Integumentary System Flashcards
What is the Primary Function of the Skin?
Protection
Which of the following are age-related changes in the hair and nails? (select all that apply)
a. Oily Scalp
b. Scaly Scalp
c. Thinner Nails
d. Thicker, brittle nails
e. Longitudinal ridging
b, d, e
The nurse assessed the client’s skin lesions as firm, edematous, and irregularly shaped with variable diameter. What are these lesions called?
Wheals
On inspection of the client’s skin, the nurse notes the complete absence of melanin pigment in patchy areas on the client’s hands. What is the assessment finding called?
Vitiligo
Individuals with dark skin are more likely to develop which of the following?
a. Keloids
b. Wrinkles
c. Rashes
d. Skin Cancer
A. Keloids
Under what circumstance is diagnostic testing recommended for skin lesions?
a. When a health history cannot be obtained
b. When a more definitive diagnosis is needed
c. When percussion reveals abnormal findings
d. When treatment with precribed medication has failed
B. When a more definitive diagnosis is needed
When assessing self-care habits in relation to the skin, what does the nurse question the client about?
a. Joint pain
b. Use of sunscreen products
c. Recent changes in exercise products
d. Family history of melanoma
B. Use of sunscreen products
During the physical examination of a client’s skin, which of the following would the nurse do?
a. Use a flashlight if the room is poorly lit
b. Note cool, moist skin as normal findings
c. Pinch up a fold of skin to assess for turgor
d. Perform a lesion specific examination first and then general inspection
C. Pinch up a fold of skin to assess for turgor
Epidermis
- Outer layer of the skin
- Relatively thin
- No lymphatic or vascular structures
- Superficial
- Breaks easily
- Sheds/Regenerates every 28 days
Dermis
Connective tissue below the epidermis
Highly vascular
Contains nerves, lymphatic vessels, hair follicles, sebaceous glands, and specialized cells such as mast cells and macrophages that protect the body from external stimuli
Wound will bleed with injury
Variety of thickness
Subcutaneous Tissue
While not part of the skin it attaches to the skin to underlying tissues such as muscle and bone
Contains loose connective tissue and fat cells that provide insulation, cushioning, temperature regulation, and energy storage
The distribution of subcutaneous tissue varies with gender, heredity, age, and nutritional status
Skin Appendages
Skin appendages include the hair, nails, and glands
What is the primary role of the integumentary system?
to protect the underlying tissues of the body from the external environment
The skin acts as a barrier against invasion by bacteria and viruses and prevents excessive water loss
What does fat do in the integumentary system?
The fat in the subcutaneous layer, insulates the body and provides protection from trauma
How does the skin regulate heat loss?
The skin regulates heat loss by responding to changes in internal and external temperature with vasoconstriction, vasodilation, and excretion of sweat
What provides sensory information in the skin?
Nerve endings and receptors located within the skin provide sensory information on environmental stimuli to the brain related to pain, temperature, touch, pressure, and vibration
What is some subjective data that needs to be collected for the Integumentary system?
Past medical history
Medications
Surgery or other treatments
Family history (ie., skin cancer)
Nutritional History (ie., vitamins that are essential to healthy skin such as vitamin A, D, and E. Food allergies that cause rashes.
Hydration Status
Social, Environmental, and Occupational Health History (ie., contact dermatitis)
Cognitive-Perceptual (ie., the patients perception to cold, pain, and touch. Joint pain and the mobility of joints)
Coping Abilities
What is some objective data that the nurse should collect for the integumentary system?
Inspection & Palpation
What do you inspect with the integumentary system?
Pigmentation, vascularity, bruising and the presence of lesions or discolouration
Nail beds, oral mucosa
Note the presence of tattoos and piercings
The colour, size, height, distribution, location, and shape of any lesions should be noted
Distribution and quantity of hair
Clubbing to nails
What does palpating the skin provide information about?
