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THE INTEGUMENTARY SYSTEM

 FUNCTIONS OF THE SKIN:

 Protection of our internal organs against invasion by bacteria and other


foreign matter; protects from constant effects of trauma
• Thicker in our feet
• The skin will always adapt to its uses, more protection for those used often
 Sensation pain, light touch and pressure
• First line for stimulus
• Sensory receptors are mostly in our hands and foot
 F & E Balance – has the capacity to absorb water; retains moisture
in SQ; water evaporates thru skin – insensible losses
• Even if you soak yourself in a tub you absorb water
• On the other hand, it is also lost thru perspiration

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 Temperature Regulation – heat is dissipated thru skin by 3
processes:
• Radiation – transfer of heat to another object of lower temperature situated at a
distance (ex. skin gets warm when sitting near a fireplace)
• Conduction – transfer of heat to a cooler object in contact with it (ex. seat gets
warm when one is sitting on it for a long time)
• Convection – movement of warm molecules away from the body’ heat
transferred by conduction to the air surrounding the body is removed by
convection. (ex. heat dissipates from the body when you enter an air-
conditioned room)
 Vitamin Production – UV light from sun synthesize Vitamin D.

 LAYERS OF THE SKIN:

 EPIDERMIS – outermost layer of skin; consists of ff. cells:


• Keratin – dead cells, insoluble, fibrous portion that forms outer barrier of skin;
principal hardening ingredients or hair and nails.
• Melanocytes (cell) – produces the pigment – melanin which colors skin and
tissue
• Merkel – receptor that transmit stimuli to the axon

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• Langerhans – plays a role in the cutaneous immune system reaction (antibodies
that pass through the skin brings them to the lymph system which activates T-
Cells to kill the invaders)
o Rete Ridges – junction between dermis and epidermis; serves as another
layer between the two (provides nutrients to the epidermis from the
dermis)
o Fingerprints – produced by the interlocking between dermis and epidermis
(produces ripples)

 DERMIS – often referred to as “true skin”; second layer; makes up


the largest portion of the skin; provides structure and strength; has 2 layers: made
up of blood and lymph vessels; nerves; sweat and sebaceous glands; hair roots.
• Papillary – lies beneath epidermis; composed of fibroblast cells that produces
collagen (which is a component of connective tissue which makes our skin
supple)
• Reticular – also produces collagen and elastic bundles

 SUBCUTANEOUS – innermost layer; also known as


hypodermis; primarily adipose tissues; fats are stored here
• Function: skin mobility, molds body contours, insulates the body

 SKIN GLANDS

 SEBACEOUS GLAND – associated with hair follicles; ducts empty out


sebum onto space between hair follicle and hair shaft
 SWEAT GLAND – formed in most part of the body except glans penis,
margin of lips, external ear and nail bed.

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♥ ECCRINE GLAND – ducts open directly to skin; produces thin,
watery sweat
♥ APOCRINE GLAND – larger and their secretion contains part of
secretory cells; the ducts open to hair follicles; found in axilla, anal, scrotum
and labia majora; produces milky sweat
 SKIN
APPENDAGES

  HAIR –
root formed in the dermis and shaft
projects beyond the skin
♥ Cycles of Hair Growth
• Anagen Phase – growing phase
– everyday we grown 100,000/day)
• Telogen Phase – resting phase or shedding phase and you could loose 50 to 100/
day)
♥ Function:
• Provides protection
• Provides insulation
♥ Controlled by sex hormones: Androgens (beard, chest,
back, legs); Testosterone (hirsutism in women)

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 NAILS
• Made of hard, transparent plate of keratin; grows from its root which lies under a
thin fold - cuticle:
• Function: to protect finger, toes and their highly developed sensory function
• Growth continues throughout life; fingernails grow faster than toenails

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 SKIN ASSESSMENT:

 COLOR:
• Pallor – pale (anemia, shock, albinism (absence of melanin), vitiligo
(destruction of melanocytes; patches of white
• Cyanosis – bluish (unoxygenated states)
• Erythema – red, pink (inc. blood flow, polycythemia vera – ↑ RBC; carbon
monoxide poisoning, venous stasis
• Jaundice – yellowish (hepatic disorders)
• Brown Tan – bronzed (Addison’s disease – low levels of cortisol will stimulate
melanocytes to produce melanin)

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PRIMARY SKIN LESIONS:

♥ Macule/Patch
• Flat, non-palpable
• Macule < 1 cm with circumscribed edges
• Patch: > 1 cm, may have irregular borders
• Ex: freckles, flat moles, petechia, vitiligo, ecchymosis
♥ Papule/Plaque
• Elevated, palpable solid mass with borders
• Papule: < 0.5 cm
• Plaque: > 0.5 cm
Vesicle/Bulla
• Circumscribed, elevated, palpable mass containing serous fluid.
• Vesicle: < 0.5 cm (ex. Herpes simplex, chicken pox, secondary burn blister

