Structure, Function, and Disorders of the Integument

Anatomy and Physiology The skin (combined with its appendages) is the largest organ of the body Hair Nails Sebaceous glands Eccrine and apocrine sweat glands

Function of Skin Cover- protects from germs, dehydration, injury First line of defense Regulates body temperature Site of many nerve endings Body temp regulation- evaporation of h20 (sweat) rids body of heat. Dogs

Skin Functions Regulates body temperature Helps regulate fluid balance regulates heat loss Helps regulate fluid balance absorbs water prevents excessive water & electrolyte loss. Slow loss up to 600 ml daily by evaporation Immune Response Function inflammatory process

Skin Functions Vitamin production exposure to UV light allows for the conversion of substances necessary for synthesizing vitamin D Necessary to prevent osteoporosis, rickets

Temporary storage of glucose, fat, water and salt. Can absorb chemical substances Nitroglycerin patch Ointment for rashes

Functional Review Protector and barrier between internal organs and external environment Barrier against foreign body intrusions against invading bacteria and foreign matter Transmits sensation – nerve receptors allows for feelings of temperature, pain, light touch and pressure

Anatomy and Physiology Maintains body surface integrity by ongoing cell replacement and increased regeneration for wound repair Maintains a buffered protective skin film by eccrine and sebaceous glands to protect against microbial and fungal agents

Anatomy and Physiology Delays hypersensitivity reactions to foreign substances Indicates emotion through color change

One Square Centimeter of Skin Contains... 3,000,000 cells 10 hairs. 1 yard of blood vessels. 4 yards of nerves. 700 sweat glands. 200 nerve endings to record pain. 3000 sensory cells at the end of nerve fibers

Skin- 3 basic layers Epidermis- epithelial cells with no blood Avascular Dermis- True skin made of connective tissue and is vascular Hypodermis- aka subcutaneous. Attaches integument to muscle Stratum geminativum

Layers of the Skin Dermis Subcutaneous layer Collagen, elastin, reticulum, and a gel-like ground substance Hair follicles, sebaceous glands, sweat glands, blood vessels, lymphatic vessels, nerves Fibroblasts, mast cells, macrophages Subcutaneous layer Adipocytes Dermal and subcutaneous collagen are continuous

Layers of the Skin Dermal appendages Blood supply Nails Hair Sebaceous glands Eccrine and apocrine sweat glands Blood supply Papillary capillaries

Aging and Skin Integrity The integumentary system reflects numerous changes from genetic and environmental factors The skin becomes thinner, drier, wrinkled, and demonstrates a changes in pigmentation Shortening and decrease in the number of capillary loops Fewer melanocytes and Langerhans cells

Aging and Skin Integrity Atrophy of the sebaceous, eccrine, and apocrine glands Changes in hair color Fewer hair follicles and growth of thinner hair

Gerontology Considerations Watch for significant changes in aging: Decrease immunity functions Susceptibility to infections Poor nutrition Decrease collagen production – loss of subcutaneous Thinning of epidermal skin layers Increase skin problems

Gerontology Considerations Taking more medications Excessive environmental exposure Dryness, wrinkling Uneven pigmentation Various proliferative lesions

Characteristics of skin lesions ATROPHY Thinning of the skin surface and loss of skin markings Skin appears translucent and paperlike

Cherry Angiomas Elderly bright red moles on the skin Papules Benign

History and Examination Relevant information; - systemic disease diabetes, hepatitis - use of medications toxic epidermal necrolysis - similar cases in family atopy - longterm sun exposure tumours - occupation contact dermatitis - geographic location insect bites, lyme disease - previous skin diseases - sexual history syphilis, gonorrhea history of particular lesion, movement, size

Assessment of the Skin Prepare the patient: explain the purpose and provide privacy and coverings Ask assessment questions Inspect the patient’s entire body including mucosa, scalp, hair, and nails

Assessment of the Skin Wear gloves Assess any lesions; palpate and measure them Note hair distribution Photographs may be used to document nature and extent of skin conditions and to document progress resulting from treatment; they may also be used to track moles