Palpating the skin provides information about temperature, turgor and mobility, moisture, and texture
What is a Punch Biopsy?
Provides full-thickness skin for diagnostic purposes
Includes dermis and some fat
Suturing may or may not be done
Scalpel blades
What is an Excisional Biopsy?
Skin closed with subcutaneous and skin sutures
Useful when good cosmetic results or entire removal or both are desired
Take a measurement with regards to the skin- called the “Safety Margin”
Ex: Take a border from around mole and then sent to a lab for diagnostics
The hope is to find “Clear Borders”
What is an incisional biopsy?
Wedge shaped incision made in lesion too large for an excisional biopsy. Useful when larger specimen than shave biopsy is needed
Ex: Skin Tag is snipped from the top of the skin.
Does not go any lower than the epidermis
Localized freezing, no deep freezing
What is a shave biopsy?
Single-edged razor blade used to shave off superficial lesions or small sample of a large lesion
Provides a thin specimen for diagnostic purposes
Shave off the epidermis and a bit of the dermal layer
What do cultures do for the skin?
Tests fungal, bacterial, and viral organisms
For bacteria= material is obtained from intact pustules or abscesses
What is Wood’s Lamp Test (Black Light)?
Identifies certain conditions on your skin, scalp, and hair. It’s often used to diagnose fungal, bacterial and parasitic infections.
Uses ultraviolet (UV) light to make certain cells show color or appear fluorescent
What is the mechanism of cell death?
The mechanisms of actual cell death may include the deterioration of the nucleus (nuclear shrinking), karyolysis (dissolution of the nucleus), disruption of cell metabolism, the rupture of the cell membrane
What does microbial invasion often result in?
Microbial invasion often results in cell injury and death
How does infection occur?
Infection occurs when pathogens invade and multiply in body tissue
What is apoptosis?
Programmed Cell Death
When does apoptosis occur?
Occurs in some regenerating tissues to create homeostasis , such as bone marrow, skin, and gut epithelium
What is necrosis?
tissue death that occurs as a result traumatic injury, infection, ischemia, or exposure to a toxic chemical that causes a local inflammatory response, which results from the release of intracellular contents after the rupture of the outer membrane of the dead cells
Defense against injury:
Mononuclear Phagocyte System
Phagocytic cells located in various tissues and organs
The functions of the macrophage system include recognition and phagocytosis of foreign material such as microorganisms, removal of old or damaged cells from circulation, and participation of the immune response
Defense Against Injury:
Inflammatory Response
A biological response to cell injury caused by pathogens, irritants, or chronic health conditions (ie., arthritis)
What does the intensity of the inflammatory response depend on?
The intensity of the response depends on the extent and severity of the injury and on the reactive capacity of the injured person
What happens to the inflammatory agent during the inflammatory response?
-the inflammatory agent is neutralized and diluted
- necrotic materials are removed
- An environment suitable for healing and repair is established
Defense Against Injury: Inflammatory Response
What occurs after cell injury as a vascular response?
After cell injury, vasoconstriction occurs to prevent bleeding by the movement of platelets to adhere to the vessels of the injured area forming a blood clot
This then releases Histamine which causes vasodilation
What part of the blood releases histamine?
Causes vasodilation to stop blood flow to the wound- platelets release histamine by causing some vasodilation to the area to fight off infection
Defense Against Injury: Inflammatory Response
In the Cellular Response, what do neutrophils do?
First leukocytes to arrive at the site of inflammation
They phagocytize (engulf) bacteria, other foreign material, and damaged cells
When dead neutrophils accumulate with other cell debris this collects and forms pus
Defense Against Injury: Inflammatory Response
In the Cellular Response, what do monocytes do?
Usually arrive at the site within 3-7 days after the onset of inflammation
Assists with phagocytosis of the inflammatory debris
Macrophages play an important role in cleaning the area before healing can occur
Essential in orchestrating the healing process
Defense Against Injury: Inflammatory Response
In the Cellular Response, what do lymphocytes do?
