Integumentary

Function
Group 1
◦ Jolce Kriska Balili – Intro, Age Related Changes in Skin Structure &
Function, & Common Problems and Conditions

◦ Leigh Yen Año – Premalignant Skin Growths & Malignant Skin Growths

◦ Angela Acabo – Lower Extremity Ulcers, Pressure Ulcers, & Outro

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INTEGUMENTARY SYSTEM
The integumentary system is the largest organ of the body. The skin,
hair, nails, and glands make up what is called the integumentary
system. The skin is the protective outer covering of the body.

Function of the skin:

◦ To serve as a barrier against harmful bacteria and other threatening
agents (first line of defense)
◦ Preventing fluid loss or dehydration
◦ Protecting the body from ultraviolet (UV) rays and other external
environmental hazards.
◦ Protecting underlying organs from injury.

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AGE-RELATED CHANGES IN
SKIN STRUCTURE AND
FUNCTION
EPIDERMIS
The epidermis is the outermost layer of
the skin. The replacement rate of the
stratum corneum, the first layer of
epidermis, declines by 50% as a person
ages.
Results:
◦ slower healing
◦ reduced barrier protection
◦ delayed absorption of medications
and chemicals placed on the skin.
The number of melanocytes, which
provide pigment and hair color,
decreases with age, giving older adults
less protection from UV rays, paler skin,
and graying hair.
Melanocytes also produce uneven
pigmentation, causing the development
of lentigines, also known as “age spots”
or “liver spots.
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AGE-RELATED CHANGES IN
SKIN STRUCTURE AND
FUNCTION
DERMIS
The dermis decreases in thickness by approximately 20% with aging. It consists of
strong connective tissue that contains sweat glands, blood vessels, nerve endings.
With aging, these also decrease in number that can lead to:
◦ diminished thermoregulatory function and inflammatory responses
◦ decreased tactile sensation
◦ reduced pain perception
◦ development of wrinkles and sagging skin as a result of loss of underlying tissue

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AGE-RELATED CHANGES IN
SKIN STRUCTURE AND
FUNCTION
SUBCUTANEOUS FAT

Aging results in a decreased amount of subcutaneous tissue and a redistribution of fat

to the abdomen and thighs. Breast tissue also changes and becomes more granular
and atrophic.

Greater risk for:

◦ Hypothermia
◦ skin shearing
◦ blunt trauma injury

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AGE-RELATED CHANGES IN
SKIN STRUCTURE AND
FUNCTION
APPENDAGES
◦ With aging, fewer eccrine glands (sweat glands of the palms, feet, and
forehead) and apocrine sweat glands (sweat glands of the axilla, scalp, face,
and genital areas) exist, resulting in decreased body odor and reduced
evaporative heat loss because of decreased sweating.
◦ The sebaceous glands and pores become larger with aging. Older adults
experience dry skin, which places them at a greater risk of infection as a result
of an impaired immune response.
◦ Hair thins, and its growth declines.
◦ Older women - increased lip and chin hair while experiencing thinning of hair
on the head, axilla, and perineal area.
◦ Men - lose scalp and beard hair and experience increased growth over the
eyebrows and in the ears and nostrils.

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COMMON PROBLEMS AND
CONDITIONS
BENIGN SKIN GROWTH
Cherry Angiomas
Cherry angiomas are common, bright
red, 1- to 5-millimeter (mm) superficial
vascular lesions that begin around age
30 and increase in number with age. The
cause of these lesions is unknown. They
are red or deep purple dome-shaped
papules.
Skin Tags (Acrochordons)
Skin tags are common stalk like, benign
tumors often found on the neck, axilla,
eyelids, and groin, although they may
occur anywhere on the body. Beginning
as early as age 20, these are tiny, flesh-
colored or brown excrescences that
develop into a long, narrow stalk (1 cm).
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COMMON PROBLEMS AND
CONDITIONS
BENIGN SKIN GROWTH
Seborrheic Keratoses
Seborrheic keratoses are benign lesions more commonly seen in the older adult.
These are scaly growths that have a “stuck-on,” crumbly appearance that varies
in color from tan to brown to black.
◦ The lesions may be elevated and range in diameter from 2 to 3 mm.
◦ Characterized by slow growth, these lesions begin to appear later in life.
◦ The borders may be round and smooth or irregular and notched.

