Integumentary System

 Skin and accessory structures

 Hair
 Nails
Skin

 Largest Organ of the Body

 Protection from environment
 Temperature regulation
 Synthesis of vitamin D
 Storage of fat and blood
 Excretion of waste
 Sensation
 Composed of the Epidermis, Dermis and
Subcutaneous layer
Figure 11.1 Skin structure. Three-dimensional view of the skin, subcutaneous tissue, glands, and hairs.
 Three Layers of Skin
Three Layers of the Skin

Epidermis or stratified squamous epithelium Stratum corneum

Basal layer includes

melanocytes

Dermis or corium Nerves, vessels, glands, hair follicles

Subcutaneous Connective tissue (mostly lipocytes)

4
Epidermis
 The epidermis is an outermost layer of stratified
epithelial cells (predominantly of keratinocytes). It
ranges in thickness from about 0.1 mm on the eyelids to
about 1 mm on the palms of the hands and soles of the
feet.
 Four distinct layers compose the epidermis
 stratum germinativum,
 stratum granulosum,
 stratum lucidum,
 And stratum corneum.
 Keratin: an insoluble, fibrous protein that forms the
outer barrier of the skin and has the capacity to repel
pathogens and prevent excessive fluid loss from the
body. It is the principal hardening ingredient of the hair
and nails.
 Cont.
 Melanocytes : special cells of the epidermis that are
primarily involved in producing the pigment melanin,
which colors the skin and hair.
 Systemic disease affects skin color as well. For
example, the skin appears
 bluish -insufficient oxygenation of the blood,
 yellow-green -jaundice,
 or red or flushed - inflammation or fever.
 Production of melanin is controlled by a hormone
secreted from the hypothalamus of the brain called
melanocyte-stimulating hormone.
 It is believed that melanin can absorb ultraviolet light in
sunlight.
 Cont.
 Merkel cells : These are receptors that transmit stimuli
to the axon through a chemical synapse.
 Langerhans cells : play a significant role in cutaneous
immune system reactions. These accessory cells of the
afferent immune system process invading antigens and
transport the antigens to the lymph system to activate
the T lymphocytes.
 Calluses & corns
 Cont.
 Rete ridges: junction of the epidermis and dermis. It is
an area of many undulations and furrows.
 This junction anchors the epidermis to the dermis and
permits the free exchange of essential nutrients
between the two layers.
 It produces ripples on the surface of the skin. On the
fingertips, these ripples are called fingerprints.
Dermis
 largest portion of the skin, providing strength and
structure.
 Composed of two layers: papillary and reticular.
 The papillary dermis lies directly beneath the epidermis
and is composed primarily of fibroblast cells capable of
producing one form of collagen, a component of
connective tissue.
 The reticular layer lies beneath the papillary layer and
also produces collagen and elastic bundles.
 It is also made up of blood and lymph vessels, nerves,
sweat and sebaceous glands, and hair roots.
 often referred to as the “true skin.”
Subcutaneous tissue
 hypodermis, is the innermost layer of the skin.
 primarily adipose tissue, which provides a cushion
between the skin layers, muscles, and bones.
 promotes skin mobility, molds body contours, and
insulates the body.
 Hair
 Outgrowth of skin
 The hair consists of a root formed in the
dermis and a hair shaft that projects
beyond the skin. It grows in a cavity
called a hair follicle.
 Proliferation of cells in the bulb of the
hair causes the hair to form
 Hair follicles undergo cycles of growth
and rest.
 The growth or anagen phase may last up
to 6 years for scalp hair, whereas the
telogen or resting phase lasts
approximately 4 months.
 There is a small bulge on the side of the
hair follicle that houses the stem cells
that migrate down to the follicle root and
begin the cycle of reproducing the hair
shaft. These bulges also contain the stem
cells that migrate upward to reproduce
skin.
 In certain locations on the body, hair
growth is controlled by sex hormones.
 Nails
 a hard, transparent plate of keratin, on the dorsal surface of
the fingers and toes
 It grows from its root, which lies under a thin fold of skin
called the cuticle.
 The nail protects the fingers and toes by preserving their highly
developed sensory functions, such as for picking up small
objects.
 Nail growth is continuous throughout life, with an average
growth of 0.1 mm daily.
 Growth is faster in fingernails than toenails and tends to slow
with aging.
 Complete renewal of a fingernail takes about 170 days,
whereas toenail renewal takes 12 to 18 months.
 Nails
Nails
•Nails are plates
made of hard keratin
that cover the dorsal
surface of the fingers
and toes.