Arrive later at the site of injury
(lymphocytes play a crucial role in mediating inflammation and the immune response as well as creating antibodies to things)
1) Neutrophils arrive (leukocytes)
2) Monocytes Arrive (macrophages)
3) Lymphocytes arrive
Defense Against Injury: Inflammatory Response
In the Cellular Response, what do Eosinophils & Basophils do?
More selective role in inflammation
Eosinophils are released during an allergic reaction. They release chemicals that act to control the effects of histamine and serotonin
They are involved in phagocytosis of the allergen antibody complex
Eosinophils contain highly caustic chemicals that are capable of destroying a parasites cell surfaces
What happens to the cellular response during cell injury?
Higher neutrophils
Higher monocytes
As the healing progression they will have higher macrophages
If the patient has an allergic reaction or an anaphylactic reaction (Increase in eosinophils and basophils)
What are Kinins during an inflammatory response?
Kinins are proteins in the blood that cause inflammation and affect blood pressure (especially causing blood pressure to go down). They also increase blood flow throughout the body. Make it easier for fluids to pass through small blood vessels.
(involved in the vascular and pain response during tissue injury)
Defense Against Injury: Inflammatory Response
What does the chemical mediator Prostaglandin do?
Control processes such as inflammation, blood flow, and the formation of blood clots
What do NSAIDs like Ibuprofen and ASA do to prostaglandins in the inflammatory response?
NSAIDs like advil are used to treat many acute and chronic conditions by inhibiting prostaglandin synthesis
ASA blocks platelet aggregation and has anti-inflammatory action
What do corticosteroids do to prostaglandins in the inflammatory response?
Corticosteroids are inhibit prostaglandins
What is the local manifestations of inflammation?
Redness
Heat
Swelling
Pain
In the local manifestations of inflammation what is pain caused by?
caused by nerve stimulation by the chemical released such as histamine and prostaglandins as well as the pressure from fluid exudate
What are the systemic manifestations of inflammation?
Malaise, nausea, and anorexia, fever, increased pulse and respiratory rate.
What is acute inflammation?
The healing occurs in 2-3 weeks usually and leaves no residual damage
What is chronic inflammation?
Lasts for weeks, months, or even years
Ex., rheumatoid arthritis, osteomyelitis, and TB
In the healing process, what is regeneration?
The replacement of lost cells and tissues with cells of the same type
In the healing process, what is repair?
is healing as a result of lost cells being replaced by connective tissue
Usually results in scar formation
Repair healing occurs by primary, secondary , or tertiary intention
What is primary intention in regard to repair in the healing process?
This healing takes place when wound margins are neatly approximated, as in surgical incisions or a paper cut
What are 3 phases of healing in primary intention?
Initial (Inflammatory) Phase
Granulation (Proliferation/Reconstructive) Phase
Maturation and Scar Contraction
Healing Process: Primary Intention
Initial (Inflammatory) Phase
Lasts 3-5 days
The edges of the incision are aligned and sutured (or stapled) in place
How long do sutures and staples typically stay insitu for?
Sutures and Staples are left in for 10-14 day
Take every other staple out to prevent the wound from dehiscing and then place steri-strips
Healing Process: Primary Intention
Granulation (Proliferation/Reconstructive) Phase
Lasts from 5 days to 3 weeks
At this stage fibrous or scar tissue begins to develop
During this phase the wound is pink and vascular
Body produces brand new cells
Increase of cells and reconstruction of cells and tissues
Healing Process: Primary Intention
Maturation and Scar Contraction
Overlaps with the granulation phase
Begins 7 days after the injury and continues for several months or years
Scar formation or the the scar disappears
Healing Process: Secondary Intention
What is secondary intention?
