Structures and Functions of Integumentary

The skin is the largest sensory organ of the body, with a surface area of 15 to 20 square feet (1.4 to 1.9 square meters) and a weight of about 9 lb (4 kg).

Functions

• Acts as the first line of defense against infections
• Protects underlying tissues and organs from injury
• Receives stimuli from the external environment; detects touch, pressure, pain, and temperature stimuli; relays information to the nervous system
• Regulates normal body temperature
• Excretes salts, water, and organic wastes
• Protects the body from excessive water loss
• Synthesizes vitamin D₃, which converts to calcitriol, for normal calcium metabolism
• Stores nutrients

Risk factors for skin problems

• Immobilization
• Overweight or obese client
• Reduced sensation related to a neurological problem
• Altered cognition from dementia or psychological problem
• Inadequate nutrition and hydration
• Excessive secretions from perspiration, urination, defecation, and wound drainage
• Use of medical devices that can cause skin injury
• Vascular insufficiency

Diagnostic

The examination for skin cancer follows the ABCDE rule:

1. Asymmetry (eg, one half unlike the other) 
2. Border irregularity (eg, edges are notched or irregular)
3. Color changes and variation (eg, different brown or black pigmentation)
4. Diameter of 6 mm or larger (about the size of a pencil eraser) 
5. Evolving (eg, appearance is changing in shape, size, color)

The rule of nines is used to estimate quickly the percentage of total body surface area (TBSA) affected by partial- and full-thickness burns in an adult client.  

Once the affected TBSA has been estimated, the volume of necessary fluid resuscitation can be calculated (eg, Parkland formula [4 mL × kg of body weight × TBSA]).  TBSA also determines the required level of care.

In general, clients require transfer to a burn center for specialty care for:

• Full-thickness burns
• Partial-thickness burns >10% TBSA
• Electrical or chemical burns
• Inhalation injuries

The Parkland Burn Formula is used to calculate the total amount of fluids needed (Lactated Ringers) 24 hours after a burn. Remember fluid resuscitation is critical after a patient experiences severe burns. 

Braden Scale 

Several factors place a patient at risk for developing a pressure injury, in addition to shear and friction. These factors include decreased sensory perception, increased moisture, decreased activity, impaired mobility, and inadequate nutrition. The Braden Scale is a standardized, evidence-based assessment tool commonly used in health care to assess and document a patient’s risk for developing pressure injuries. Risk factors are rated on a scale from 1 to 4, with 1 being “completely limited” and 4 being “no impairment.” The scores from the six categories are added, and the total score indicates a patient’s risk for developing a pressure injury based on these ranges:

• Mild risk: 15-18
• Moderate risk: 13-14
• High risk: 10-12
• Severe risk: less than 9

Wood’s light examination (black light test or UV test)

Skin is viewed under ultraviolet light through a special glass (Wood’s glass) to identify superficial infections of the skin.

Preprocedure intervention: Explain the procedure to the client, reassuring the client that the light is not harmful to the skin or the eyes. Darken the room before the examination.

Postprocedure intervention: Assist the client during adjustment from the darkened room.

Interventions 

To prioritize the initial management of burn injuries, nurses should use the ABCs (ie, airway, breathing, circulation).

Circulatory compromise is common after sustaining a burn, as extensive tissue injury combined with the systemic inflammatory response causes increased capillary permeability, fluid and electrolyte shifts, and decreased intravascular volume.  These intravascular losses begin rapidly after a burn and may lead to hypovolemic shock and death.  Therefore, the nurse should prioritize initiation of fluid resuscitation.

Cause large fluid shifts and can decrease perfusion to the gastrointestinal tract, resulting in inconsistent absorption of oral medications.  Burns damage the muscle and subcutaneous tissue, causing generalized body edema and decreased circulating blood volume.  These physiological changes reduce the absorption ability for the intramuscular and subcutaneous routes.

The best way to get medication into the system of a client with severe burns is to access the circulatory system directly via the intravenous route.

After a burn injury, increased capillary permeability leads to third spacing (fluid shifts to areas where normally minimal or absent), allowing proteins, plasma, and electrolytes to leave the vascular space and occupy other spaces and tissues.  

Sunburn 

It is a painful inflammatory skin reaction resulting from overexposure to ultraviolet radiation (eg, natural sunlight, tanning beds).  Sunburns may be classified as superficial (ie, red, painful) or partial-thickness (ie, blistering, weeping) burns. Severe sunburns may cause systemic symptoms such as fever, chills, nausea, and headache.  Sunburns increase insensible fluid loss and place the client at an increased risk for dehydration.

Sunburn prevention is important because sunburn may cause permanent skin damage and increases the risk of skin cancers.  However, when minor sunburns occur, symptom management includes:

• Protecting the burned area from further sun exposure (eg, avoid going outside during midday, when the sun’s rays are hottest).
• Promoting increased fluid intake to avoid dehydration.
• Providing pain relief with over-the-counter analgesics such as ibuprofen or acetaminophen.
• Reducing inflammation and pain by taking tepid baths; using cool compresses; and applying soothing, protective lotions or gels (eg, aloe vera, calamine) to the sunburned area.
• Corticosteroid creams (eg, hydrocortisone) have not been shown to reduce symptom severity or healing times.  Some preparations can be drying to the skin, which may exacerbate symptoms of sunburn.

