{"id":1090,"date":"2022-12-12T11:53:03","date_gmt":"2022-12-12T16:53:03","guid":{"rendered":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/chapter\/introduction-to-integumentary-system\/"},"modified":"2024-05-03T15:27:53","modified_gmt":"2024-05-03T19:27:53","slug":"introduction-to-integumentary-system","status":"publish","type":"chapter","link":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/chapter\/introduction-to-integumentary-system\/","title":{"raw":"Introduction to Integumentary System","rendered":"Introduction to Integumentary System"},"content":{"raw":"The integumentary system includes the skin, hair, nails, and [pb_glossary id=\"1434\"]sebaceous[\/pb_glossary] and sweat glands. It has important functions including thermoregulation, sensory functioning, ensuring fluid balance, serving as a protective barrier to external substances, and providing immune defense against foreign bodies.<\/span>\r\n\r\nThe integument can be an indicator of the client\u2019s general health status. For example, the integumentary system can signal other systemic functions of the body like [pb_glossary id=\"1436\"]diaphoresis[\/pb_glossary] during cardiac events, [pb_glossary id=\"1474\"]cyanosis[\/pb_glossary] related to respiratory insufficiency and other conditions, and [pb_glossary id=\"1476\"]pallor[\/pb_glossary] during times of stress and other conditions. As a nurse, it is important to hone your assessment skills and pay close attention to potential cues that may signal underlying concerns that require your intervention. See Figure 1<\/strong> for an anatomical overview of the integumentary system.<\/span>\r\n\r\n\"The\r\n\r\nFigure 1:<\/strong> Integumentary system anatomy. <\/span>\r\n\r\n(Image in public domain and adapted from the National Cancer Institute:<\/span> https:\/\/commons.wikimedia.org\/wiki\/File:Anatomy_The_Skin_-_NCI_Visuals_Online.jpg<\/a>)\r\n\r\n \r\n\r\nYou have already learned about the anatomy and physiology of the integumentary system: for a quick overview see<\/span> https:\/\/youtu.be\/OxPlCkTKhzY<\/a>\r\n\r\nYou need a basic understanding of disease-specific presentations to effectively interpret findings from your assessment. Be alert to signs and symptoms of greater systemic issues that may require further assessment and possibly immediate intervention. For example, Cullen\u2019s sign (Figure 2<\/strong>) is a serious concern: it appears as bruising and edema of the subcutaneous fatty tissue around the navel and can be an indication of acute pancreatic trauma and\/or internal bleeding. Certain skin symptoms can also prompt the use of personal protective equipment (PPE); for example, small flat red spots that appear on the face and spread down the body may be an indication of [pb_glossary id=\"1432\"]measles[\/pb_glossary] (Figure 3<\/strong>), necessitating airborne precautions.<\/span>\r\n\r\n\"A\r\n\r\nFigure 2:<\/strong> Cullen\u2019s sign.<\/span>\r\n\r\n(Attribution: Photo by Herbert L. Fred, MD and Hendrik A. van Dijk - http:\/\/cnx.org\/content\/m14904\/latest\/, CC BY 2.0,<\/span> https:\/\/commons.wikimedia.org\/w\/index.php?curid=5038484<\/a>)\r\n\r\n\"Flat\r\n\r\nFigure 3:<\/strong> Measles.<\/span>\r\n\r\n(Attribution: This photo is in the public domain in the United States because it is a work prepared by an officer or employee of the United States Government as part of that person\u2019s official duties under the terms of Title 17, Chapter 1, Section 105 of the US Code.