Wounds with wide or irregular wound margins that cannot be approximated will heal with secondary intention
Healing Process: Secondary Intention
Examples of Secondary Intention
chronic wounds such as venous leg ulcers, and wounds caused by trauma or pressure
Healing Process: Secondary Intention
What are some characteristics of Secondary Intention?
Irregular margins or the wound is wider
The edges cannot be brought together to be approximated
Maturation, Proliferation, and maturation takes longer to occur due to the wound
Slough Tissue- non-viable tissue → needs to be debrided (chemically debride or surgically debride, or medical maggots)
Healing Process: Tertiary Intention
When does tertiary intention occur?
Occurs when the wound is left intentionally open because if the wound is closed immediately, healing could be impaired due to contamination (ex., animal bite or foreign material), infection or high risk of infection, edema or poor circulation
Healing Process: Tertiary Intention
How is tertiary intention treated?
The wound is later closed surgically after the tissue is controlled or resolved
Usually results in a larger and deeper scar
Ex., Vac Therapy
Healing Process: Tertiary Intention
What is tertiary intention?
Delayed primary intention
How are wounds Classified?
- By cause (Surgical wound, non-surgical wound)
- By pathology (vascular, pressure diabetes related)
- By duration (Acute vs. Chronic)
- By level of contamination (Is it infected?)
- By type of tissue involved (Superficial, partial thickness, or full thickness)
- By wound bed colour (Necrotic/black, yellow, or mixed colour)
Complications of Healing:
Adhesions
Bands of scar tissue that for between or around organs
They may develop in the abdominal cavity or between the lungs and pleura
Adhesions in the abdomen may cause an intestinal obstruction
Complications of Healing:
Contractures
Wound contraction is an important part of healing. This process may become abnormal when contraction is excessive, which results in deformity, or contracture
When do contractures typically occur?
Shortening of muscle or scar tissue, especially over joints, results from excessive fibrous tissue formation
Contractures frequently occur in burn injuries, when extensive skin and subcutaneous tissue are lost
Complications of Healing:
Dehiscence
The separation and disruption of previously joined wound edges. It usually occurs when the primary healing site bursts open
Complications of healing:
Evisceration
Occurs when the wound edges separate o the extent that intestines protrude through the wound
(this is a medical emergency - soak gauze with normal saline and place it on the protruding organ)
Complications of Healing:
Excess granulation tissue
Portrudes above the wound
Complications of Healing:
Fistula
An abnormal passage that forms between organs or a hollow organ and the skin
Complications of Healing:
Infection
Increased risk of infection when it contains necrotic tissue, when the blood supply is decreased, when the immune function is depressed, or if a patient is malnourished, or has multiple stressors, or is diabetic.
Complications of Healing:
Hemorrhage
Bleeding is normal immediately after tissue injury and ceases with clot formation
Complications of Healing:
Keloids
Keloid Scars form when the body produces excess collagen
What is a pressure injury?
Localized injury to the skin and the underlying soft tissue, usually over a bony prominence, as a result of excessive or prolonged pressure, shear, and tissue deformation
How are pressure injuries staged?
They are staged according to the deepest level of tissue damage
Stages of Pressure Ulcers: Stage One
Intact skin with a localized area of nonblanchable erythema, which may appear darkly pigmented
Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visible changes
Stages of Pressure Ulcers: Stage Two
Partial thickness loss of skin with exposed dermis
The wound bed is viable, pink, or red, moist, and may also appear as an intact or ruptured serum filled blister
Neither adipose or deeper tissues are visible
If you take your index finger and press on the red area and there is no blanching then that means that there is inadequate blood flow
Stages of Pressure Ulcers: Stage Three
Full thickness loss of skin, in which adipose is visible in the ulcer and granulation tissue and rolled wound edges are often present
Slough or eschar, or both may be visible
Undermining or tunneling may occur
Stages of Pressure Ulcers:
Stage Four
Full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer
Slough, eschar, or both may be visible
Rolled edges, undermining, or tunneling, or a combination of these often occur
Depth varies based on anatomical location
What makes pressure ulcers unstageable?
