42. The Integumentary System

The Integumentary System



Clinical Practice

Key Terms

biopsy (BĪ-ŏp-sē, p. 957)

erythrasma (ĕ-rĭth-RĂZ-mă, p. 957)

exudate (ĔKS-ū-dāt, p. 957)

keloid (KĒ-loid, p. 958)

keratoses (kĕr-ă-TŌ-sēs, p. 958)

macule (MĂK-ūl, p. 959)

papule (PĂP-ūl, p. 959)

plaque (plăk, p. 959)

pustule (PŬS-tūl, p. 959)

senile lentigines (SĒ-nīl lĕn-TĪJ-ĭ-nēz, p. 954)

senile purpura (SĒ-nīl PŬR-pū-ră, p. 960)

vesicle (VĔS-ĭ-kŭl, p. 959)

wheal (WĒL, p. 959)

image evolve.elsevier.com/deWit/medsurg

Overview of Anatomy and Physiology of the Integumentary System

What is the Structure of the Skin, Hair, and Nails?

• The skin consists of two layers of tissue, the epidermis and the dermis (Figure 42-1).

• The skin is attached to underlying structures by subcutaneous tissue.

• The epidermis consists of squamous epithelium and contains no blood vessels; cells receive nutrients by diffusion from vessels in the underlying tissue.

• Cell growth occurs from the bottom of the epidermis and pushes cells above to the surface, where they eventually die and slough off or are washed off. This layer is called the stratum corneum.

• The bottom layer of the epidermis contains melanocytes that contribute color to the skin.

• The dermis, also called the corium, is thicker than the epidermis and consists of dense connective tissue.

• The dermis contains both elastic and collagenous fibers that give it strength and elasticity.

• The dermis contains blood vessels and nerves as well as the base of hair follicles, glands, and nails that are derived from the epidermis.

• A hair consists of a shaft and a root made up of dead keratinized epithelial cells.

• The hair root is below the surface of the epidermis and is enclosed in a hair follicle that is embedded in the dermis.

• Fibroblasts that produce new cells to heal the skin are contained in the dermis.

• Glands contained in the skin are sebaceous (sweat producing) or ceruminous (wax producing).

• Nails are dead stratum corneum with a very hard type of keratin.

What are the Functions of the Skin and its Structures?

• The skin acts as a protective covering over the entire surface of the body.

• The keratin in the skin makes it waterproof, preventing water loss from the underlying tissues and too much water absorption during swimming and bathing.

• Skin provides a barrier to bacteria and other invading organisms.

• Skin protects underlying tissues from thermal, chemical, and mechanical injury.

• The skin helps regulate body temperature by dilating and constricting blood vessels and by activating or inactivating sweat glands.

• When the skin is exposed to ultraviolet light, molecules in the cells convert the rays to vitamin D.

• Melanin pigment absorbs light and acts to protect tissue from ultraviolet light.

• The nerve receptors in the dermis transmit feelings of heat, cold, pain, touch, and pressure.

• Hair follicles contained in the skin produce hair.

• Sebaceous glands secrete sebum that functions to keep hair and skin soft and pliable. Sebum also inhibits bacterial growth on the surface of the skin and, because of its oily nature, helps prevent water loss from the skin.

• Sweat glands act to excrete water and salt when the body temperature increases; sweat evaporates, producing a cooling effect.

• Sweat glands in the axillae and external genitalia secrete fatty acids and proteins as well as water and salts. They become active at puberty and are stimulated by the nervous system in response to sexual arousal, emotional stress, and pain.

• Hair color is produced by melanocytes in the skin and depends on the type of melanin produced.

• The shape of the hair shaft determines whether hair is straight or curly.

• Hair assists the body to retain heat.

• Nails cover the distal ends of the fingers and toes.

• Each nail has a free edge, a nail body, and a nail root that is covered by skin.

• The cuticle of each nail is a fold of stratum corneum.

What Changes Occur in the Skin and its Structures with Aging?

• The number of elastic fibers decreases and adipose tissue diminishes in the dermis and subcutaneous layers, causing skin to wrinkle and sag.

• Loss of collagen fibers in the dermis makes the skin increasingly fragile and slower to heal.

• The skin becomes thinner and more transparent.

• Reduced sebaceous gland activity causes dry skin that may itch.

• Thinned skin and decreased sebaceous gland activity reduce temperature control and lead to an intolerance of cold and a susceptibility to heat exhaustion.

• A reduction in melanocyte activity increases risk of sunburn and skin cancer.

• The number of hair follicles decreases and the growth rate of hair declines; the hair thins.

• A decrease in the numbers of melanocytes at the hair follicle causes gradual loss of hair color.

• Nail growth decreases, longitudinal ridges appear, and the nails thicken; nails become more susceptible to fungal infections.

• Some areas of melanocytes increase in production, producing brown “age spots” or “liver spots,” properly named senile lentigines (Figure 42-2).

