ATI MED SURG : MEDICAL-SURGICAL NURSING:Integumentary System
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Course
ATI MED SURG
Institution
ATI MED SURG
Integument – Skin The skin is the largest organ of the body As the external covering of the body, the skin performs the vital function of protecting internal body structures from harmful microorganisms and substances. FUNCTIONS: 1. Protection Covers and protects the entire body from microorga...
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.
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