The Integumentary

System
Table of contents

01 Anatomy of the
Integumentary System 02 Functions of Integumentary
System and its parts’

Integumentary
03 Assessment of the
Skin
04 Disorders
 Prepare ¼ sheet of yellow
paper
This pre-test is a 15-point test that will help us assess the
prior knowledge that you have on the anatomy and
physiology of Integumentary System.
Answer the following;
01 Outermost layer of the stratified epithelial cells that is composed
predominantly of keratinocytes.

02 Cells that are primarily involved in producing pigment melanin.

03 Part of the hair that projects beyond the skin.

04 Largest organ of the body.

Layer of the skin that contains nerves and blood vessels, and the origin
05 of hair, nails, and the skin’s accessory glands.
06 Substance that is responsible for coloration of the skin.

07 Layer of the skin that provides heat and insulation.

08 Other term for sweat glands

09 Two kinds of sweat glands.

10 Five functions of Integumentary system.

 Answer Key
1. Epidermis 6. Melanin
2. Melanocytes 7. Subcutaneous Tissue/ Hypodermis
3. Hair Shaft 8. Sudoriferous Glands
4. Skin 9. Apocrine Glands & Sweat Glands
5. Dermis 10. Protection, Fluid Balance, thermo-regulation,
Sensation, Vitamin Production, Immune Response
Function
 Integumentary system
The skin and its appendages are collectively call the integumentary system or
the integument, which simply means “covering”. It is the largest organ system
of the body and is essential in human life.
 Integumentary system

Skin Accessory Organs

First line of defense against
microorganisms

Nails Glands
Epidermis Hypodermis Hair
Dermis
Skin
The skin provides the first line of defense
against microorganisms. It is composed of
three layers: epidermis, dermis, and
subcutaneous tissue.
Epidermis
It is an outermost layer of stratified epithelial cells, composed of
keratinocytes and melanocytes.

Dermis
It is made up of dense connective tissue and makes up the largest
portion of the skin. It provide strength and structure in the form of collagen
and elastic fibers. It contains blood and lymph vessels, nerves, sweat and
sebaceous glands, and hair roots.

Subcutaneous Tissue
Also called hypodermis, is primarily adipose and connective tissue,
which provides heat, insulation, shock absorption, and a nutritional
reservoir.
Hair
An outgrowth of the skin.
The hair consists of a root formed in the dermis
and a hair shaft that projects beyond the skin. It
grows in a cavity called a hair follicle.
Proliferation of cells in the bulb portion of the
follicle causes the hair to form.
Human hair with significant functions includes the eyelashes and
eyebrows, which keep dust and sweat out of the eyes, and nostril hair,
which filters air entering the nasal cavities. Hair on the head provides
thermal insulation.
Nails
It is a hard, transparent plate of Keratin that
overlies the skin. The nail grows from its root,
which lies under a thin fold of skin called the
cuticle. The nail protects the fingers and toes by
preserving their highly developed sensory
functions, such as for picking up small objects.
Glands
There are two types of skin glands: sebaceous
glands and sweat glands.
 Sebaceous Glands
The sebaceous glands are associated with hair follicles.
The ducts of the sebaceous glands empty sebum (fatty
secretions) onto the space between the hair follicle and the hair
shaft, thus lubricating the hair and rendering the skin soft and
pliable. Sebum also contain chemicals that can kill bacteria,
thus preventing bacterial infection of the skin.
 Sudoriferous (Sweat) Glands
Sweat glands are subclassified into two categories: eccrine and
apocrine.

Eccrine glands are found throughout Apocrine glands are larger

the dermis but are most numerous on the than eccrine glands. These are
face, palms, and soles. They are activated really modified scent glands and
by high temperatures or by exercise and are most numerous in the axillae
secrete sweat onto the skin surface. The and genital area; they are
sweat is evaporated by excess body heat, activated by stress and emotions.
which is a very effective cooling mechanism, Specialized apocrine glands
although it does have the potential to lead to called ceruminous glands are
dehydration if water is not replaced by found in the external ear, where
drinking. they produce cerumen.
 Functions of integumentary system include;

1. Protection against invasion of bacteria and other foreign matters, traumas,

epidermal water loss, penetration of environmental factors (ultraviolet radiation,
chemicals, microbes and insect bites).

2. Sensation. The receptor endings in the skin are to sense temperature, pain, light
touch and pressure (or heavy touch).

3. Fluid Balance. the outermost layer of the epidermis—has the capacity to absorb
water, thereby preventing an excessive loss of water and electrolytes from the
internal body and retaining moisture in the subcutaneous tissues.
4. Temperature Regulation. The heat produced by the body is dissipated primarily
through the skin. Three major physical processes are involved in loss of heat from
the body to the environment; radiation, conduction, and convection.
a) Radiation is the transfer of heat to another object of lower
temperature situated at a distance.
b) Conduction is the transfer of heat from the body to a cooler object in
contact with it.
c) Convection is the transfer of heat by conduction to the air
surrounding the body.