Skin Assessment Visual inspection Palpation Olfactory senses Adequate lighting Remove necessary clothing while providing respect and privacy Appropriate client positions

Assessing the Skin Lesions: Lightly palpate any lesions to detect tenderness, firmness, and depth. Measure length, width, and depth also. Birthmarks/Moles: Note location, color, shape, and size. Assess with the following four warning signs (ABCD) that might indicate the presence of skin cancer: A little later

Visible changes if the Skin Changes in skin color texture Eczema, infections Assess the vascularity & hydration of skin Edema – swelling, pitting edema 1+ 2 mm 3+ 6 mm 2+ 4 mm 4+ 8 mm Nails – configuration, consistency, color Hair – color and distribution, alopecia, location

Visual inspection Skin color: Palor Cyanosis Jaundice Erythema Hyperpigmentation Hypopigmentation – vitiligo

Assessing light to dark skin Description Light skin Dark skin Cyanosis - bluish Bluish tinge Ashen gray Pallor - paleness Loss of rosy glow Ashen gray (dark skin) Yellowish brown (brown skin) Erythema - redness Visible redness Diffused; rely on palpation of warmth or edema Petechiae – small size pinpoint ecchyumosis Purplish pinpoints Usually invisible; check oral Mucosa, conjunctiva, eyelids, conjunctiva covering eyeballs.

Assessing light to dark skin Description Light skin Dark skin Jaundice - yellow Yellow sclera, skin, fingernails, soles, palms, oral mucosa Reliable on sclera, hard palate, palms and soles. Ecchymosis – large diffused bluish black Purplish to yellow-green Difficult to see, check mouth or conjunctiva Brown-Tan – cortisol deficiency, increased melanin production Bronze; Tan to light brown Easily masked.

A particular terminology has developed to define skin lesions Description A particular terminology has developed to define skin lesions primary: describes morphology or lesion type macule, papule, plaque, wheal, cyst, nodule, tumor, vesicle, bulla and pustule. secondary: configuration, texture, scale, crust, lichenification, scar, excoriation, fissure, ulceration, ulcer, erosion and atrophy. vascular lesions: blood sequellae, pathology purpura, petechiae, ecchymoses, telangiectasia shape: annular, serpiginous, flat-topped, domed

Macule A macule is a change in the color of the skin. It is flat, if you were to close your eyes and run your fingers over the surface of a purely macular lesion, you could not detect it. A macule greater than 1 cm. may be referred to as a patch

Characteristics of skin lesions MACULE Circumscribed Flat Discoloration Brown Blue Red Hypo-pigmented

Characteristics of skin lesions MACULE Freckles Flat moles (nevi) Petechiae Measles Scarlet fever Macule/patch (mongolian spot)

molluscum contagiosum Papule Solid raised lesion that has distinct borders and is less than 1 cm in diameter. May have a variety of shapes in profile (domed, flat-topped, umbilicated) and may be associated with secondary features such as crusts or scales scabies molluscum contagiosum

Characteristics of skin lesions PAPULE Circumscribed Elevated Superficial Solid lesion > 0.5 cm in diameter Often confluent

Characteristics of skin lesions PAPULE Wart Elevated mole Lichen planus Venereal wart

Characteristics of skin lesions PLAQUE Elevated Firm Rough Flat-top > 1cm in diameter A solid, raised, flat-topped lesion greater than 1 cm. in diameter. It is analogous to the geological formation, the plateau PLAQUE Psoriasis Seborrheic keratoses Actinic keratoses Plaque (psoriasis)

Wheal (hive) WHEAL Elevated Irregular shaped Cutaneous edema Solid An area of edema in the upper epidermis “Edematous, transient papule or plaque caused by infiltration of dermis by fluid WHEAL Elevated Irregular shaped Cutaneous edema Solid Transient Variable diameter An elevated, white to pink edematous lesion that is unstable and associated with pruritus. Wheals are evanescent – they appear and disappear quickly. Seen in mosquito bites and hives.