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COMMON PROBLEMS AND
CONDITIONS
INFLAMMATORY DERMATOSES
Seborrheic Dermatitis
Seborrheic dermatitis is a common, chronic inflammation of the skin. The scalp,
ear canals, eyebrows, eyelashes, nasolabial folds, axilla, breasts, chest, and groin
are common sites. It is more common in patients who have Parkinson disease or
who have suffered a stroke. Seborrheic dermatitis appears as a white or yellow
scale with a plaquelike appearance.
◦ Dandruff is scaling without inflammation.
◦ Seborrheic dermatitis is an inflammatory response sometimes associated
with scaling.
◦ Dandruff may evolve into seborrheic dermatitis.

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COMMON PROBLEMS AND
CONDITIONS
INFLAMMATORY DERMATOSES

Intertrigo
Intertrigo is a form of seborrheic dermatitis.
◦ It results from the friction of opposing skin surfaces and the irritation this
causes.
◦ It is usually found in the armpits, inner aspects of the thighs, skin folds of the
breasts, and abdominal folds.
◦ The area is erythematous and may itch.
◦ Intertrigo occurs more often in aging patients who are obese or have diabetes.

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COMMON PROBLEMS AND
CONDITIONS
INFLAMMATORY DERMATOSES
Psoriasis Pruritus
◦ The condition may affect persons of ◦ Pruritus is another term for itching
any age, although it often begins that is so intense that it causes the
during early adult-hood. patient to scratch the offending
◦ Sometimes associated with other area. The most common cause of
itching is dry skin, or xerosis.
diseases such as arthritis,
myopathy, enteropathy, spondylitic ◦ Itching may be precipitated by heat,
heart disease, and acquired sudden temperature changes,
immunodeficiency syndrome sweating, clothing, cleaning
(AIDS). products such as soap, fatigue, and
◦ Psoriatic lesions are typically seen emotional stress, and it may be
more severe in the winter.
as well circumscribed, pink plaques
covered with silver-white, loosely
adherent scales.

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COMMON PROBLEMS AND
CONDITIONS
INFLAMMATORY DERMATOSES
Candidiasis
◦ Candidiasis is an inflammatory
process of the epidermis caused by
the yeastlike fungus Candida
albicans. C. albicans is a normally
occurring flora in the mouth, vagina,
and gut (moist habitats).
◦ Candidiasis is most commonly seen
in diaper-clad infants, patients with
incontinence, and bedbound
individuals and in the moisture-
prone areas of the body.
Herpes Zoster (Shingles)
◦ Caused by the reactivation of
latent varicella zoster
(chickenpox) virus. The virus
remains in the dorsal nerve
endings after an episode of
chicken-pox, which is usually
experienced in childhood.
◦ The main reason for recurrence is
an immune system deficiency.
◦ Often has prodromal symptoms of
tingling, hyperesthesia,
tenderness, and burning or itching
pain along the affected
dermatome.
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PREMALIGNANT SKIN GROWTHS:
ACTINIC KERATOSIS
Actinic Keratosis
◦ Premalignant lesion of the epidermis that is caused by long-term exposure to UV
rays
◦ Common in individuals with light complexions and occurs most commonly on the
dorsum of the hands, scalp, outer ears, face, and lower arms.

NURSING MANAGEMENT:

Assessment
1. Determine risk factors.
2. Inspect the skin.
3. Refer to primary physician whenever a suspicious lesion is found.

