ATI MED SURG : MEDICAL-SURGICAL NURSING:Integumentary System

Medical and Surgical Nursing
Integumentary System Lecture Notes
Prepared by: Mark Fredderick R. Abejo RN,MAN 1



LAYERS

A. Epidermis
 Avascular outermost layer
 Stratified squamous epithelium
 Composed of keratinocytes (produce keratin
responsible for formation of hair and nails) and
melanocytes (produce melanin).
MEDICAL AND SURGICAL NURSING  Form the appendages (hair and nails) and glands
 Epidermis
Integumentary System  Stratum basale
 Stratum granulosum
Lecturer: Mark Fredderick R. Abejo RN,MAN  Stratum spinosum
________________________________________________  Stratum lucidum
 Stratum corneum
Integument – Skin
B. Dermis
The skin is the largest organ of the body  Layer beneath the epidermis composed of
As the external covering of the body, the skin performs the connective tissues.
vital function of protecting internal body structures from  Contains lymphatics, nerves and blood vessels.
harmful microorganisms and substances.  Elasticity of the skin results from presence of
collagen, elastin and reticular fibers.
FUNCTIONS:  Responsible for nourishing the epidermis.

1. Protection C. Subcutaneous layer
 Covers and protects the entire body from  Layer beneath the dermis.
microorganisms  Composed of loose connective tissues and adipose
 Protects from UV rays – melanin (pigment in the cells.
skin)  Stores fat.
 Keratin – a protein in the outermost layer of the skin  Important for thermoregulation.
“waterproofs” and “toughens” skin and protects
from excessive water loss, resists harmful APPENDAGES
chemicals, and protects against physical tears
Hair
2. Regulation  Covers most of the body surface (except the palms,
 Maintains normal body temperature by regulating soles, lips, nipples and parts of the external
sweat secretion and regulating the flow of blood genitalia).
close to the body surface.  Hair follicles: tube-like structures, derived from the
 Evaporation of sweat from the body epidermis, from which hair grows.
surface  Functions as protection from external elements and
 Radiation of heat at the body surface due from trauma.
to the dilation of blood vessels close to  Protects scalp from ultraviolet rays and cushions
the skin blows.
 Excessive heat loss causes shivering (contraction of  Eyelashes, hair in nostrils and in ears keep particles
skeletal muscle) increasing heat production and from entering organ.
goosebumps (contraction of arrector pili muscle)  Hair growth controlled by hormonal influences and
pulling hair shaft vertical, creating an insulated air by blood supply.
space over the skin.  Scalp hair grows for 2 to 5 years.
 Approximately 50 hairs are lost each day.
3. Absorption  Sustained hair loss of more than 100 hairs each day
 Absorbs oxygen and carbon dioxide and UV rays usually indicates that something is wrong
 Steroids (hydrocortisone) and fat-soluble vitamins Nails
(ie D) are readily absorbed  Dense layer of flat, dead cells, filled with keratin.
 Topical medications – motion sickness patch etc  Systemic illnesses may be reflected by changes in
the nail or its bed:
4. Synthesis  Clubbing
 Skin produces melanin, keratin, vitamin D  Beau’s line
 Melanin protects the skin from UV rays; determines
skin color Glands
 Keratin helps waterproof the skin and protects from  Eccrine sweat glands are located all over the body
abrasions and bacteria and produce inorganic sweat which participate in
 Vitamin D stimulated by UV light. Enters blood and heat regulation.
helps develop strong healthy bones. Vitamin D  Apocrine sweat glands are odiferous glands, found
deficiency causes Rickets primarily in the axillary, areolar, anal and pubic
areas; the bacterial decomposition of organic sweat
5. Sensory causes body odor.
 Sensory nerve endings tell about environment  Sebaceous glands are located all over the body
 They respond to heat, cold, pressure, touch, except for the palms and soles; produce sebum.
vibration, pain

,Medical and Surgical Nursing
Integumentary System Lecture Notes
Prepared by: Mark Fredderick R. Abejo RN,MAN 2


