Ch09

Chapter 9
The Integumentary System
Copyright © 2018 Wolters Kluwer · All Rights Reserved

Anatomy and Physiology
v Provides a barrier
v Regulates body temperature
v Synthesizes vitamin D
v Sensory perception
v Provides nonverbal communication
v Provides identity
v Allows wound repair
v Allows excretion of metabolic wastes

The Skin #1

The Skin #2
v Layers
o Epidermis
§ Superficial, thin, no blood vessels
o Dermis
§ Blood vessels, connective tissue, sebaceous
glands, sweat glands, hair follicles
o Subcutaneous or adipose
§ Connects to underlying structures

The Skin #3
v Pigments
o Melanin
o Carotene
o Oxyhemoglobin
o Deoxyhemoglobin

The Skin #4
v Abnormal colors
o Jaundice (yellowish color)
§ Deposition of bilirubin
§ Easier to observe in sclera, nails, palms, soles
o Cyanosis (bluish color)
§ Lack of oxygen (central)
§ Lack of blood flow (peripheral)

Appendages #1
v Hair
o Vellus: short, fine, inconspicuous, unpigmented
o Terminal: coarser, thicker, conspicuous, usually
pigmented

Appendages #2
v Nail
o Protect distal ends of
fingers and toes
o Nail plate
o Lunula
o Cuticle

Glands
v Sebaceous glands
o Produce sebum
o Lubricates hair and skin
o Reduces water loss through skin
v Sweat glands
o Eccrine: widely distributed, open directly on surface,
help control body temperature
o Apocrine: in axillary and genital areas, stimulated by
emotional stress, responsible for adult body odor

The Health History #1
v Purpose to identify the following:
o Diseases of the skin
o Systemic diseases that have skin manifestations
o Physical abuse
o Risk for pressure ulcer formation
o Risk for skin cancer
o Need for health promotion education regarding the
skin

Common or Concerning Common or Concerning

Symptoms Symptoms
Rash Lesions
Nonhealing lesions Bruising (ecchymosis)
Moles Hair loss
Growths Nail changes

v Past history
o Skin diseases
o Diabetes or peripheral vascular disease
o Allergies or food sensitivities
o Burns or sunburns
o Corticosteroid medications
o Medication use
o Immunization record

v Family history
o Same or similar symptoms
o Skin diseases
o Allergies

v Lifestyle and personal habits
o Bathing and shampooing routines
o Change of products
o Wear false nails or wigs
o Go to nail salon or gym
o Sun exposure
o Skin self-examination
o Exposure to chemicals or radiation
o Diet

Question #1
v The skin is recognized for performing which function?
A. Temperature control
B. Synthesizes vitamin K
C. Excretion of excessive electrolytes
D. Motor perception

Answer #1
v The skin is recognized for performing which function?
v A. Temperature control
v The functions of the skin include synthesis of vitamin D
from sunlight, provide a barrier of protection, regulate
body temperature, sensory perception, provide identity,
allow wound repair, and allow excretion of metabolic
waste.

Physical Examination of Skin #1
v Use natural or artificial light that resembles it.
v Ensure patient is properly draped.
v Inspect and palpate.
v Color
o Look for increased pigmentation, loss of
pigmentation, or redness of skin.
o Assess for cyanosis or pallor.
o Assess for jaundice.

Skin Color Changes #1





v Moisture
o Excessive dryness, sweating, oiliness
o Should be dry to touch without flaking or cracking
o Carefully inspect skin folds

v Temperature
o Use back of hand
o Note generalized warmth or coolness
o Note increased temperature with erythema

v Texture
o Roughness or smoothness
v Mobility and turgor
o Lift fold of skin.
o Ease with which it lifts—mobility
o Speed with which it returns into place—turgor


v Edema
o Excess fluid in interstitial spaces
• Localized: injury
• Systemic: most often in the dependent portions of
body
– Skin puffy and feels tight
§ Pitting: interstitial fluid mobile
§ Nonpitting: local infection or trauma; brawny
edema


Question #2
v During your physical examination of the patient, you
gently pinch the back of the hand. The skin remains in a
“tent” shape and slowly returns to its normal position.
This is a sign of:
A. Infection
B. Overhydration
C. Dehydration
D. Properly hydrated

Answer #2
v During your physical examination of the patient, you
gently pinch the back of the hand. The skin remains in a
“tent” shape and slowly returns to its normal position.
This is a sign of:
v C. Dehydration
v “Tenting” is a sign of poor turgor and occurs when a
patient is dehydrated, often occurring with excessive
vomiting, diarrhea, or heat-related situations. The
patient should be further assessed for the need of
intravenous fluids.

v Lesions
o Color
o Size
o Elevation
o Number
o Texture
o Type of skin lesions
o Shape and Pattern
o Anatomic location and distribution