•At the base of most nails a lunula or whitish

half-moon is an area where keratin and other
cells have mixed with air.

•The cuticle is a narrow band of epidermis that

surrounds the base or bottom of nails.
13
Glands of Skin
 sebaceous glands and sweat glands
 The sebaceous glands are associated with hair
follicles.
 The ducts of the sebaceous glands empty sebum onto
the space between the hair follicle and the hair shaft,
thus lubricating the hair and rendering the skin soft and
pliable.
 Sweat glands are found in the skin over most of the
body surface, but they are most heavily concentrated in
the palms of the hands and soles of the feet.
 Only the glans penis, the margins of the lips, the
external ear, and the nail bed are devoid of sweat
glands.
 The rate of sweat secretion is under the control of the
sympathetic nervous system.
Sweat glands are sub classified
into two categories
The Major Functions of the Skin
 Perceiving touch, pressure, temperature, and pain via the nerve
endings
 Protecting against mechanical, chemical, thermal, and solar
damage
 Protecting against loss of water and electrolytes
 Regulating body temperature
 Repairing surface wounds through cellular replacement
 Synthesizing vitamin D
 Allowing identification through uniqueness of facial contours,
skin and hair color, and fingerprints
Assessment
 Health History
 Physical Assessment
 Skin colour,
 Skin rash,
 Skin lesion,
 vascularity and hydration,
 assessing hairs and nails.
 Skin Colour
Pallor
Anemia—decreased hematocrit
Shock—decreased perfusion,vasoconstriction Local
arterial insufficiency
Albinism—total absence of pigment melanin
Vitiligo—a condition characterized by destruction of the
melanocytes in circumscribed areas of the skin (may be
localized or widespread)
Cyanosis
Increased amount of unoxygenated hemoglobin:
Central—chronic heart and lung diseases cause arterial
desaturation
Peripheral—exposure to cold, anxiety
 Cont.

Erythema
Hyperemia—increased blood flow through engorged
arterial vessels, as in inflammation, fever, alcohol intake,
blushing
Polycythemia—increased red blood cells, capillary stasis
Carbon monoxide poisoning
Venous stasis—decreased blood flow from area, engorged
venoules
 Cont.

Jaundice
Increased serum bilirubin concentration(23 mg/100 mL)
due to liver dysfunction or hemolysis, as after severe burns
or some infections
Carotenemia—increased level of serum carotene from
ingestion of large amounts of carotene-rich foods
Uremia—renal failure causes retained urochrome
pigments in the blood
Brown-Tan
Addison’s disease—cortisol deficiency stimulates
increased melanin production
Café-au-lait spots—caused by increased melanin pigment
in basal cell layer
 Cont.
Café-au-lait spots Jaundice
Skin Lesion

• Primary lesions are areas of tissue that are altered

because of a pathological condition.
• Secondary lesions result from changes in the primary
lesions.
• Vascular lesions are blood vessel lesions that show
through the skin.
Primary Lesions
Types of Skin Lesions

26
Distribution of Skin Lesion
Assessment of Nails
 Transverse depressions known as Beau’s lines in the
nails may reflect retarded growth of the nail matrix
because of severe illness or, more commonly, local
trauma.
 Paronychia, an inflammation of the skin around the nail,
is usually accompanied by tenderness and erythema.
 Pitted surface of the nails is a definite indication of
psoriasis.
 Spoon-shape nails can indicate a severe iron deficiency
anemia.
 Clubbing of the nails, which can occur from hypoxia, is
manifested by a straightening of the normal angle (180
degrees or greater) and softening of the nail base. The
softened area feels sponge like when palpated.
Figure 11.83 Spoon nails (Koilonychia).
Figure 11.85 Beau’s line.
Assessment of Hairs
 Colour, Distribution , Texture and hair loss
 It is believed to be related to heredity, aging, and
androgen(male hormone) levels. Androgen is necessary
for male pattern baldness to develop.
 The pattern of hair loss begins with receding of the
hairline in the frontal-temporal area and progresses to
gradual thinning and complete loss of hair over the top
of the scalp and crown.
 Exudate/Fungi
•Exudate (pus) is material that passes out of
tissues. The laboratory can use this to determine
the types of bacteria present.

