1. The Integumentary System Dr. Zyad Saleh JU School of Nursing

2. Introduction SKIN is the largest and heaviest organ in the body (16% of body weight). Skin contains three layers: 1)Epidermis: does not contain blood vessels. Depends on dermis for its nutrition. melanin and keratin are formed 2)Dermis: well supplied with blood. Contains connective tissue, sebaceous glands, sweat glands, nerve ending, lymph vessels, and hair follicles.

3. 3) Subcutaneous (adipose; fat) tissue.

4. The color of normal skin depends primarily on four pigments: -melanin, -carotene, -oxyhemoglobin, -and deoxyhemoglobin.

5. Functions of the skin: Protection (ex. Mechanical, chemical, thermal, UV light, microorganisms, loss of water or electrolytes). Temperature regulation (ex. Heat storage in fat insulation; heat dissipation through sweat glands). Synthesize vit. D from cholesterol by action of UV light. Sensory perception (ex. Pain, pressure, temp, touch). Communication (ex. Facial movements). Provides identity (ex. Facial features). Excretion of metabolic wastes (ex. Electrolytes, uric acid).

6. Hair Two general type of hair :  Vellus : which is short, relatively unpigmented and fine present over much of the body.  Terminal : (scalp and eye brow) longer, darker and coarser than vellus hair - Additional terminal hair appear more after puberty - Function; scalp hair protective covering Nasal hair, ear hair and eye lashes filter dust from the air.

7. Nail - Hard, transparent plates of keratinized epidermal cells. - Grow from a root underneath skin the skin fold called cuticle. - The nail protect distal ends of the fingers and toes.

8. Sebaceous Glands and Sweat Glands. -Sebaceous glands produce a fatty substance secreted onto the skin surface through the hair follicles. -These glands are present on all skin surfaces except the palms and soles. -The eccrine glands are widely distributed, open directly onto the skin surface, and by their sweat production help to control body temperature. -the apocrine glands are found chiefly in the axillary and genital regions and usually open into hair follicles. (adult body odor).

9. Functions of the skin: Cause of integumentary history is to identify: Diseases of the skin. Systematic diseases. Physical abuse. Risk for pressure ulcer formation. Risk for skin cancer. Need for health education related to skin.

10. Start your inquiry about the skin with a few open-ended questions: -“Have you noticed any changes in your skin?... your hair?... your nails?”

11. The Health History Concerning Symptoms  Rash  Lesions  Bruising  Hair loss  Moles  Bed sores  Rash  Lesions  Bruising  Hair loss  Moles  Bed sores

12. The Health History OLD CART Have you had any rashes? Sores? Lumps? Itching?

13. The Health History Onset: when did it start? Have you started any new meds? Been out of the country? Have it before? Location: where it is located? Any spread or change in size? Duration: how long have you had it? Does it come and go? Characteristic symptoms: Describe it? What did it first look like? Has it changed? Associated manifestations: Does it itch? Cause pain? Is there any discharge ? Relieving/ Exacerbating factors: Is there something make it better / Worse? Treatment: Did you try to treat it?

14. The Health History Past History:  Do you have any skin diseases (ex. Melanoma, eczema, psoriasis)?

15. The Health History  Do you have DM or peripheral vascular disease?  Do you have any allergies or food sensitivities?  Have you ever had sunburn?  What medications are you taking?  Any recent hair loss? Gradual or sudden? Symmetrical? Associated with stress?  Any change in nails? Shape ? Color?

16. The Health History Family History:  Do any family members have the same or similar symptoms?  Has anyone in your family had melanoma, eczema, psoriasis?  Does anyone have allergies?

17. Lifestyle: The Health History Describe your bathing and shampooing routine? Have you change product brands recently? Do you wear false nails? Wig? Do you go to nail salon? Gym? Pool? How much sun expose do you receive? Do you use sunscreen? What SPF? Are you exposed to any chemicals, radiations? Do you perform skin self-examination? Describe your diet? Activity level?