If slough or eschar obscures the extent of tissue loss
If the slough or eschar are removed, a stage 3 or 4 pressure injury is revealed
When you cannot see the wound bed
What is the Braden Scale (Risk Assessment)?
Patient is assessed on a subscale of 6 things: sensory perception, moisture, activity, mobility, nutrition, and friction and shear
Scores can range from 6 to 23
The lower the score, the higher the patients risk of developing a pressure injury
What are some nursing interventions for Pressure Ulcers?
Patient should be assessed on admission and periodic intervals throughout their hospital admission
The patient should be repositioned frequently (Q2H)
Air bed that changed patients pressure on the bed
Foam dressings
Wheelchair cushions
Padded commode seats
Heel boots (foam, air)
Nutrition (Do we need to get an order for a dietician? Increase their protein intake)
Mobilization (Maybe we need to get PT/OT involved)
Maybe provide a wheelchair user with gloves to prevent blisters and calluses from forming
Healing- requires consistency and timelines
What are some overarching Nursing Management Considerations for the Integumentary System?
- Observation & Vital Signs
- Fever
- RICE
- Wound Management
What is R.I.C.E?
R.I.C.E (rest, ice, compression, and elevate)
- 20 minutes on and 20 minutes off with ice
- For swelling we initially use ice
- When wrapping an injury you wrap distal to proximal to mimick venous return (wrap from the bottom up)
- Always elevate above heart level
Skin Infections and Infestations:
Bacterial Infections: Cellulitis
What is cellulitis?
Deep inflammation of subcutaneous tissue due to enzymes produced by bacteria
Skin Infections and Infestations:
Bacterial Infections: Cellulitis
How do you assess cellulitis?
Draw a line of demarcation to ensure that the redness does not travel up the leg
Measure the diameter of the affected area to make sure that it does not increase
Assess pulse on affected limb
Skin Infections and Infestations:
Bacterial Infections: Cellulitis
What are the clinical manifestations of Cellulitis?
Hot
Tender
Erythematous
Edematous area with diffuse borders
Chills, malaise, and fever
Skin Infections and Infestations:
Bacterial Infections: Cellulitis
How do you treat cellulitis?
Moist, heat, immobilization and elevation
Systemic ABX therapy
Progression of gangrene is possible if left untreated
Common Infestations and Insect Bites:
What are clinical manifestations of bed bugs?
Wheal surrounded by vivid flare
Firm urticaria transforming into persistent lesion
Severe pruritus
Often the bites will be in groups of threes
Usually feed at night
Common Infestations and Insect Bites:
What is the treatment and prognosis of bed bugs?
Environmental treatments include steam cleaning vacuuming, heating, freezing, washing, and disposal of items
Severe itching possibly necessitates use of antihistamines and corticosteroids - or if they are itching and the skin opens and an infection occurs, antibiotics may need to be given
Common Infestations and Insect Bites:
What is scabies?
Mite penetrates the skin and deposits eggs
Common Infestations and Insect Bites:
How is scabies transmitted?
Transmission by direct physical contact, only occasionally by shared personal items
Common Infestations and Insect Bites:
What are the clinical manifestations of scabies?
Severe itching, especially at night, usually not on the face
Presence of burrows, especially in interdigital webs, flexor surface of the wrists, genitalia, and anterior axillary folds
Erythematous papules (may be crusted), possible vesiculation, inter digital web crusting
Track Lines (migration patterns)
Common Infestations and Insect Bites:
What is the treatment and prognosis of scabies?
Topical lotions/creams (the topical cream provides a barrier and kills the scabies that are underneath)
Treat all sexual partners and cohabitants
Treat environment with plastic covering for 5 days
Launder all clothes and linen with bleach
Antibiotics if secondary infections are present