<\/span> https:\/\/commons.wikimedia.org\/wiki\/File:Measles_child_Philippines.jpg<\/a>)<\/span>\r\n\r\nContextualization of integumentary issues in relation to other symptomatology like fever, cough, and inflammation can provide insight into underlying conditions. Table 1<\/strong> provides some general descriptions related to the integument and underlying pathophysiology. With experience, you will learn to identify patterns, recognize cues, and begin to discriminate between [pb_glossary id=\"1492\"]benign[\/pb_glossary] skin conditions and skin conditions that require further investigation.<\/span>\r\n\r\nTable 1:<\/strong> General descriptions of integument pathophysiology.<\/span>\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n
 \r\n\r\nIntegumentary grouping<\/span><\/strong><\/td>\r\n \r\n\r\nExamples<\/span><\/strong><\/td>\r\n \r\n\r\nCommon presentation<\/span><\/strong><\/td>\r\n<\/tr>\r\n
 \r\n\r\nSkin trauma<\/strong><\/span>\r\n\r\nTrauma can affect a single or multiple layers of the skin as a result of injury or illness.<\/span><\/td>\r\n \r\n\r\nBurns, scars, cuts, tears of the skin, keloids (thick, raised scars).<\/span>\r\n\r\n\"A<\/span>\r\n\r\nKeloid.<\/span>\r\n\r\n(Attribution: Photo by Htirgan - Own work, CC BY-SA 3.0, https:\/\/commons.wikimedia.org\r\n\/w\/index.php?curid=32782658<\/a><\/span><\/td>\r\n \r\n\r\nSwelling, erythema, inflammation, bleeding, pain, blisters, peeling of skin, and sometimes darkened or lightened areas of skin with scars.<\/span><\/td>\r\n<\/tr>\r\n
 \r\n\r\nInfections<\/strong><\/span>\r\n\r\nBacterial, viral, fungal, and parasitic skin infections are caused by various pathogens and can range from mild to severe. Many skin infections require treatment.<\/span>\r\n\r\n\"Coalesced\r\n\r\n[pb_glossary id=\"1426\"]Shingles[\/pb_glossary].<\/span>\r\n\r\n(Attribution: Photo by James Heilman, MD - Own work, CC BY-SA 3.0,<\/span> https:\/\/commons.wikimedia.org\r\n\/w\/index.php?curid=14082247<\/a>)<\/span><\/td>\r\n \r\n\r\nViral: Human papillomavirus (HPV), herpes zoster virus, warts, COVID-19, shingles.<\/span>\r\n\r\nBacterial: Staphylococcus-aureus, Methicillin-resistant Staphylococcus aureus (MRSA), impetigo, cellulitis, boils, and abscesses.<\/span>\r\n\r\nFungal (typically skin and mucosal surfaces): Tinea corporis (ringworm), tinea pedis (athlete\u2019s foot), candidosis (yeast infection), nail fungus.<\/span>\r\n\r\nParasitic: Lice, bedbugs.<\/span>\r\n\r\nOther stings and bites that can cause infection: Spider bites, ticks, animal bites.<\/span>\r\n\r\n\"A\r\n\r\nTick bite with bull\u2019s-eye rash (an early sign of Lyme disease).<\/span>\r\n\r\n(Attribution: CDC \/ James Gathany - https:\/\/phil.cdc.gov\/Details.aspx?pid=9874, Public Domain,<\/span> https:\/\/commons.wikimedia.org\r\n\/w\/index.php?curid=91609710<\/a>)<\/span><\/td>\r\n \r\n\r\nViral: Some rashes can follow a [pb_glossary id=\"1428\"]dermatome[\/pb_glossary] (e.g., shingles, varicella, herpes simplex) with lesions, papules, or pain. They can appear in cluster\/closely grouped or as a single lesion, and can be generalized, regional, or asymmetrical presentation (i.e., rash on one side of the body).<\/span>\r\n\r\nBacterial: Odour, exudate, small red bumps increasing in size, fever, yellowish-brown crusts, redness, heat, swelling, tenderness, pain.<\/span>\r\n\r\nFungal: Deep erythema, swelling, itchiness, scaly, flaky patches, or loss of normal pigmentation of the skin causing discolouration.<\/span>\r\n\r\nParasitic: Itchiness, rash, regional lymphadenopathy (diseases of the lymph nodes resulting in enlarged lymph nodes).<\/span><\/td>\r\n<\/tr>\r\n