18. Preparation: Control External variables that influence skin color such as: emotional states, temperature, prolonged elevation/dependent position of extremities, and inactivity. Equipment needed: strong direct lighting, small centimeter ruler, penlight, gloves. Privacy Explain procedure to the patient. Physical Examination

19. SKIN: Inspect and palpate the skin 1.Color: general pigmentation vary according to genetic background. Ex. olive, tan, brown, or golden hues. Look for increase or decrease pigmentation. Vitiligo

20. Look for increased brown pigmentation, loss of pigmentation, redness, pallor, cyanosis, and yellowing of the skin. Assess the red color of oxyhemoglobin and the pallor (the fingernails, the lips, and the mucous membranes, particularly those of the mouth and the palpebral conjunctiva). Pallor results from decreased redness in anemia and decreased blood flow,

21. Central cyanosis is best identified in the lips, oral mucosa, and tongue. Cyanosis of the nails, hands, and feet may be central or peripheral in origin. Anxiety or a cold examining room may cause peripheral cyanosis. lung disease, congenital heart disease, and hemoglobinopathies.

22. Look for the yellow color of jaundice in the sclera. Jaundice may also appear in the palpebral conjunctiva, lips, hard palate, undersurface of the tongue, tympanic membrane, and skin. liver disease or excessive hemolysis of red blood cells. the yellow color that accompanies high levels of carotene, look at the palms, soles, and face.

24. 2) Moisture: note excessive dryness (dehydration), sweating (diaphoresis), and oiliness. 3) Temperature: Use the back of your hand Normal: warm and equal bilaterally, hand and feet slightly cooler Hypothermia: generalized coolness (hypothyroidism). Hyperthermia: generalized hotness (fever). Local warmth (inflammation). 4) Texture: roughness/ smoothness. Should feel smooth and firm with an even surface.

25. Lift a fold of skin and note how easily it lifts up (mobility) and how quickly it returns into place (turgor). 5) Mobility and Turgor: Lift a fold of skin and note how easily it lifts up (mobility) and how quickly it returns into place (turgor).: elastic and mobile. Decreased mobility in edema, decreased turgor in dehydration

26. 6) Edema: the presence of excess fluid in the interstitial space. Localize (injury), or result of systematic problem (heart failure). It can be pitting or nonpitting.

27. Edema Scale 1 + Mild pitting, slight Indentation / 2mm 2 + Moderate pitting, indentation subsides quickly / 4mm 3 + Deep Pitting, indent remains for a short period leg looks swollen / 6 mm 4 + Very Deep Pitting, indent lasts a long time. leg is very swollen /8 mm 1 + Mild pitting, slight Indentation / 2mm 2 + Moderate pitting, indentation subsides quickly / 4mm 3 + Deep Pitting, indent remains for a short period leg looks swollen / 6 mm 4 + Very Deep Pitting, indent lasts a long time. leg is very swollen /8 mm

28. 7) Lesions: Location, distribution. Patterns and shapes : linear, clustered, annular (in a ring). Color Elevation: flat, raised, depressed Size Any exudate: color, odor, quantity.

29. Types of skin lesions (macules, papules, vesicles). Macule: Change in color Flat Less than 1 cm Ex: Freckles

30. Papules: Something you can feel – elevation Less than 1 cm Ex: mole Vesicles: Elevated Contain fluid about 1 cm

31. Scar: Fibrosis after healing of a wound Fissure: Linear crack Abrupt edges Dry or moist

32. Erosion: Shallow depression Superficial Moist No bleeding Ulcer: Deeper depression Irregular Bleed

33. ABCDEs of examining moles for possible melanoma: A: asymmetry of one side of mole to other B: irregular borders. C: change in color, especially blue or black D: diameter more or equal 6mm, changing, itching, bleeding E: evolving; changing in size, shape, or color.

34. HAIR: Quantity Distribution Color: pale blond – black. Texture: silky fine – coarse thick; straight – curly. Baldness??: Alopecia refers to hair loss—diffuse, patchy, or total. Scalp: lesions, flaking, parasites.

35. NAILS: Color: pink with white lunulae. Capillary refill Color return instantly or less than 1-2 seconds Texture: smooth, firm Surface: rounded in shape with 160 angle between the nail base and skin.

36. Consistency: the surface is smooth and regular Uniform thickness Firmly adhere to nail bed The nail base is firm to palpation