation of proximal and lateral nail folds, acute or chronic. Folds red, swollen, may be tender.
• Anonychia


  Complete absence of nails
• Platunychia


  Flatting nails
• Onycholysis


  Painless separation of nail plate from nail bed, starting distally. Many causes.
• Terry's nails


  Whitish with a distal band of reddish brown. Seen in aging and some chronic diseases.
• Leukonychia


  White spots caused by trauma. They grow out with nail.

  
• Transverse white lines


  Bands appearing in the nail plate are often caused by trauma to the more proximal matrix in the area of the proximal nail fold; however, some bands, such as Mees lines and Muehrcke lines, are associated with systemic disease.
• Splinter hemorrhages


  Tiny blood clots that tend to run vertically under the nails. In certain conditions (in particular, infective endocarditis) clots can migrate from the affected heart valve and find their way into various parts of the body.
• Hair assessment


  • Quantity (thin, thick)
  • Distribution (patchy or total alopecia)
  • Texture (fine, coarse)
• Alopecia areata


  • Clearly demarcated round or oval patches of hair loss, usually affecting young adults and children. There is no visible scaling or inflammation.
• Trichotillomania


  • Hair loss from pulling, plucking, or twisting hair. Hair shafts are broken and of varying lengths. More common in children, in setting of family or psychosocial stress.
• Tinea Capitis (Ringworm)


  • Round scaling patches of alopecia. Hair broken off close to surface of scalp. Usually caused by Trichophyton tonsurans from humans, microsporum canis from dogs or cats. Mimics seborrheic dermatitis.