Skin Lesions #1

Skin Lesions #2

Skin Lesions #3

Skin Lesions #4

Skin Lesions: Patterns and Shapes #1



Primary Skin Lesions
(Initial Presentation) #1

Primary Skin Lesions(Initial Presentation)
#2

#3

#4

Primary Skin Lesions (Initial
Presentation) #5

Primary Skin Lesions (Initial
Presentation) #6



Secondary Skin Lesions
Overtreatment, Excess Scratching, Infection #1



Depressed #1

Depressed #2

Acne Vulgaris
Primary Lesions

Acne Vulgaris
Secondary Lesions

Vascular Lesions

Purpuric Lesions

Skin Tumors #1

Skin Tumors #2

Benign Nevi

Question #3
v Vesicles in a unilateral dermatomal pattern are typical of:
A. Herpes zoster
B. Herpes simplex
C. Tinea capitis
D. Acne vulgaris

Answer #3
v Vesicles in a unilateral dermatomal pattern are typical of:
v A. Herpes zoster
v Herpes zoster (also known as shingles) forms vesicles
that follow a dermatome of the body, usually trunk.
These usually occur on only one side of the body
(unilateral).

Evaluating Patient With Decreased
Mobility
v Susceptible to skin damage and ulceration
v Pressure sores
o Sustained compression
o Shearing forces from bodily movements
o Easier to prevent than heal
o Assessment tool: Braden scale for predicting
pressure sore risk (pages 184–185)

Pressure Ulcers #1

Pressure Ulcers #2

Pressure Ulcers #3

Hair
v Note quantity, distribution, and texture.
v Inspect for lesions, flaking, and parasites.
v Inspect body, axillae, and pubic hair.
v Changes
o Loss of hair on legs: peripheral artery disease
o Changes in pubic or axilla: hormonal problems
v Inquire about laser hair removal treatments.

Hair Loss #1

Hair Loss #2

Hair Loss #3

Nails #1
v Inspect and palpate fingernails and toenails.
v Note color, shape, and any lesions.
o Should be pink with white lunulae
o Smooth and firm in texture
o Rounded in shape

Nails #2

Findings in or Near the Nails #1




Record Your Findings
v May use sentences
v May use phrases
v Carefully record your findings

Health Promotion and Counseling
v Important topics
o Skin cancer prevention
o Risk factors for skin cancers
o Avoidance of excessive sun exposure and artificial
tanning lamps
o Use of sun screen

Skin Cancer
v Basal cell carcinoma
o Basal level of epidermis
o 80% of skin cancers, rarely metastasize
v Squamous cell carcinoma
o Upper layer of epidermis
o 16% of skin cancers, can metastasize
v Melanoma
o Arise from melanocytes in epidermis
o 4% of skin cancers, most lethal

Skin Tumors #3

Skin Tumors #4

Malignant Melanoma

Some Risk Factors for Melanoma #1
v Personal or family history of previous melanoma
v Atypical or dysplastic moles
v Male gender
v 50 or more common moles
v Red or light hair

Some Risk Factors for Melanoma #2
v Light eye or skin color
v Actinic keratoses, solar lentigines
v Ultraviolet radiation from heavy sun exposure, sunlamps
or tanning booths
v Severe blistering sunburns as child
v Immunosuppression from HIV or chemotherapy

Preventing Skin Cancer
v Avoiding ultraviolet radiation and tanning beds
o Intermittent sun exposure more harmful
o Best defense—avoidance
v Regular use of sunscreen prevents skin cancer
o Recommend use of Sun Protective Factor (SPF) 30
and broad spectrum protection
o Water exposure should use water-resistant
sunscreen

Skin Cancer Screening
v Clinician Screening
o Remain alert during routine assessments
o Full body examinations recommended for patients
over 50
o Take advantage of “opportunistic screening”

Skin Self-Examination #1
v Equipment
o Full-length mirror
o Hand-held mirror
o Well-lit room
o Privacy

Examine body front and back in mirror, then

right and left sides with arms raised.

Bend elbows and look carefully at forearms,

upper underarms, and palms.

Look at back of legs and feet, the spaces between

toes and the sole of feet.

Examine back of neck and scalp with hand mirror. Part

hair for closer look.

Check back and buttocks with hand mirror.

ABCDE-EFGs of Examining Moles for
Possible Melanoma #1
v A: Asymmetry of one side of mole compared to other
v B: Irregular borders, especially ragged, notched, blurred
v C: Variation or change in color, especially black or blue
v D: Diameter ≥6 mm or different from others, especially if
changing, itching, or bleeding
v E: Evolving, a mole or skin lesion that looks different
from the rest or is changing in size, shape, or color

ABCDE-EFGs of Examining Moles for
Possible Melanoma #2
v Suggested adding EFG to help detect aggressive nodular
melanomas
v E: Elevated
v F: Firm to palpation
v G: Growing progressively over several weeks

Question #4
v To prevent skin cancer, a sunscreen with a “skin
protection factor” (SPF) of _____ is recommended.
A. 10
B. 20
C. 30
D. 40

Answer #4
v To prevent skin cancer, a sunscreen with a “skin
protection factor” (SPF) of _____ is recommended.
v C. 30
v An SPF of at least 30 and broad spectrum protection is
recommended.

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Chapter 9

The Integumentary System

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

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Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Common or Concerning Common or Concerning

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Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

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Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

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Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved

Copyright © 2018 Wolters Kluwer · All Rights Reserved