The Integumentary System

Sasha Alexis Rarang, RN, MSN NURS 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

Functions of the skin:



Thermoregulation

   

Vitamin D production Protection Absorption & 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.

The skin

 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.

Five distinct sub-layers of the Epidermis:

 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.

The Dermis

 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.

Factors that influence Color

Assessing Clients with Integumentary Disorders

Functional Health

  Use 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.    Who or what will be able to help pt. cope with stress from this skin problem?

11. Value-Belief

 Are health problems with pt. skin created stress for him/her? Explain. Describe what pt. do to cope with stress. How will this health problem affect pt. future?

Techniques of assessing the Integumentary system.

   Pressure Ulcers - Tissue necrosis commonly occurring adjacent to bony prominences caused by unrelieved pressure blocking blood flow to the region.

- Most common sites Sacrum Heels

Integumentary Problems

Pressure Ulcer – heel

Pressure Ulcer- sacrum

      Skin changes related to aging Immobility Incontinence or excessive moisture Skin friction and shearing Vascular Disorders Obesity

Risk Factors

          Inadequate nutrition and/or hydration.

Anemia Fever Impaired circulation Edema Sensory deficits Low diastolic blood pressure Impaired cognitive functioning Neurological disorders Chronic Diseases – e.g. Diabetes Millitus, Chronic Renal Failure, CHDs, CLD

Contributing Factors

    Wound Culture and Sensitivity CBC with Differential Blood Cultures Serum albumin and Pre-albumin

Diagnostic Procedures

    Monitor for s/s – assess stage of the wound Wound Stages ( pressure ulcer) Some ulcers cannot be staged Assess/monitor Alteration in skin integrity Skin Moisture status Incontinence Nutritional status See Braden Scale assessment tool.

Assessment

    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 blanch Recersible if pressure is relieved.

Stage I

     Relieve pressure Frequent turning repositioning Use 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.

Nursing Intervention

    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 painful Takes several weeks to heal after pressure is relieve.

Stage II

    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.

Nursing Interventions

     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 bed May require several months to heal after pressure is relieved.

Staqe III

 1.

Clean and/or debride – wet to dry dressing 2.

3.

   surgical intervention Proteolytic enzymes – e.g. accuzyme.

Provide nutritional supplement prn.

Administer analgesics prn Administer antimicrobials ( topical or systemic)

Nursing Interventions

     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 sepsis May take months or several years to heal.

Stage IV

     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)

Nursing Interventions

   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

Prevention of Pressure Ulcers

  Deterioration Systemic Infections

Nursing Considerations

 

When 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.

Complications and 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.

Nursing considerations

   Vacuum-Assisted Wound Closure Hyperbaric oxygen Therapy Surgical debridement and/or wound grafting.

Therapeutic Procedures

     1.

2.

3.

Burns are 6 th 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; Type of burning agent Duration of contact Site of injury

Care of Clients with Burn

     Eyelids Ears Nose Genitalia And the tops of the hands and feets ( including fingers and toes).

Areas most vulnerable to burns

Tissue layer damage Color Blister Edema Pain Eschar Tx Healing

Superficial

Epedermis Pink to red No Mild Yes No

Partial Thickness

Entire epedermis to some of dermis

Deep Partial Thickness

Extend to deeper layer of the dermis

Full Thickness

Ertire Dermis Pink to red

Deep Full Thickness

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

Black yes Mild to moderate Yes No Red to white rare Moderate Black, brown, yellow No Severe No Absent yes No Yes, soft and dry Yes and No Yes, hard and inelastic Absent Yes, hard and elastic No

Classifications

3-5 days No 2 weeks Depending on the area, a local ED ER at the scene and transfer to burn center 2-6 weeks Weeks to months Care and nearest ED and transfer to burn center Weeks to months

   Age more than 60 years Burn involves > 40 % total body surface Inhalation Injury

Risk for Death from Burns

 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 injury Fluid mobilization ( 48-72 hours after injury

Diagnostic Procedures

       Assess/monitor: Head to toe assessment Airway patency ( esp. burn in the face and in close door spaces.

Signed hair in the nostrils – inhalation injury Oxygenation status V/S, heart rhythm esp. electrical burns Fluid status   Circulatory status – hypovolemia Size and depth of burns (BSA) rule of nine, lund browder.

Assessment

   

Estimation of Surface Area

Use 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

Calculcation of Burned BSA

    Size and depth of burns Renal function – urine output decreased first 24 hours.

Bowel sound – commonly reduced/absent.

Stool and emesis for evidence of bleeding (ulcer risk)

Assessment

     Ensure airway patency – intubation , trach provide O2 if prn Maintain 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 .

Nursing Interventions

   

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 * %BSA Afterwards, 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%

Burn resuscitation Formula

           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.

Nursing Interventions

    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.

Complications

   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 Burn

    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.

Care of Client with Burns