Diagnosis
 Impaired Skin Integrity, related to removal of a lesion
 Risk for Infection, related to a break in skin integrity
 Disturbed Body Image, related to disfigurement and scarring resulting from removal
of lesion
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 PREMALIGNANT SKIN GROWTHS:
ACTINIC KERATOSIS
Planning and Expected Outcomes
 The goals of nursing management after the removal of premalignant lesions are the
prevention of secondary infection and assistance in coping with any body image
disturbance.
 Expected outcomes include the following:
1. The site of lesion removal will heal without evidence of secondary infection.
2. The patient will demonstrate no changes in body image perception.
3. The patient will demonstrate behavior change through adoption of preventive skin
care practices.
Intervention
◦ reinforcing the treatment regimen with the patient and family
◦ monitoring the treated site to prevent secondary infection
◦ providing support
◦ teaching preventive strategies
Evaluation
 Evaluation of nursing management is supported with documentation
addressing treatment progress, which includes a physical description, patient
comprehension of educational information, and identification of and coping
with any body image disturbances.
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MALIGNANT SKIN GROWTHS
Basal Cell Carcinoma NURSING MANAGEMENT:
◦ Basal cell carcinoma (BCC) is the most
Assessment
common skin cancer and is more
prevalent in fair-skinned, blond, or red- ◦ Interview the patient.
headed individuals with extensive
previous sun exposure.
◦ Skin assessment (inspection and
palpation of lesions).
◦ BCC rarely occurs in black persons
because the darker skin pigmentation Diagnosis
plays a protective role against UVB ◦ Impaired Skin Integrity, related to
radiation. removal of a cancerous lesion.
◦ It occurs more often in men than in ◦ Risk for Infection, related to a break in
women. skin integrity and a surgical wound.
◦ BCC is most commonly found on the ◦ Fear, of cancer, pain, or death, related
face and scalp, less often on the trunk, to having a cancerous skin lesion.
and rarely on the hands. It may also
arise from scars or burns, particularly in
older adults who have experienced
chronic sun damage.

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MALIGNANT SKIN GROWTHS
Planning
◦ To facilitate the referral of patients for
treatment and removal of suspicious
lesions and to prevent secondary
infections.
◦ Time should be scheduled to discuss
the patient’s and family’s feelings about
having a cancerous lesion.
Expected Outcomes
◦ The site of BCC will heal without
evidence of infection.
◦ The patient will demonstrate no
disturbance in body image.
◦ The patient will verbalize concerns
regarding the diagnosis and will be able
to articulate feelings and concerns
related to the diagnosis.
◦ The patient will adopt preventive
strategies into his or her lifestyle.
◦ The patient will demonstrate increased
knowledge of his other condition.
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MALIGNANT SKIN GROWTHS

Interventions

◦ Reinforcement of the treatment

regimen
◦ Monitoring the wound for
secondary infection
◦ Teach the patient or family about
dressing care and signs of
infection
◦ Focus is placed on comfort,
education, and emotional
support.

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MALIGNANT SKIN GROWTHS
Squamous Cell Carcinoma NURSING MANAGEMENT:
◦ SCC is skin cancer arising from the
Assessment, Diagnosis, and
epidermis and is found most often on
the scalp, outer ears, lower lip, and Planning are the same with the
dorsum of the hands. Basal Cell Carcinoma.
◦ SCC may also develop in chronic leg
ulcers or open fractures and has a 20% Expected Outcomes
incidence of metastasis, generally to ◦ Skin lesions will remain free from
regional lymph nodes (Helm & Marks, necrotic tissue and infection.
1998). ◦ Skin lesions will heal with minimum
◦ The etiologic factors of SCC may be UV scarring.
rays, chemical carcinogens, and x-rays. ◦ The patient will demonstrate
◦ SCC is more common in men and older positive adaptation to body image
adults. changes, as evidenced by
◦ Most common skin cancer in blacks. verbalization of feelings of
acceptance.
◦ The patient will verbalize
acceptance of the diagnosis and
seek appropriate care.
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MALIGNANT SKIN GROWTHS

Interventions Evaluation

Nursing intervention is the same as ◦ Supported by documentation,

with BCC; however, more focuses on the
disfigurement may be present after appearance of wound infection
removal. ◦ The patient’s coping response
to changes in body image
◦ Comprehension of teaching.