•A scraping can also be done and placed on a

growth medium to identify the presence of fungi.
33
Diagnostic Evaluation

 Skin Biopsy : performed on skin nodules, plaques,

blisters, and other lesions to rule out malignancy
 Immunofluorescence: Designed to identify the site of
an immune reaction. It combines an antigen or antibody
with a fluorochrome dye. Antibodies can be made
fluorescent by attaching them to a dye. (Direct
immunofluorescence and Indirect immunofluorescence)
 Patch Testing : Performed to identify substances to
which the patient has developed an allergy, patch
testing involves applying the suspected allergens to
normal skin under occlusive patches.
 development of redness, fine elevations, or itching is
considered a weak positive reaction;
 fine blisters, papules, and severe itching indicate a
moderately positive reaction;
 and blisters, pain, and ulceration indicate a strong
positive reaction.
 Skin Scrapings
 Tissue samples are scraped from suspected fungal
lesions with a scalpel blade moistened with oil so that
the scraped skin adheres to the blade. The scraped
material is transferred to a glass slide, covered with a
coverslip, and examined microscopically.
 The spores and hyphae of dermatophyte infections, as
well as infestations such as scabies, can be visualized.
 Tzanck Smear : used to examine cells from blistering
skin conditions, such as herpes zoster, varicella,
herpessimplex, and all forms of pemphigus.
 The secretions from a suspected lesion are applied to a
glass slide, stained, and examined.
 Wood’s Light Examination
 Wood’s light is a special lamp that produces long-wave
ultravioletrays, which result in a characteristic dark
purple fluorescence.
 The color of the fluorescent light is best seenin a
darkened room, where it is possible to differentiate
epidermal from dermal lesions and hypopigmented and
hyperpigmented lesions from normal skin.
 Lesions that still contain melanin almost disappear under
ultraviolet light, whereas lesions that are devoid of
melanin increase in whiteness with ultraviolet light.
Wood’s Light Examination
 Clinical Photographs
 Photographs are taken
to document the nature
and extent of the skin
condition and are used
to determine 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.
Thank You
 Primary Lesions

Macule and Patch

Flat, nonpalpable skin color
change (color may be brown,
white, tan, purple, red)
• Macule: less than 1 cm,
circumscribed border
• Patch: greater than 1 cm,
may have irregular border
Papule and Plaque
Elevated, palpable, solid mass
with a circumscribed border
Plaque may be coalesced
papules with flat top
• Papule: less than 0.5 cm
• Plaque: greater than 0.5 cm
Specific Questions

 Illness or infection
 Symptoms
 Pain
 Behaviors
 Infants and children
 Pregnant females
 Older adults
 Environment
Box 11.2 Self-
Examination of the Skin
Removal of:

 Clothing
 Jewelry
 Cosmetics
 Wigs
 Hairpieces
Abnormal Skin Findings

 Primary and secondary lesions

 Vascular lesions
 Purpuric lesions
 Infections
 Malignant lesions
 ABCDE Criteria
Figure 11.22 ABCDE Criteria for Melanoma Assessment
Table 11.2 Potential
Secondary Sources for
Client Data Related to the
Skin, Hair, and Nails
Figure 11.29 Spoon nail.
Figure 11.30 Hemangioma.
Figure 11.31 Port-wine stain (nevus flammeus).
Figure 11.32 Spider (star) angioma.
Figure 11.33 Venous lake.
Figure 11.34 Petechiae.
Figure 11.35 Purpura.
Figure 11.36 Ecchymosis (bruise).
Figure 11.37 Hematoma.
Figure 11.38 Macule and patch.
Figure 11.39 Papule and plaque.
Figure 11.40 Nodule and tumor.
Figure 11.41 Vesicle and bulla.
Figure 11.42 Wheal.
Figure 11.43 Pustule.
Figure 11.44 Cyst.
Figure 11.45 Atrophy.
Figure 11.46 Erosion.
Figure 11.47 Lichenification.
Figure 11.48 Scales.
Figure 11.49 Crust.
Figure 11.50 Ulcer.
Figure 11.51 Fissure.
Figure 11.52 Scar.
Skin Lesions