The Integumentary System

The skin is the first line of defense against invasion by pathogenic bacteria living in the environment. When an area of the skin is destroyed by disease or trauma, its protective functions are immediately impaired. This impairment makes the body susceptible to infection. If very large areas of skin are destroyed, as in an extensive burn, fluid and electrolyte balance is disturbed. Protein and body heat are lost from burned areas. Skin diseases are common; they are often difficult to diagnose and cure and tend to recur. The physical effects of skin diseases are not often serious. However, when the disorder renders the patient unattractive, there is a psychological impact that threatens self-image and damages self-esteem. The skin also reflects systemic diseases.

Disorders of the Integumentary System


More than 3000 disorders of the skin have been officially named, and many more are not included in any official nomenclature. The majority of the recognized and named skin disorders arise from some pathology in the skin itself. The remainders are manifestations of some systemic disease. Skin disorders may occur from immunologic and inflammatory disorders, proliferative and neoplastic disorders, metabolic and endocrine disorders, and nutritional problems. Physical, chemical, and microbiologic factors also can damage the skin.

Many patients with dermatologic disease are not hospitalized and are seen only in physicians’ offices and outpatient clinics. Others do not seek medical attention but treat their skin disorder themselves with home remedies and over-the-counter drugs. In some cases self-care measures are successful, but they also have the potential for aggravating the condition or only temporarily relieving more severe symptoms. This can lead to delay in treatment and allows the disease to progress to a chronic and sometimes untreatable state.



The ritual of the daily bath is almost an obsession with the average American. Traditionally, plenty of soap, hot water, and friction were considered a necessity for cleanliness; however, many facilities have adopted disposable cleaning cloths to replace the individual bathing basin. In a recent study, Johnson and colleagues (2009) cultured bath basins and cleaning sponges and found bacteria growing in 98% of the samples, including Staphylococcus aureus (23%), vancomycin-resistant enterococci (13%), and methicillin-resistant S. aureus (8%). Soap and water continues to have a place in hygiene, but beyond infection control, the astute nurse will assess for and consider skin type. Blondes and redheads with a fair complexion usually have very delicate skin that requires special care to prevent drying and irritation. If the skin appears dry and scaly, frequent bathing with soap and hot water only aggravates the condition. Oils and creams are available that cleanse the skin quite effectively and help replace the natural oils at the same time. On the other hand, people with dark hair usually have skin that is oilier and less susceptible to excessive drying and irritation. The person with oily skin will need to clean the skin frequently with a liberal amount of soap and water and there will be less need to apply additional oils to the skin.


Even borderline deficiencies of vitamins and minerals will cause the skin to take on a sallow and dull appearance. Severe nutritional deficiencies lead to skin breakdown and the development of sores and ulcers. Dehydration causes loss of skin turgor and predisposes to pressure ulcers. People can be so concerned about their physical appearance that they refuse to eat properly for fear of gaining weight; however a well balanced diet will enhance appearance.


Young people are not the only ones who should be concerned with the care of their skin. As we grow older, our skin undergoes certain changes that easily lead to irritation and breakdown if proper care is not given. The oil and sweat glands become less active, and the skin has a tendency to become dry and scaly. It also loses some of its tone, becoming less elastic and more fragile. Frequent cleansing of the skin becomes unnecessary as the skin ages, and alcohol and other drying agents must be used sparingly, if at all. Assist older patients to establish a regular routine of massaging oil, cream, or oily lotion into the skin.


Several environmental factors can have a direct effect on the health of the skin. These include prolonged exposure to chemicals, excessive drying from repeated immersions in water, very cold temperatures, and prolonged exposure to sunlight. Some of these are occupational hazards. A change of jobs may be necessary to eliminate contact with a factor that is causing a skin disorder. One of the Healthy People 2020 imageobjectives is to reduce occupational skin diseases or disorders among full-time workers.

Overexposure to the ultraviolet rays of the sun can seriously and permanently damage the superficial and deeper layers of the skin. The damage results in severe wrinkling and furrowing, as well as loss of elasticity, and the skin assumes a tissue-paper transparency. In addition to the potential for premature aging and degenerative changes, solar damage also can result in malignant changes. Ultraviolet rays from the sun have long been known to be carcinogenic. This is especially true for fair-skinned people who have subjected their skin to prolonged exposure to sunshine. Although sunburns are particularly harmful, it is the normal daily exposure of unprotected fair skin to sun that causes long-term damage.


Health Promotion

Sun Exposure Precautions

Health teaching to inform the public about the dangers of solar ultraviolet radiation should include the following information:

• Although fair-skinned people who freckle easily are more likely to suffer sun-damaged skin, people of all complexions and races can and do burn if exposed to sufficient sunlight.