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MALIGNANT SKIN GROWTHS
Melanoma NURSING MANAGEMENT:

◦ Melanoma is a malignant neoplasm of Assessment, Diagnosis, and

pigment-forming cells that is capable of Planning are the same with the
metastasizing to any organ of the body, Basal Cell Carcinoma.
even before the lesion is noted;
therefore, early detection is crucial.
Expected Outcomes
◦ Melanoma represents 2% of all cancers ◦ The site of excision will heal without
evidence of infection.
and 1% of cancer related deaths, and it
is the second most common cause of ◦ The patient will verbalize fears
death in men ages 30 to 49. related to the diagnosis and
actively seek information and
clarification.
◦ The patient will identify community
resources for support and
additional information.
◦ The patient will verbalize
understanding of the treatment
plan.
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MALIGNANT SKIN GROWTHS

Interventions Evaluation

◦ Includes reinforcement of the treatment ◦ Focuses on monitoring for infection.

regimen by monitoring the wound for ◦ The effectiveness of pain control
secondary infection. measures, comprehension of patient
◦ Explain that a risk of metastasis exists education.
and refer the patient to the ACS, ◦ Discussions related to body image
Internet sources, or the local library for changes and fears about cancer.
additional information.
◦ The nurse should teach the patient or
family dressing care
and signs of infection.

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LOWER EXTREMITY ULCERS
Chronic leg ulcers are a common problem in older adults, occurring primarily from three
causes:

1. Arterial insufficiency

2. Diabetic neuropathy

3. Venous hypertension

ARTERIAL ULCERS
◦ Arterial insufficiency is also referred to as peripheral vascular disease (PVD).

◦ Usually located on the feet and toes.

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LOWER EXTREMITY ULCERS
Arteriosclersois – thickening and hardening of the arterial wall – is the primary cause
for decreased blood flow that results in ischemia and eventually tissue death.

Arteosriclerosis obliterans – is used when atheromatous lesions develop in the lower

extremities below the abdominal aorta.

Risk Factors:

◦ Smoking

◦ Diabetes

◦ Hyperlipoproteinemia

◦ Hypertension

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LOWER EXTREMITY ULCERS
Signs and symptoms:
◦ Pain with exercise, at night, while resting – is the most common sign
◦ Pain at rest indicates severely restricted arterial blood flow
◦ Cramping, burning, aching
◦ As the disease advances, the extremity, develops a cyanotic hue and becomes
cool.
◦ The skin becomes thin, shiny, and dry and has an associated loss of hair and
thickened nails
Treatment
◦ Surgical intervention with revascularization
◦ If disease advanced - amputation

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LOWER EXTREMITY ULCERS
Diabetic Neuropathic Ulcers
◦ Pain and temperature are usually the first sensation affected by neuropathy
◦ Ulcers resulting from diabetic peripheral neuropathy tend to be bilateral, symmetric, and
located on the plantar surface of the foot

Risk Factors for diabetic foot ulcers:

◦ Smoking
◦ Lipoprotein abnormalities (particularly elevated low-density lipoprotein)
◦ Chronic hyperglycemia
◦ Absent vibratory sensation in the lower extremities
◦ PVD
◦ Poor outpatient diabetes education
◦ Hypertension

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LOWER EXTREMITY ULCERS
Signs and symptoms:

 Pain and paresthesia

 Pain relieved from walking is one diagnostic sign of neuropathy

Treatment:

 Testing for neuropathy and the identification of high foot pressures

 An easy and inexpensive device for establishing neuropathy is the Semmes-Weinstein

monofilament

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LOWER EXTREMITY ULCERS
Venous Ulcers
Also known as venous dermatitis

Primary cause is venous hypertension

The cause of this chronic, costly condition is not completely known, but it has been
attributed to chronic venous insufficiency

Usually located on the medial aspect of the lower leg, with flat or shallow craters and
irregular borders, accompanied by varicosities, liposclerosis (brown-ruddy color and
thickened skin), and itching

Homans stated in 1917 that venous ulcers were related to venous stagnation, which led to
anoxia and ulceration

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LOWER EXTREMITY ULCERS
Browse and Burnand (1982) revealed the most current etiologic factor: An
enlarged capillary bed from venous hypertension that causes leakage of fibrinogen
into interstitial tissue, creating a fibrin cuff.