 \r\n\r\nAuto-immune and\/or inflammatory disorders causing lesions\/eruptions (acute and chronic)<\/strong><\/span>\r\n\r\nRegional or generalized, may involve inflammation of the skin.<\/span><\/td>\r\n \r\n\r\n[pb_glossary id=\"1414\"]Psoriasis[\/pb_glossary], [pb_glossary id=\"1416\"]eczema[\/pb_glossary], [pb_glossary id=\"1418\"]seborrheic dermatitis[\/pb_glossary], [pb_glossary id=\"1420\"]vitiligo[\/pb_glossary], [pb_glossary id=\"1422\"]lupus[\/pb_glossary], [pb_glossary id=\"1424\"]alopecia[\/pb_glossary].<\/span>\r\n\r\n\"A\r\n\r\nAlopecia.<\/span>\r\n\r\n(Attribution: Photo by Abbassyma at English Wikipedia - Transferred from en.wikipedia to Commons, Public Domain,<\/span> https:\/\/commons.wikimedia.org\r\n\/w\/index.php?curid=3121007<\/a>)<\/span><\/td>\r\n \r\n\r\nEczema (scaling, itching, ill-defined), psoriasis ([pb_glossary id=\"1412\"]well-demarcated[\/pb_glossary], scaly plaques), vitiligo (depigmentation, patchy loss of skin colour, premature whitening of hair), alopecia (hair loss).<\/span><\/td>\r\n<\/tr>\r\n
 \r\n\r\nMetabolic and nutritional disorders<\/strong><\/span>\r\n\r\nPoor nutrition or absorption issues can lead to vitamin deficiencies. Excess vitamins can also lead to cutaneous abnormalities.<\/span><\/td>\r\n \r\n\r\nVitamin A, C, D, E, K, B1, B2, B3, B6, B9, B12, iron, zinc, and selenium deficiencies.<\/span>\r\n\r\nVitamin A, E, and selenium excess.<\/span><\/td>\r\n \r\n\r\nVaries depending on metabolic\/nutritional disorders, e.g., dermatitis, flushing, hyperpigmentation, white spots.<\/span><\/td>\r\n<\/tr>\r\n
 \r\n\r\nVascular disorders<\/strong><\/span>\r\n\r\nCutaneous vascular disorders commonly involve arteries, veins, and\/or lymphatic vessels.<\/span><\/td>\r\n \r\n\r\nUlcers, [pb_glossary id=\"1410\"]cherry angiomas[\/pb_glossary], venous insufficiency.<\/span>\r\n\r\n\"A\r\n\r\nVenous insufficiency.<\/span>\r\n\r\n(Attribution: Photo by Ashashyou - Own work, CC BY-SA 4.0,<\/span> https:\/\/commons.wikimedia.org\r\n\/w\/index.php?curid=122884459<\/a>)<\/span>\r\n\r\n\"Several\r\n\r\nCherry angioma.<\/span><\/td>\r\n \r\n\r\nVaries depending on venous insufficiency (flooding of fluid to the skin due to inadequate venous return) or arterial deprivation (deprivation of nutrients to the skin due to poor arterial perfusion).<\/span>\r\n\r\nVariations such as cherry angiomas are not harmful. They can begin small and then grow in size, become slightly raised, and multiply over time.<\/span><\/td>\r\n<\/tr>\r\n
 \r\n\r\nPsychological and neurological disorders<\/strong><\/span>\r\n\r\nInvolve interactions between the mind and skin.<\/span><\/td>\r\n \r\n\r\nPersistent [pb_glossary id=\"1406\"]pruritus[\/pb_glossary] and [pb_glossary id=\"1408\"]prurigo[\/pb_glossary], neuropathic pain (often related to shingles), trichotillomania (a psychiatric condition resulting in compulsive hair pulling).<\/span><\/td>\r\n \r\n\r\nIrresistible itching and scratching, urge to scratch exacerbated by anxiety, skin picking, recurrent pulling out of hair.<\/span><\/td>\r\n<\/tr>\r\n
 \r\n\r\nSystemic disorders<\/strong><\/span>\r\n\r\nThe integumentary system can be involved in clinical manifestation of some systemic disorders.<\/span><\/td>\r\n \r\n\r\nGout, arthritis, Addison disease, Cushing syndrome, thyroid disease, chronic liver disease, hepatitis, diabetic ulcers.<\/span><\/td>\r\n \r\n\r\nVaries depending on the <\/span>underlying systemic disorder.<\/span>\r\n\r\n\"Two\r\n\r\nGout.<\/span>\r\n\r\n(Attribution: Photo by Gonzos <\/span>ft - Own work, CC BY 3.0 de,<\/span> https:\/\/commons.wikime<\/a>\r\n\r\ndia.org\/w\/index.php?curid=10868917<\/a>)<\/span><\/td>\r\n<\/tr>\r\n