ASSESSMENT
Effects of Aging in the Skin
Health History  Skin vascularity and the number of sweat and
 Presenting problem sebaceous glands decrease, affecting
 Changes in the color and texture of the skin, thermoregulation.
hair and nails.  Inflammatory response and pain perception
 Pruritus diminish.
 Infections  Thinning epidermis and prolonged wound healing
 Tumors and other lesions make elderly more prone to injury and skin
 Dermatitis infections.
 Ecchymoses  Skin cancer more common.
 Dryness
 Lifestyle practices
 Hygienic practices LABORATORY / DIAGNOSTIC STUDIES
 Skin exposure
 Nutrition / diet  Blood chemistry / electrolytes: calcium, chloride,
 Intake of vitamins and essential nutrients magnesium, potassium, sodium
 Water and Food allergies  Hematologic studies
 Use of medications  Biopsy
 Steroids  Removal of a small piece of skin for
 Antibiotics examination to determine diagnosis
 Vitamins  Nursing Interventions
 Hormones Preprocedure
 Chemotherapeutic drugs - Secure consent
 Past medical history - clean site
 Renal and hepatic disease Postprocedure – place specimen in a
 Collagen and other connective tissue diseases clean container & send to pathology
 Trauma or previous surgery laboratory
 Food, drug or contact allergies - use aseptic technique for biopsy
 Family medical history site dressing, assess site for
 Diabetes mellitus bleeding & infection
 Allergic disorders - instruct px to keep dressing in
 Blood dyscrasias place for 8hrs & clean site daily
 Specific dermatologic problems - instruct the patient to keep
 Cancer biopsied area dry until healing
occur
Physical Examination  Skin Culture
 Color  Used for microbial study
 Areas of uniform color  Viral culture is immediately placed on ice
 Pigmentation  Obtain prior to antibiotic administration
 Redness  Wood’s Light Examination
 Jaundice  Skin is viewed through a Wood’s glass
 Cyanosis under UV
 Vascular changes Nursing Interventions
 Purpuric lesions Preprocedure – darken room
 Ecchymoses Postprocedure – assist px in adjusting to
 Petechiae light
 Vascular lesions  Skin testing
 Angiomas  Administration of allergens or antigens on
 Hemangiomas the surface of or into the dermis to
 Venous stars determine hypersensitivity
 Lesions  Types:
 Color  Patch
 Type  Prick
 Size  Intradermal
 Distribution
 Location
 Consistency DIAGNOSIS
 Grouping
 Annular  Impaired skin integrity
 Linear  Pain
 Circular  Body image disturbance
 Clustered  Risk for infection
 Ineffective airway clearance
 Edema (pitting or non-pitting)  Altered peripheral tissue perfusion
 Moisture content
 Temperature (increased or decreased;
distribution of temperature changes)
 Texture
 Mobility / Turgor

, Medical and Surgical Nursing
Integumentary System Lecture Notes
Prepared by: Mark Fredderick R. Abejo RN,MAN 3


PLANNING AND IMPLEMENTATION  Protecting grafted skin from direct
sunlight for at least 6 months.
 Goals  Protecting graft from physical
 Restoration of skin integrity. injury.
 The patient will experience relief of pain.  Need to report changes in graft.
 The patient will adapt to changes in  Possible alteration in pigmentation
appearance. and hair growth; ability to sweat
 The patient will be free from infection. lost in most grafts.
 Maintenance of effective airway  Sensation may or may not return.
clearance.
 Maintenance of adequate peripheral tissue EVALUATION
perfusion.  Healing of burned areas; absence of drainage,
edema and pain.
 Interventions: Skin Grafts  Relaxed facial expression/body posture.
 Replacement of damaged skin with  Changes into self-concept without negating self-
healthy skin to provide protection of esteem
underlying structures or to reconstruct  Achieves wound healing
areas for cosmetic or functional purposes.  Lungs clear to auscultation
 Sources:  Palpable peripheral pulses of equal quality
 Autograft – patient’s own skin
 Isograft – skin from a genetically
identical person Disorders of the Integumentary System
 Homograft or allograft – cadaver
of same species Primary Lesions of the Skin
 Heterograft or xenograft – skin
from another species Macule is a small spot that is not palpable and is
 Nursing care: Preoperative less than 1 cm in diameter
 Donor site: Cleanse with Patch is a large spot that is not palpable & that is >
antiseptic soap the night before 1 cm.
and morning of surgery as ordered. Papule is a small superficial bump that is elevated
 Recipient site: Apply warm & that is < 1 cm.
compresses and topical antibiotics Plaque is a large superficial bump that is elevated
as ordered. & > 1 cm.
 Nursing care: Postoperative Nodule is a small bump with a significant deep
 Donor site: component & is < 1 cm.
 Keep area covered for 24 to Tumor is a large bump with a significant deep
48 hours. component & is > 1 cm.
 Use bed cradle to prevent Cyst is a sac containing fluid or semisolid material,
pressure and provide greater ie. cell or cell products.
air circulation. Vesicle is a small fluid-filled bubble that is usually
 Outer dressing may be superficial & that is < 0.5 cm.
removed 24 to 72 hours post- Bulla is a large fluid-filled bubble that is superficial
surgery; maintain fine mesh or deep & that is > 0.5 cm.
gauze until it falls of Pustule is pus containing bubble often categorized
spontaneously. according to whether or not they are related to hair
 Trim loose edges of gauze as follicles:
it loosens with healing.  follicular - generally indicative of local
 Administer analgesic as infection
ordered (more painful than  folliculitis - superficial, generally multiple
recipient site).  furuncle - deeper form of folliculitis
 Recipient site:  carbuncle - deeper, multiple follicles
 Elevate site when possible. coalescing
 Protect from pressure through
the use of a bed cradle. Secondary lesions of the Skin
 Apply warm compresses as
ordered. Scale is the accumulation or excess shedding of the
 Assess for hematoma, fluid stratum corneum.
accumulation under graft.  Scale is very important in the differential
 Monitor circulation distal to diagnosis since its presence indicates that the
the graft. epidermis is involved.
 Provide emotional support and  Scale is typically present where there is
monitor behavioral adjustments; epidermal inflammation, ie. psoriasis, tinea,
refer for counseling if needed. eczema
Crust is dried exudate (ie. blood, serum, pus) on the
 Provide client teaching and discharge skin surface.
planning concerning: Excoriation is a loss of skin due to scratching or
 Applying lubricating lotion to picking.
maintain moisture on the surface Lichenification is an increase in skin lines &
of healed graft for at least 6 to 12 creases from chronic rubbing.
months. Maceration is raw, wet tissue.