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• Bulla: > 0.5 cm. (contact dermatitis; large bun blisters)
♥ Pustule
• Pus-filled vesicle or bulla
• Ex: acne, impetigo, furuncles, carbuncles
♥ Wheal
• Elevated mass with transcalent borders; often irregular size and color vary
• Ex: urticaria, hives, insect bites
♥ Nodule/Tumor
• Elevated, palpable, solid mass; extends deeper into the dermis
• Nodule: 0.5 to 2 cm circumscribed. (ex: lipoma, poorly absorbed injection)
– babies after injection apply hot compress
• Tumor: >1 to 2 cm; does not always have sharp borders (ex. larger lipoma
and carcinoma)

 SECONDARY SKIN LESIONS:


♥ Erosion

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♥ Ulcer – skin loss is past epidermis (bed sores)
♥ Fissure – linear crack in skin (chapped lips)
♥ Scales – desquamated dead skin (dry skin during cold or after beach or
swimming in pool)
♥ Crust – residue of serum, blood, pus on skin surface
♥ Scar – Cicatrix; healed wound or healed surgery incision
♥ Keloid – hypertrophied scar tissue
♥ Lichenification – thickening and roughing of skin

VASCULAR SKIN LESIONS:


♥ Petechiae: red, pinpoint macule associated with bleeding (ex. Dengue
hemorrhagic stage)
♥ Ecchymosis – associated with trauma and bleeding

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♥ Cherry angioma – red/purple, papular and round; N-age-related skin
alteration; no clinical significance
♥ Spider angioma – red, arteriole (S/SX: liver cirrhosis) lesions associated
with liver disese. Vitamin B. Deficiencies
♥ Telangiectasia – venous star; varicosities

COMMON NAIL DISORDERS

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ALOPECIA/BALDNESS

LABORATORY/DIAGNOSTIC EXAMINATIONS

 SKIN BIOPSY
 Tissue of skin removed for exam
 Either by scalpel excision or skin punch instrument
 Dermal punch: an electrical punch that can penetrate skin to a
certain depth
 Mgt: Clean area with antiseptic solution; local anesthesia applied;
specimen examined by histologist.

 PATCH TESTING
 Identifies substances to which the patient is sensitive to
 Patch left 24 to 48 hours
 20 minutes after, it is removed a reading is made

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 Reading
→ Weak (+): redness, fine bumps, itching
→ Moderate (+): fine blisters, papules, severe itching
→ Strong (+): blisters, pain, ulceration

 SKIN SCRAPINGS
 Samples are scraped from a suspected fungal lesion with a scalpel
blade which is moistened with oil
 Sample are transferred to the slide to be examined

 TZANCK SMEAR
 Examine cells of blistering conditions (herpes zoster, varicella,
herpes simplex)
 Secretions are transferred to a glass slide and stained and examined

 IMMUNOFLUORESCENCE
 Identify site of an immune reaction
 Combines antigen or antibody with a fluorochrome dye
 Antigen/antibody can be made fluorescent by attachment to dye
 Detects auto-antibodies directed against portion of the skin

 WOOD LIGHT’S EXAMINATION


 Uses a special lamp which produces long warm UV rays which results in dark
purple fluorescence
 Differentiates epidermal from dermal lesions; hyperpigmentation/hypopigmentation
from normal skin
 Color of light best seen in darkened room
 Light not harmful to skin and eyes
 Lesions with melanin – disappears with light
 Lesions without melanin increased in whiteness with light

 CLINICAL PHOTOGRAPHS
 Photographs are taken to record extent and progression of skin
disorder
 Before and after photos

 GOALS OF CARE FOR INTEGUMENTARY SYSTEM


1. Protecting the skin (bathing, using mild soap, drying thoroughly, changing
dressings)
2. Preventing secondary infections (adhere to standard precautions, handwashing &
gloving, proper disposal of contaminated dressings; keep nails short & avoid
scratching)
3. Reversing inflammatory Process (local or topical medications)

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 INTERVENTIONS:

1. WOUND CARE
• Wound – a disruption in the continuity and regulatory processes of tissue cells
• Wound Healing – the restoration of the skin continuity; may or may not restore
normal cellular function

I. PHYSIOLOGY OF WOUND HEALING


A. Inflammatory Phase (lasts 1-5days) – vascular & cellular response
B. Proliferative Phase (lasts 2-20 days) – granulation period
C. Maturation Phase (21 days to months & even years) – collagen production & scar
formation

II. TYPES OF WOUND HEALING


A. First-Intention Healing (Primary Union)
• Wounds are made aseptic with a minimum of tissue damage & tissue reaction;
wound edges are properly approximated with sutures
• Granulation tissue is not visible and scar formation is typically minimal
B. Second-Intention Healing (Granulation)
• Wounds are left open to heal spontaneously or surgically closed at a later date
• Examples: burn, traumatic injuries, ulcers, suppurative infected wounds
• Produces a deeper, wider scar