 Tinea
 Measles
 Varicella
 Herpes
 Psoriasis
 Dermatitis
 Eczema
 Impetigo
Figure 11.63 Tinea corporis.
Figure 11.64 Measles (rubeola).
Figure 11.65 German measles (rubella).
Figure 11.66 Chickenpox (varicella).
Figure 11.67 Herpes simplex.
Figure 11.68 Herpes zoster (shingles).
Figure 11.69 Psoriasis.
Figure 11.70 Contact dermatitis.
Figure 11.71 Eczema (atopic dermatitis).
Figure 11.72 Impetigo.
Malignant Lesions

 Basal cell carcinoma

 Squamous cell carcinoma
 Malignant melanoma
 Kaposi’s sarcoma
Figure 11.73 Basal cell carcinoma.
Figure 11.74 Squamous cell carcinoma.
Figure 11.75 Malignant melanoma.
Figure 11.76 Kaposi’s sarcoma.
Abnormal Hair Findings

 Seborrhea
 Tinea capitis
 Alopecia areata
 Infection
 Folliculitis
 Furuncles
 Hirsutism
Figure 11.77 Seborrheic dermatitis (cradle cap).
Figure 11.78 Tinea capitis (scalp ringworm).
Figure 11.79 Alopecia areata.
Figure 11.80 Folliculitis.
Figure 11.81 Furuncle/abscess.
Figure 11.82 Hirsutism.
Abnormal Nail Findings

 Spoon nails
 Paronychia
 Beau’s line
 Splinter hemorrhage
 Onycholysis
Figure 11.84 Paronychia.
Figure 11.86 Splinter hemorrhages.
Figure 11.88 Onycholysis.
Special Considerations

 Developmental, Psychosocial, Cultural, and Environmental

Developmental Considerations

 Pediatric
 Newborn skin is covered with vernix caseosa.
 Infants have skin that is thin, soft, and free of terminal hair.
 Milia and “Stork bites” are common, harmless markings in
newborns
 Infants may be born with lanugo present
 Temperature regulation is inefficient in infants.
Figure 11.3 Milia.
Figure 11.4 Mongolian spots.
Developmental Considerations

 Pregnant Female
 Skin pigmentation increases.
 Development of melasma and the linea nigra are common
Figure 11.6 Melasma.
Figure 11.7 Linea nigra.
Developmental Considerations

 Geriatric
 Skin elasticity decreases with aging
 Sebum production decreases and causes dryness
 Perspiration decreases
 Decrease in melanin production resulting in graying hair
 Increased sensitivity to sunlight
 Nails tend to become thicker and more brittle
Figure 11.8 Tenting. A. Step 1: Nurse grasps the skin.

A
Figure 11.8 (continued) Tenting. B. Step 2: Nurse releases grasp, tenting present.

B
Psychosocial Considerations

 Stress-induced illnesses
 Visible skin disorders and self-esteem/body image
Cultural and Environmental
Considerations
 Religion
 Birth anomalies
 Dietary deficiencies
Table 11.1 Color
Variations in Light
and Dark Skin
Table 11.1 Color
Variations in Light and
Dark Skin (continued)
Table 11.1 Color
Variations in Light and
Dark Skin (continued)
Box 11.1
Coining,
Cupping,
Pinching
Obese Clients

 Skinfold
 Incontinence
 Hygiene
Objectives for Skin Health
Outlined in Healthy People 2020
 Occupational skin disorders
 Education on skin cancer risks and prevention
Key Objectives for Occupational
Skin Disorders
 Reduce occupational skin disorders in full-time workers
Key Objective for Skin Cancer

 Increase the number of persons using protective measures to

reduce the rate of sunburns