5. Vitamin Production. Skin exposed to ultraviolet light can convert substances

necessary for synthesizing vitamin D (cholecalciferol).
6. Immune Response Function. The skin has the capacity to generate innate and
adaptive immune responses.
 Physical Assessment
The nurse obtains important information through the health history and direct
observations. Assessment of the skin involves the entire skin area, including the
mucous membranes, scalp, hair, and nails. The skin is a reflection of a person’s
overall health, and alterations commonly correspond to disease in other organ
systems.
Normally the skin is intact, with no abrasions, and is
smooth, dry, well hydrated, and warm. Skin turgor is
firm and elastic. The skin surface is flexible and soft.
Skin color ranges from light to ruddy pink or olive in
white-skinned patients and light brown to deep
brown in dark-skinned patients.
Inspection
SKIN COLOR

Skin color can be influenced by many factors, including the

temperature of the patient, oxygenation, blood flow, exposure to
UV rays, and positioning. Because skin color can differ genetically
from very light to very dark, skin assessment can be difficult for
the novice practitioner.

Commonly noted alterations can include: cyanosis, erythema,

jaundice, pallor, and brown color.
 Cyanosis
A bluish discoloration of the skin and mucous membranes resulting from a
local or generalized excess of deoxygenated hemoglobin or a structural
defect in the hemoglobin molecule. The best places to inspect for cyanosis
are the lips, nailbeds, conjunctivae, and palms

DISORDER AND CAUSE CHANGE IN LIGHT SKIN CHANGE IN DARK SKIN

Acute and chronic disorders Dusky blue (may be generalized Skin may appear darker, but
of the structure and function or local, depending on cause) will be dull; cyanosis is more
of the heart and lungs readily assessed in the nail
(arterial insufficiency; beds, oral mucous
exposure to cold, membranes, and
hypothermia) Conjunctivae
 Erythema
Redness of the skin or mucous membranes that is the result of dilatation and
congestion of superficial capillaries. Erythema is best assessed on the
face or in an area of trauma.

DISORDER AND CAUSE CHANGE IN LIGHT SKIN CHANGE IN DARK SKIN

Hyperemia (inflammation, Red or bright pink Difficult to assess, skin may
increased body temperature, have dark red cast or
hot environmental temperature, purplish-gray tinge
embarrassment, alcohol
ingestion)
 DISORDER AND CAUSE CHANGE IN LIGHT SKIN CHANGE IN DARK SKIN

Carbon monoxide poisoning Cherry red in face and upper Cherry red lips, oral mucous
(carbon monoxide displaces torso membranes, and nail beds
oxygen on the hemoglobin
molecule, causing hypoxia,
carboxyhemoglobinemia)

Venous stasis (inability of veins Dusky Red of dependent Difficult to assess, easily
to return blood to heart; may extremities masked
result from edema, varicose
veins, or pressure)

Polycythemia Ruddy blue in face, oral Well concealed by pigment

mucosa, conjunctivae, hands
and feet
 Jaundice
Yellowish discoloration of the skin, mucous membranes, and sclerae of the
eyes, caused by increased amounts of bilirubin or other pigments in the
blood. The best place to inspect for jaundice is in the sclera of the
eye.

DISORDER AND CAUSE CHANGE IN LIGHT SKIN CHANGE IN DARK SKIN

Increased serum bilirubin to Yellowing of skin follows Yellowing is best assessed at
>2–3 mg/100 mL (liver disease, yellowing of sclerae and the junction of the hard
pancreatic disease, mucous membranes; may also palate and the soft palate or
gallbladder disease, hemolysis, be assessed in the fingernails on the palms of the hands.
such as following and palms of the hands Sclerae may be yellow near
blood transfusion, severe burns the limbus (do not confuse
or infections) with normal yellow eye
pigmentation)
 DISORDER AND CAUSE CHANGE IN LIGHT SKIN CHANGE IN DARK SKIN
Uremia (retained urochrome Orange-green or gray cast to Difficult to assess; may
pigments in the blood) skin appear as yellowish green
color in the scleral of the eye