III. DEGREE OF CONTAMINATION


A. CLEAN: an aseptically made wound, as in surgery, that does not enter the
alimentary, respiratory, or genito-urinary tracts
B. CLEAN-CONTAMINATED: as aseptically made wound that enters the
respiratory, alimentary, or GU tracts; wounds have a slightly higher probability of
wound infection than do clean wounds
C. CONTAMINATED: wounds exposed to excessive amounts of bacteria; wounds
may be open or accidentally made or the result of surgical operations in which
there are major breaks in aseptic techniques or gross spillage from GI tract
D. INFECTED: a wound that retains devitalized tissue or involves existing infection
or perforated viscera; such wounds are left open to drain

IV. DRESSINGS
• Principles:
a. Dressing change depends on patient, wound & dressing assessment not on
standardized routines; but traditionally 3-4x/day
b. Natural wound healing process should not be disrupted; chronic wounds covered
for 48-72 hours; acute wounds covered for 24hours; unless wound is with heavy
discharges
• Purposes:
a. Protect the wound from mechanical injury

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b. Splint or immobilize the wound
c. Absorb drainage
d. Prevent contamination from bodily discharges (feces, urine)
e. Promote hemostasis, as in pressure dressings
f. Debride the wound by combining capillary action & the entwining of necrotic
tissue within its mesh
g. Inhibit or kill microorganisms by using dressings with antiseptic or antimicrobial
properties
h. Provide physiologic environment conducive to healing
i. Provide mental & physical comfort for the patient

 TYPES OF DRESSINGS:

A. WET DRESSINGS
• Wet compress is applied to skin
• Indicated for acute weeping, inflammatory lesions (vesicles, bullae, pustules,
ulcers)
• Could be sterile or clean technique depending on the disorder
• Purposes:
a. Reduce inflammation by producing constriction of blood vessel
b. Clean exudates, crusts, & scales
c. Maintain drainage of infected areas
d. Promote healing by facilitating free movement of epidermal cells across
involved skin so new granulation could form

• Wet-to-Dry Dressing:
 Particularly useful for untidy or infected wounds that must be debrided & closed
by secondary intention
 Gauze saturated with sterile saline or antimicrobial solution is packed into the
wound
 The wet dressing is then covered by dry dressing
 As drying occurs, wound debris & necrotic tissue are absorbed into gauze
dressing
 The dressing is changed when it becomes dry
• Wet-to-Wet Dressing:
 Used on clean open wounds or on granulating surfaces; sterile saline or an
antimicrobial agent may be used to saturate the gauze
 Provide a more physiologic environment (warmth & moisture) which can enhance
the local healing processes as well as assure patient of greater patient comfort;
thick exudates is more easily removed
 Disadvantage – surrounding tissues can become macerated, the risk of infection
may rise, and bed linens become damp

B. MOISTURE-RETENTIVE DRESSINGS
• Performs same function as wet dressing

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• More efficient in removing exudates because of ↑ moisture-vapor transmission rate
• Has reservoir that can hold excessive exudates
• Already impregnated with saline solution, zinc-saline solution, hydrogel,
antimicrobial agents
• Advantages: reduced pain, fewer infections, less scar tissue, gentle debridement, ↓
frequency of dressing change
• Forms: Hydrogels, Hydrocolloids, Foams, Ca. Alginates

C. DRY-TO-DRY DRESSINGS
• Used primarily for wounds closing by primary intention
• Offers good wound protection, absorption of drainage, & provides pressure (if
needed) for hemostasis
• Disadvantage – they adhere to the wound surface when drainage dries; removal can
cause pain & disruption of granulation tissue

D. OCCLUSIVE DRESSINGS
• Commercially produced or from sterile or clean gauze squares or wrap
• Purpose: cover topical meds applied to dermatosis
• Kept airtight by using plastic film (thin & readily adapts to size, body shape & skin
surface)
• Should be used no more than 12 hours each day

 WOUND DRAINAGE
• Placed on wounds only when abnormal fluid collections are present or expected
• Collection of body fluids in wounds can be harmful: provides media for bacterial
growth, ↑ pressure in wound site interfering with blood flow to the area, causes
pressure on the adjacent area, causes local irritation & necrosis due to fluids such as
pus
• Commonly made of soft rubber or plastic & placed within wounds – typically
attached to portable suction with a collection bottle
• Drains within wounds are removed when the amount of drainage ↓ over a period of
days

2. THERAPEUTIC BATH
• BALNEOTHERAPY – bath or soaks; useful when large areas of skin are affected
• Purposes:
a. Removes crusts, scales & old medications
b. Relieve inflammation & itching that accompany acute dermatoses
• Principles: water temperature must be comfortable to the patient; should not exceed
20-30 minutes to avoid skin maceration

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• Bath Solutions:
a. Water – same effect as wet dressing; fill the tub half-full
b. Saline – for widely disseminated lesions; keep water at comfortable temperature
c. Colloidal (Aveeno, Oatmeal) – antipruritic, soothing; don’t allow water to cool
excessively
d. Sodium Bicarbonate (Baking Soda) – cooling; use bath mat; causes tub to be
slippery
e. Starch – soothing; same mgt as baking soda
f. Medicated Tars (Balnetar, Doak Oil, Lavatar) – for psoriasis, chronic eczema;
apply emollient cream to damp skin after bath
g. Bath Oils – antipruritic & emollient action

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