1. Medical-Surgical Nursing: Concepts & Practice
3rd edition
Chapter 41
The Integumentary System
Copyright © 2017, Elsevier Inc. All rights reserved.

2. Theory Objectives Describe the structure and functions of the skin.
Compare and contrast the various causes of integumentary disorders.
Analyze important factors in the prevention of skin disease.
Plan specific measures to prevent skin tears.

3. Theory Objectives (Cont.)
Interpret laboratory and diagnostic test results for skin disorders.
State nursing responsibilities in the diagnosis of skin disorders.
Write outcome objectives for a patient with a problem of altered skin integrity.

4. Clinical Practice Objectives
Teach three patients to perform a self-assessment of the skin.
Analyze the changes that have occurred with aging that affect the skin barrier for one of your older adult patients.
Perform a focused integumentary assessment on a patient.

5. Clinical Practice Objectives (Cont.)
Provide skin care for an older adult with dry skin.
Implement a teaching plan appropriate for adolescents and young adults for the prevention of skin cancer.

6. Integumentary System Skin Structure –
1. epidermis – top layer – thin tissue – no blood vessels- cell growth occurs at the bottom of the epidermis and pushes cells up to the surface. Bottom layer contains melanocytes – give color to the skin.
2. dermis – inner layer – contains blood vessels and nerves, base of hair follicles, glands and nails. Fibroblasts are in this layer to produce new cells to heal the skin.
3. subcutaneous tissue – skin is attached to underlying structures

7. Functions of the Skin
Protective covering – keratin in the skin makes it waterproof
Barrier to bacteria
Protects underlying tissues from injury
Regulates body temperature
With sunlight, converts rays to Vitamin D
Nerves receptors conveys touch (heat, cold)

8. Effects of Aging on the Skin
Elastic fibers adipose tissue decrease – skin will wrinkle and sag
Collagen fibers decrease – skin becomes fragile
Skin thinner, more transparent
Decrease sebaceous gland activity reduced temp control –
Decrease melanocytes – increase in sunburn,skin cancer
Susceptible to fungal infections – thick nails.

10. Audience Response Question 1
Which physiologic change(s) associated with aging predispose(s) older adults to skin breakdown? (Select all that apply.)
Decreased melanocytes
Loss of collagen
Increased elastic fibers
Decreased adipose tissues
Reduced sebaceous gland activity
Correct Answer: 2, 4, and 5

11. Integumentary System – Causes for Disorders of the Skin
Pathology in the skin itself – bacteria, virus
Manifestations of systemic disease – immune/inflammatory disorder (i.e: allergies), neoplastic disorder, metabolic disorder, endocrine disorder or nutritional disorder

12. Prevention Factors Hygiene
Diet – dehydration causes loss of skin turgor
Age- old & sweat glands become less active, less elasticity
Environment – exposure to chemicals, cold temp, water immersion, exposure to sun, occupational hazards.

13. Audience Response Question 4
The nurse reminds teenagers regarding the importance of protecting their skin from ultraviolet rays by (Select all that apply.)
using a sunscreen with a skin protective factor (SPF) of at least 15.
applying sunscreen thinly.
wearing light, loose-fitting clothing.
gauging exposure while in the sun.
wearing sunglasses and a hat.
Correct Answer: 1 and 5

14. Good nursing care – Skin integrity
See Box 41-1 page 960
And Box 41-2 page 960
Causes can be careless handling, friction
Skin tears are classified Payne Martin classification system
Category I – skin tear without tissue loss
Category II – skin tear with partial tissue loss
Category III – skin tear with complete tissue loss - epidermal flap is missing

15. Risk Factors for Skin Tears
Dry skin with dehydration
Areas of ecchymoses
Presence of friction, shearing, or pressure from bed or chair
Impaired sensory perception
Impaired mobility
Taking multiple medications
Prolonged use of corticosteroids
See Box 41-1 on p. 960.

16. Risk Factors for Skin Tears (Cont.)
Presence of renal disease, congestive heart failure, or stroke impairment
Incorrect removal of adhesive dressings
Rough handling when being bathed, dressed, transferred, or repositioned

17. Skin Tear Protocol Continuously cleanse the wound.
Conform to the wound.
Absorb exudates.
Keep the wound bed moist and reduce pain and discomfort.

18. Audience Response Question 3
The nurse launching an information campaign to prevent skin tears among the residents in a long-term care facility should include (Select all that apply.)
encouraging wearing long sleeves and pants.
providing adequate lighting.
using germicidal soap every day on extremities.
supporting dangling arms and legs with pillows or blankets.
removing tape and dressings with extreme caution.
Correct Answer: 1, 2, 4, and 5

19. Diagnostic Test and Procedures
Biopsy – identify benign or malignant lesions or cause for infection – bacterial/fungal
Culture and sensitivity test – sample exudate to help identify best antibiotic for treatment
Special light inspection – Cold light/Wood
Diascopy – glass pressed on skin
Skin patch testing

20. Assessment (Data Collection)
Focused assessment on the skin – see page 962
Physical assessment – done under good lighting be aware elderly have common skin conditions like keratosis, keloids or senile purpura. Pictures following 3 slides
Note any lesions with metric measurements – see Table 41-1 Types of Skin Lesions

21. Seborrheic Keratoses

22. Keloid Scar
See Figure 41-3 on p. 962.

23. Senile Purpura

24. Types of Skin Lesions Table 41-1
Macule
Papule
Vesicle
Plaque
Wheal
Pustule
See Table 41-1 on p. 963.

25. Patient Teaching for Skin Self-Exam
Darkening or spreading of color or increasing unevenness of color
Increase in size or diameter
Change in shape (Has the lesion become elevated, or have its formerly regular edges become irregular?)
Redness or swelling of surrounding skin, or any other noticeable change around the lesion

26. Patient Teaching (Cont.)
Itching, tenderness, or other change in sensation
Crusting, scaling, oozing, ulceration, or other change in the surface of the lesion
When assessing for melanoma, check for the ABCDs: A = asymmetrical, B = irregular border, C = color, D = diameter change greater than 1/4 inch

27. Assessment (Data Collection)
Older adult considerations
Skin breakdown
Skin lesion documentation
Observation while bathing

28. Audience Response Question 5
The patient presents with a rash of unknown origin. Which assessment question(s) would help determine the cause? (Select all that apply.)
“When did the rash or lesion first appear?”
“Can you think of any event or different food you ate or substance you were using just before the rash appeared?”
“Which drugs are you taking? Do you take any over-the-counter preparations?”
“Have you ever had radiation therapy?”
“Do you have a history of any skin disorders in your family?”
Correct Answer: 1, 2, 3, 4, and 5

29. Planning Restore the skin to normal. Decrease pain and itching.
Protect the skin from further damage.
Prevent infection.
Prevent scarring as much as possible.

30. Implementation Giving medicated baths – pat dry-keep warm
Laundry requirements- no added fragrances, no dryer sheets, new clothes wash/dry before wearing
Application of wet compresses or dressings – open are changed repeatedly every 20 to 30 minutes – closed dressings soaked with solution and wrapped
Application of topical therapy for skin lesions

31. Guidelines for Applying Topical Medications
Powders – dry area before application- cornstarch not recommended
Ointment- small amount massaged in
Gels – usually contain alcohol
Lotions – powders suspended in water, leave residue. Wash off residue before applying more lotion
See Box 41-3 on p. 967.