 \r\n\r\nNeoplastics (abnormal growths) and cancer\u00a0<\/strong><\/span>\r\n\r\nBenign [pb_glossary id=\"1394\"]cutaneous[\/pb_glossary] [pb_glossary id=\"1396\"]neoplasms[\/pb_glossary] are very common. Some abnormal growths are benign (non-cancerous). However, some neoplasms become [pb_glossary id=\"1430\"]malignant[\/pb_glossary] and require intervention.\u00a0<\/span><\/td>\r\n \r\n\r\nBenign: Freckles, [pb_glossary id=\"1398\"]lentigo[\/pb_glossary], [pb_glossary id=\"1400\"]caf\u00e9-au-lait spots[\/pb_glossary], [pb_glossary id=\"1482\"]nevi[\/pb_glossary], [pb_glossary id=\"1402\"]seborrheic keratosis[\/pb_glossary], wart, [pb_glossary id=\"1404\"]cutaneous cysts[\/pb_glossary].<\/span>\r\n\r\nMalignant: [pb_glossary id=\"1484\"]Atypical nevi[\/pb_glossary], [pb_glossary id=\"1486\"]basal cell carcinoma[\/pb_glossary], [pb_glossary id=\"1488\"]squamous cell carcinoma[\/pb_glossary], [pb_glossary id=\"1490\"]melanoma[\/pb_glossary].<\/span>\r\n\r\n\"A<\/span>\r\n\r\nSeborrheic keratosis (the large brown raised lesion).<\/span><\/td>\r\n \r\n\r\nVaries depending on the underlying cause, e.g., spots on the skin, palpable mass, depression of the skin.<\/span>\r\n\r\nBasal cell carcinoma.<\/span>\r\n\r\n\"A\r\n\r\n(Attribution: Photo by James Heilman, MD - Own work, CC BY 3.0,<\/span> https:\/\/commons.wikimedia.<\/a>\r\n\r\norg\/w\/index.php?curid=6827823<\/a>)<\/span><\/td>\r\n<\/tr>\r\n
 \r\n\r\nSkin disorders caused by external agents<\/strong><\/span>\r\n\r\nCutaneous adverse reactions can occur because of reactions to drugs or other external agents. Adverse reactions can also occur from heat and cold exposures.<\/span><\/td>\r\n \r\n

Steven-Johnson syndrome and\r\ntoxic epidermal necrolysis are rare life-threatening skin disorders where the skin peels and blisters often caused by a medications and infections. Toxic erythema from chemotherapy is a skin reaction including eruptions of red\/purple rash and plaques.\r\nPhotosensitivity is a skin sensitivity when exposed to the sun c<\/span>aused by medications like chemotherapy drugs, HIV medications and antibiotics, frostbite.<\/span><\/p>\r\n<\/td>\r\n

 \r\n\r\nSkin reactions like rashes that start after exposure to external agents like medications.<\/span><\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n
<\/div>\r\n*genetic disorders not listed<\/span>\r\n\r\n \r\n
\r\n

Clinical Tip<\/strong><\/h2>\r\n<\/header>\r\n
\r\n\r\nDid you know that some dermatological conditions are emergencies? For example, necrotizing fasciitis (a rare bacterial infection also known as flesh-eating disease) can spread very quickly throughout the body, at a rate of 1 inch per hour. Symptoms include erythema, warmth to the touch, swelling, severe pain, and fever. If not treated immediately, it can lead to [pb_glossary id=\"1384\"]sepsis[\/pb_glossary], [pb_glossary id=\"1386\"]shock[\/pb_glossary], organ failure, and even death. As a nurse, you must report these findings to the physician or nurse practitioner so immediate treatment can be started.<\/span>\r\n\r\n<\/div>\r\n<\/div>\r\n
\r\n

Knowledge Bites: Pathophysiology<\/strong><\/h2>\r\n<\/header>\r\n
\r\n\r\nHow do you distinguish between common viral and bacterial infections? Common characteristics of a bacterial infection are inflammation, [pb_glossary id=\"1382\"]exudate [\/pb_glossary] (such as pus), erythema, swelling, pain, odour. Common characteristics of a viral infection are a grouping\/cluster of lesions, generally asymmetrical (one side of body), and specific regions on the body (e.g., mouth, nose, feet, hands).<\/span>\r\n\r\n<\/div>\r\n<\/div>\r\n

Activity: Check Your Understanding<\/span><\/h2>\r\nName the integument pathophysiology images:<\/span>\r\n\r\n \r\n\r\n[h5p id=\"76\"]<\/span>","rendered":"

The integumentary system includes the skin, hair, nails, and