Carotenemia Yellow-orange tinge in Yellow-orange tinge in palms

forehead, palms and soles, and soles
and nasolabial folds, but no
yellowing in sclerae or
mucous membrane
 Pallor
A decrease or absence in skin color as the result of a decrease in tissue
perfusion; a decrease in shape, size, or amount of RBCs; or absence of
melanin (local or generalized). Pallor is best assessed on the face,
conjunctivae, nailbeds, and lips.
DISORDER AND CAUSE CHANGE IN LIGHT SKIN CHANGE IN DARK SKIN
Anemia, Hemorrhage, Shock Generalized paleness Brown skin is dull and has a
yellow cast; black skin is dull
and has an ashen gray cast.
Arterial Insufficiency Localized paleness Dull, ashen gray
Vitiligo Patches of white spots, most Patches of white spots, most
often found over skin of the often found over skin of the
face, hands, or groin face, hands, or groin.
Albinism White/pink Tan, cream, or white
 Brown Color

This may be caused by increased melanin production and can indicate chronic
exposure to sunlight or pregnancy. This is best assessed on areas exposed to
the sun; changes in pregnancy can be seen on the face, areolae, and nipples.

A brownish color may also be the result of chronic peripheral vascular disease,
especially noted on the lower extremities.
LESIONS

A lesion is any change or injury to tissue. Assessment of skin

lesions helps determine the cause of a skin disorder. Lesions are
described as primary or secondary.

 Primary Lesion are the initial reaction to a disease process.

 Secondary Lesion are the changes that take place in the primary
lesion because of trauma, scratching, infection, or various stages of a
disease.

When assessing and documenting skin lesions, note the color or colors of the
lesion, the size (usually in centimeters), location, distribution, and
configuration (patterns of lesions). Also note any exudate, including amount,
color, and odor, and any accompanying symptoms.
Primary Lesions
PRIMARY LESION DESCRIPTION

Macule, Patch Flat, nonpalpable skin color change (color

may be brown, white, tan, purple, red)
• Macule : <1 cm; circumscribed border
• Patch: >1 cm; may have irregular
border
Papule, Plaque Elevated, palpable, solid mass with a
circumscribed border.
Plaque may be coalesced papules with a
flat top
• Papule : <0.5 cm
• Plaque: >0.5 cm

Nodule, Tumor Elevated palpable, solid mass that

extends deeper into the dermis than a
papule
• Nodule: 0.5-2 cm; circumscribed
• Tumor: >1-2 cm; tumor do not always
have sharp borders
Vesicle, Bulla Circumscribed, elevated, palpable mass
containing aerous fluid
• Vesicle : <0.5 cm
• Bulla: >0.5 cm

Wheal Elevated mass with transient borders;

often irregular; size and color vary

Caused by movement of serous fluid into

the dermis; does not contain free fluid in a
cavity (e.g. as a vesicle does)
Pustule Pus-filled vesicle or bulla

Cyst Encapsulated fluid-filled or semisolid mass

in the subcutaneous tissue or dermis
Secondary Lesions
SECONDARY LESION DESCRIPTION

Erosion Loss of superficial epidermis that does not

extend to dermis; depressed, moist area
Ulcer Skin loss extending past epidermis;
necrotic tissue loss; bleeding and scarring
possible

Fissure Linear crack in the skin that may extend to

dermis
Scales Flakes secondary to desquamated, dead
epithelium that may adhere to skin
surface; color varies (silvery, white);
texture varies (thick, fine)

Crust Dried residue of serum, blood, or pus on

the skin surface
Large, adherent crust is a scab.
Scar Skin mark left after healing of a wound or
lesion; represents replacement by
connective tissue of the injured tissue
• Young scars: Red or purple
• Mature scars: White or glistening

Keloid Hypertrophied scar tissue secondary to

excessive collagen formation during
healing; elevated, irregular, red

Greater incidence among African

Americans
Atrophy Thin, dry, transparent appearance of
epidermis; loss of surface markings;
secondary to loss of collagen and elastin;
underlying vessels may be visible

Lichenification Thickening and roughening of the skin or

accentuated skin markings that may be
secondary to repeated rubbing, irritation,
scratching
Excoriation Traumatized abrasions of the epidermis or
linear scratch marks
Configuration
Palpation
• Palpation is used in conjunction with inspection. Use the dorsum
(back) of the hand to palpate temperature because this part of the
hand is most sensitive to changes in temperature.

• Use the fingertips to gently palpate over the skin to determine size,
contour (flat, raised, depressed), and consistency (soft or indurated)
of lesions.

• If the lesion is moist or draining, wear gloves to protect against the

spread of infectious organisms. Note the degree of pain or
discomfort associated with light palpation of lesions.
MOISTURE OR DRYNESS

Assessment of moisture provides clues to the patient’s level of

hydration. Observe the skin for dryness, moisture, scales, and flakes.
Moisture may be found in skin fold areas. The skin should normally be
smooth and dry. Flaking and scaling of the skin indicate dry skin.