• Although a good tan might be considered by many to be desirable, dermatologists say that there is no such thing as a “healthy tan.” Tanning causes damage to the skin. If one insists on lying out in the sun, the initial exposure should be slow and gradual, and an adequate sunscreen with a sun protection factor (SPF) of at least 30, as well as ultraviolet A (UVA) and ultraviolet B (UVB) protection, should always be used. Too much sun too soon only leads to blistering and peeling.

• Select a sunscreen preparation on the basis of skin type and ability to tan, as well as its active ingredients and the amount of time to be spent in the sun. Remember that the sunscreen can be washed off by water or perspiration or rubbed off on sand and towels and must be periodically reapplied. Apply sunscreen liberally 15 to 30 minutes before sun exposure (American Academy of Dermatology, 2010). Reapply every 2 hours.image

• Avoid exposure to the sun during the time its rays are most hazardous; that is, between 10 A.M. and 2 P.M. standard time or 11 A.M. and 3 P.M. during daylight saving time. Local radio and television stations often give information about current weather conditions and the chances for being burned by the sun at particular times during each day.

• You can be sunburned on a cloudy or overcast day.

• Light, loosely woven clothing will not give adequate protection from the sun’s rays.

• Remember that snow, water, and sand can reflect the sun’s rays and increase the intensity of exposure.

• Do not try to gauge how much you are being burned while in the sun. It may be 6 to 8 hours before a painful burn becomes obvious.

• Wear sunglasses and a hat when you go out in the sun, and, when possible, wear protective clothing.

• Never use a tanning booth; there is an eightfold increased risk to develop melanoma for persons under age 36 (Strayer & Schub, 2009).image

Integrity of Skin

Good nursing care includes protection of the skin and prevention of skin tears. A skin tear is a potentially preventable, traumatic wound that occurs primarily on the extremities of older adults because of age and debility. The wound occurs as a result of careless handling, friction alone or shearing and friction forces that separate the epidermis from the dermis or separate both structures from the underlying tissue. More than 1.5 million skin tear injuries occur each year among institutionalized adults in health care facilities; 80% occur on upper extremities, 50% have no apparent cause, 25% are wheelchair injuries, and 25% are caused by simply bumping into objects (Miner et al., 2009). The epidermis thins and becomes less elastic with age, making it susceptible to tearing with little trauma. Those individuals who require total care are at the highest risk. Risk factors for skin tears, other than age over 65, are presented in Box 42-1.

The Payne-Martin classification system (Ayello & Sibbald, 2008) classifies skin tears as:image

Nursing Management

Rigorous nursing care (Box 42-2) to prevent skin tears is obviously preferable to treating skin tears that could have been avoided. However when a skin tear is discovered, steps for its management are:

• Gently cleanse the skin tear with saline.

• Allow the area to air-dry, or pat dry gently and carefully.

• If the skin tear flap has dried, remove it using scissors and sterile technique.

• If the skin tear flap is viable, gently roll the flap back into place using a moistened cotton-tipped applicator.

• If bleeding has stopped, silicone-coated net dressings are preferred; Steri-Strips or petroleum-based protective ointments are also used. Cyanoacrylate skin protectants are in a liquid form; when applied, a barrier is created to protect damaged skin. The substance does not need to be removed because it will shed in approximately 1 week (Fleck & Kesselman, 2009).

• If bleeding continues, dress with alginate and a secondary dressing.

• Manage the same as a skin graft. The flap should not be disturbed for about 5 days to allow the skin flap to readhere.

• Assess and measure the size of the skin tear.

• Document assessment and treatment.

Box 42-2

Measures to Prevent Skin Tears and Protect Fragile Skin

• Have patients wear long sleeves and long pants to protect the extremities, or protect the fragile skin on extremities with stockinettes.

• Provide adequate lighting to reduce the risk of bumping into furniture or equipment.

• Maintain the patient’s nutrition and hydration; offer fluids between meals.

• Lubricate the skin with cream or lotion twice a day, paying special attention to the arms and legs.

• Use an emollient soap for bathing, and do not use soap every day on extremities if no soiling has occurred.

• Use a lift sheet to move and turn patients.

• Avoid wearing rings or bracelets that could snag the skin.

• Use transfer techniques that prevent friction or shear.

• Pad bed rails, wheelchair arms, leg supports, or other equipment where the patient might bump an extremity.

• Support dangling arms and legs with pillows or blankets.

• Use nonadherent dressings on fragile skin. Use gauze wraps or stockinettes to secure dressing. If tape must be used, use a paper or nonallergenic tape and apply it without tension.

• Mark the dressing with an arrow showing the direction it should be removed.

• Remove tape and dressing with extreme caution:

• Use a solvent or saline to loosen the adhesive bond.

• Slowly peel tape away from anchored skin (stabilize skin).

• If a thin hydrocolloid or solid wafer skin barrier is used as a protective barrier between the skin and the dressing, allow it to fall off naturally.

Nov 17, 2016 | Posted by in NURSING | Comments Off on 42. The Integumentary System
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