Falanga and Eaglstein (1993) – proposed that fibrin cuff facilitates the trapping of
growth factors, which impedes healing.

Signs and symptoms:

 Discoloration and thickening of the skin (liposclerosis)

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LOWER EXTREMITY ULCERS
Nursing Intervention

o Keeping the legs elevated above the heart

o Implementing compression therapy

o Administering wound care

o Educating the patient about the causes

o The nurse should also discuss the patient’s feelings regarding chronicity
and body changes

o Instruct on dressing changes and how to place 15-20cm blocks at the foot
of the bed at home for long-term edema management

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PRESSURE ULCERS
Pressure Ulcers
◦ Also known as bedsores, decubitus, or pressure sores
◦ In 1962, researchers first demonstrated that moisture, applied with occlusive
dressings, increase epithelialization (the healing process) (Krasner, 1991).

Risk Factors of hospitalized patients:

◦ Quadriplegic patients
◦ Older patients with hip fractures
◦ Orthopedic patients who are immobile
◦ Critical care patients

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PRESSURE ULCERS
Etiology of pressure ulcers:
◦ Pressure on soft tissue over bony prominences or other hard surfaces is the
primary causative factor in pressure ulcer formation.
◦ Begin at the point of contact between soft tissue and a hard surface
◦ Common bony prominences susceptible to pressure ulcer development are
the sacrum, ischial tuberosity, lateral malleolus, trochanter, and heels

Shearing – is the sliding of parallel surfaces, causes stretching and occlusion of

the arterial supply, usually of the fascia and muscle.

Friction – is the rubbing of skin against another surface, primarily affects the
epidermal and dermal layers, causing a superficial abrasion

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PRESSURE ULCERS
Signs and symptoms:
◦ Localized heat
◦ Edema
◦ Induration
◦ Darkly pigmented skin
Preventive strategies:
◦ Cleanse the skin of a patient with incontinence with a mild, nonirritating
cleanser using warm – not hot – water at the time of soiling to minimize skin
irritation and dryness
◦ Moisturizers such as emollient lotions, should be used to keep the skin from
drying and cracking
◦ Best to apply lotion immediately after bathing to increase the moisture
absorbed by the skin
◦ Skin should not be rubbed or massaged over bony prominences
◦ Proper turning and placement of patients in a minimum of every 2 hours

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STAGING CRITERIA
Stage/Category I: Nonblanchable
Erythema
◦ An area of red, deep pink or mottled
skin that does not blanch with
fingertip pressure.
Stage/Category II: Partial thickness
◦ Skin loss involving epidermis,
dermis or both. It may look like an
abrasion, blister, or shallow crater.
Stage/Category III: Full-thickness skin
loss
◦ Looks like a deep crater and may
extend to fascia. Subcutaneous
tissue is damaged or necrotic.
Stage/Category IV: Full-thickness
tissue loss
◦ Extensive tissue necrosis or
damage to muscle, bone, or
supporting structures, sinus tracts
may be present.
Unstageable/Unclassified: Full-
thickness skin or tissue loss
◦ Loss of full thickness of tissue. The
base of the ulcer is covered by
eschar (tan, brown, or black in
color). Stable eschar on the heels
serves as “the body’s natural cover”
and should not be removed.
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DEBRIDEMENT
◦ Necrotic tissue provides the ideal Key point:
environment for bacteria growth,
which may cause inflammation and
◦ Prevention is the first-line strategy
for pressure ulcer care
impair the body’s ability to fight
infection. ◦ To minimize shearing forces, the
◦ Necrotic tissue must be debrided as
nurse should not elevate the head
of the bed greater than 30-45
soon as possible, and measures degrees.
should be taken to resolve bacterial
insults until purulent discharge has
dissipated.

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