Characteristics of skin lesions WHEAL Urticaria Insect bite Allergic reaction Desired technique

Deeper in dermis than a papule Nodule Nodule is a raised solid lesion more than 1 cm. and may be in the epidermis, dermis, or subcutaneous tissue NODULE Elevated Firm Circumscribed Deeper in dermis than a papule 1-2 cm in diameter

Characteristics of skin lesions NODULE Erythema nodosum Lipoma

Characteristics of skin lesions TUMOR Elevated Solid May or may not be clearly demarcated Deeper in dermis >2 cm in diameter

Characteristics of skin lesions TUMOR Neoplasm Benign Lipoma hemangioma

Characteristics of skin lesions VESICLE Elevated Circumscribed Superficial Filled with serous fluid <1 cm in diameter

Vesicle Raised lesions less than 5mm. in diameter that are filled with clear fluid (blister) http://z.about.com/d/dermatology/1/0/M/5/three_lesions.jpg

Characteristics of skin lesions VESICLE Varicella (chicken pox) Herpes Zoster (shingles)

Characteristics of skin lesions BULLA Vesicle greater than 1 cm in diameter

Characteristics of skin lesions BULLA Blister Pemphigus vulgaris

Characteristics of skin lesions PUSTULE Elevated Superficial Similar to vesicle but filled with purulent fluid Circumscribed elevated lesions that contain pus They are most commonly infected (as in folliculitis) but may be sterile (as in pustular psoriasis)

Characteristics of skin lesions PUSTULE Impetigo acne

Characteristics of skin lesions Cyst Elevated Circumscribed Encapsulated In dermis or subcutaneous layer Filled with liquid or semisolid material

Characteristics of skin lesions ULCER Loss of epidermis and dermis Concave Varies in size

Characteristics of skin lesions FISSURE Linear crack or break from the epidermis to the dermis May be moist or dry

Characteristics of skin lesions FISSURE Athlete’s foot Crack at the corner of the mouth

Characteristics of skin lesions SCALE Heaped-up Keratinized cells Flaky skin Irregular Thick or thin Dry or oily Variation in size

Characteristics of skin lesions SCALE Flaking of skin with seborrheic dermatitis following Scarlet fever Drug reaction Dry skin

Characteristics of skin lesions LICHENIFICATION Rough Thickened epidermis secondary to persistent rubbing, itching, or skin irritation Often involves flexor surface of extremities

Characteristics of skin lesions LICHENIFICATION Chronic dermatitis Eczema Contact dermatitis.

Characteristics of skin lesions EROSION Loss of part of the epidermis Depressed Moist Glistening Follows rupture of a vesicle or bulla

Characteristics of skin lesions EROSION Varicella Variola after rupture

Characteristics of skin lesions TELANGIECTASIA Fine Dilation of capillaries Irregular red line

Characteristics of skin lesions PURPURA Red-purple nonblanchable discoloration Greater than 0.5 cm in diameter

Characteristics of skin lesions SPIDER ANGIOMA Red central body with radiating spider-like legs Blanch with pressure to central body

Characteristics of skin lesions Close-up of a spider angioma in a male with cirrhosis of the liver   These are AV fistulas and will disappear when the central portion of the lesion is compressed. SPIDER ANGIOMA Liver disease Vitamin B deficiency idiopathic

Characteristics of skin lesions PETECHIAE Red-purple nonblanchable discoloration

Characteristics of skin lesions PETECHIAE Intravascular defects Infection Found in the mouth Vancomycin-Induced Thrombocytopenia

Characteristics of skin lesions VENOUS STAR A small red nodule formed by a dilated vein in the skin. Caused by increased venous pressure Bluish spider Linear or irregularly shaped Does not blanch with pressure

Characteristics of skin lesions VENOUS STAR Increased pressure in superficial veins

Characteristics of skin lesions CAPILLARY HEMANGIOMA (Nevus flammeus) Red Irregular Macular patches

Characteristics of skin lesions CAPILLARY HEMANGIOMA (Nevus flammeus) Dilation of dermal capillaries