• Assess turgor and texture of the skin. Skin turgor is a measure of the
amount of skin elasticity.
• To assess for turgor, the skin on the back of the forearm or over the
sternum is pinched between the thumb and forefinger and then
released.
• Normally, the skin lifts easily and then quickly returns to its normal
state. Poor skin turgor is indicated by “tenting” of the skin, with
more gradual return to its normal state.

• Poor skin turgor may indicate dehydration. Normal aging of skin

produces some loss of skin elasticity; the preferred place to check
skin turgor in the elderly is over the sternum.
EDEMA
Edema occurs because of a build-up of fluid in the tissues.

• Edema can cause the skin to become stretched, dry, and shiny.
• Assess and document the location, distribution, and color of edematous
areas.
• If edema is unilateral, compare it with the opposite side of the body.
• Measure edematous extremities to track improvement or worsening of the
condition.
• Dependent edema is edema that occurs in the part of the body that is at
the lowest point, typically noted in the feet and ankles or in the sacrum if
the patient is lying down.

.
• If edema is suspected, palpate those areas to assess for tenderness,
mobility, and consistency. When pressure from your fingers leaves an
indentation, this is called pitting edema.

• Pitting edema is classified by its depth. Press the edematous area (against
bone, if possible) with your thumb for 5 seconds and then release. One
way to measure edema is to measure depth of the pitting in millimeters..
• 1+ edema = 2-mm depth, or trace
edema

• 2+ edema = 4-mm depth of

indentation, or a small amount

• 3+ edema = 6-mm depth,

moderate edema

• 4+ edema =8-mm depth,

indentation lasts 2 to 3 minutes,
very edematous
 Diagnostic Evaluation
The results of diagnostic tests of the structure and function of the integumentary
system are used to support the diagnosis of a specific injury or disease, to provide
information to identify or modify the appropriate medication or treatments used
to treat the disease, and to help nurses monitor the patients’ responses to nursing
care interventions.

Here are the major diagnostic tests for assessing integumentary disorders as well as
common nursing actions associated with each test.
BLOOD CHEMISTRY TESTS

A blood chemistry test analyzes a blood sample for potassium, sodium,

calcium, phosphorus, ketones, glucose, osmolality, chloride, blood urea
nitrogen, and creatinine.

Nursing actions
1. Explain the procedure to the client.
2. Withhold food and fluids before the procedure, as directed.
3. Check the venipuncture site for bleeding after the procedure.
SKIN BIOPSY

Removal of a piece of skin by shave, punch, or excision technique

to detect malignancy or other characteristics of skin disorders.

Types of Biopsy
1. Shave biopsy—scalpel used to remove raised lesions, leaving lower
layers of dermis intact.
2. Punch biopsy—special instrument used to remove round core of lesion,
containing all layers of skin. Biopsy site is usually closed with sutures.
3. Excisional biopsy—scalpel and scissors used to remove entire lesion,
usually with prescribed margins; suturing required.
Nursing Action
1. Explain the procedure, check if patient has any known allergies to local
anesthetics, and any current medications.
2. Obtain written consent.
3. Check the site for bleeding and apply pressure and appropriate dressing
to the site.
ALLERY EXAM
Skin testing uses a patch, scratch, or intradermal technique (injection
administered at a 15-degree angle) to administer an allergen to the skin’s
surface or into the dermis. The skin can then be analyzed for reaction.

Nursing actions
1. Explain the procedure to the client.
2. Keep the area dry.
3. Record the site, date, and time of test.
4. Inspect the site for erythema, papules, vesicles, edema, and induration.
5. Record the date and time for follow-up site reading.
WOOD LIGHT EXAMINATION
Wood light is a special lamp that produces long-wave ultraviolet rays,
which result in a characteristic blue to dark purple fluorescence. The color
of the fluorescent light is best seen in a darkened room, where it is possible
to differentiate epidermal from dermal lesions and hypo- and
hyperpigmented lesions from normal skin.

Nursing actions
1. Explain the procedure to the client.
SKIN SCRAPING
Tissue samples are scraped from suspected fungal lesions with a scalpel
blade that has been moistened with oil so that the scraped skin adheres to
the blade. The scraped material is transferred to a glass slide, covered with a
coverslip, and examined microscopically.

Nursing actions
1. Explain the procedure to the client.
2. Check the scraping site for bleeding and infection.
UNDER THE MICROSCOPE
A skin study is a microscopic examination of skin that includes gram
stain, culture and sensitivity, cytology, and immunofluorescence.

Nursing actions
1. Explain the procedure to the client.
2. Follow laboratory procedure guidelines.
3. Note current antibiotic therapy.
 Diagnostic Evaluation
The nurse obtains important information through the health history and direct
observations. Assessment of the skin involves the entire skin area, including the
mucous membranes, scalp, hair, and nails. The skin is a reflection of a person’s
overall health, and alterations commonly correspond to disease in other organ
systems.