This creates a state of hypovolemic shock, which poses the highest risk of mortality in the initial phase of the burn process.  Therefore, aggressive fluid resuscitation to correct hypovolemia is a priority.  Adequate urine output (at least 30 mL/hr, or 0.5 mL/kg/hr) depends on adequate renal perfusion and is the greatest indicator that fluid resuscitation therapy has effectively restored tissue perfusion.

Burn injuries cause cellular destruction, capillary leaking, and fluid shifts.  Fluids are lost during the emergent phase (first 24-72 hours), resulting in hypovolemia and hyponatremia.  The blood becomes more viscous and increased hematocrit and hemoglobin values result.  Cellular damage releases potassium, which causes hyperkalemia.

The rehabilitation phase begins after the client’s wounds have fully healed and lasts about 12 months.  The initiation of this phase depends on the extent of the burns and the client’s ability to care for themselves. Interventions in the rehabilitation phase are aimed at improving mobility and independence and  minimizing the potential for long-term complications.  These interventions include:

• Counseling or other psychosocial support
• Gentle massage with water-based lotion to alleviate itching and minimize scarring
• Planning for reconstructive surgery
• Pressure garments to prevent hypertrophic scars and promote circulation 
• Range-of-motion exercises to prevent contractures 
• Sunscreen and protective clothing to prevent sunburns and hyperpigmentation 

Skin cancers

Are most often caused by damage to the skin’s DNA.  This damage is typically due to exposure to ultraviolet (UV) radiation, primarily from the sun but also from other sources (eg, tanning beds, sunlamps).  The instructions to prevent sunburn and other sun-related damage include:

• Avoid the sun, if possible, especially between 10 AM and 4 PM.  UV rays are not blocked by cloud coverage and can be reflected off water, sand, snow, and concrete.  As a result, clients can burn in the shade or even during outdoor winter activities (eg, skiing) 
• Wear protective clothing (eg, long sleeves, wide-brimmed hats, umbrellas) when possible.
• Avoid the use of tanning beds as they emit UV radiation

Apply sunscreen:

• Use a broad-spectrum sunscreen to block both UVA and UVB rays.
• Choose a sunscreen with SPF ≥15 for daily use or SPF ≥30 for outdoor activities and sun-sensitive individuals.  Sunscreen should be applied 15-30 minutes prior to sun exposure to allow the formation of a protective film on the skin.  Regardless of the type of sunscreen used, it should be reapplied at least every 2 hours, or more often if possible.
• Because sunscreen is washed off with swimming and sweating, it should be reapplied, even for products labeled “water-resistant” or “very water-resistant” 

Common pathologies 

Psoriasis is a chronic autoimmune disease that causes a rapid turnover of epidermal cells.  Characteristic silver plaques on reddened skin may be found bilaterally on the elbows, knees, scalp, lower back, and/or buttocks.  The goal of therapy is to slow epidermal turnover, heal lesions, and control exacerbations.

• Plaque Psoriasis: The most common form of the disease and often appears as red, raised patches of skin that are covered with a silvery, white buildup of dead skin cells. These patches, or plaques, most often are present of the scalp, knees, elbows, and lower back. They are often itchy, painful, and are prone to cracking and bleeding.
• Guttate: Appearing as small, dot-like lesions, Guttate Psoriasis often starts in childhood, adolescence, or young adulthood, and can be triggered by a Strep infection. Approximately 10 percent of people who develop Psoriasis will develop this type, leaving it as the second most common form.
• Inverse: Appearing as red lesions in body folds, such as behind the knee, under the arm, or in the groin, inverse psoriasis often accompanies other forms. It may appear smooth and shiny as well. Usually, people also have another type of Psoriasis on their body at the same time as Inverse. 
• Pustular: Characterized by white pustules (noninfectious blisters) surrounded by red skin, pustular psoriasis can occur on any part of the body but most often develops on the hands or feet. 
• Erythrodermic: This particularly rare, severe form of psoriasis can lead to widespread, fiery redness over large areas of the body, leading to severe itching and pain as well as widespread exfoliation (skin peeling). This type only occurs in 3% of people with psoriasis, and can be life-threatening.

There is no cure for psoriasis; disease management includes avoidance of triggers (eg, stress, trauma, infection), topical therapy (eg, corticosteroids, moisturizers), phototherapy (eg, ultraviolet light), and systemic medications, including cytotoxic (eg, methotrexate) and biologic (eg, infliximab) agents. The client should avoid alcohol as it can worsen psoriasis. In addition, the liver, kidneys, and bone marrow are specifically affected by the systemic medications commonly used to control psoriasis. Exposure to ultraviolet light (eg, phototherapy, sunlight) can help slow epidermal turnover and decrease exacerbations; however, there is a greater long-term risk of skin cancer.  Therefore, frequent skin examinations by a health care provider are important.

Psoriasis Triggers (Remember) 

• Stress
• Skin damage or injury
• Infections or a compromised immune system.
• Certain medications
• Allergies
• Diet
• Weather

Tinea corporis (ringworm) is a fungal infection of the skin often transmitted from one person to another or from an infected animal to a human.  It appears as a scaly, pruritic patch that is often circular or oval in shape.  It is highly contagious and can be spread via items such as grooming tools, hats, towels, and bedding.  Tinea corporis often spreads via shared athletic equipment or in athletic locker rooms due to the proximity of infected gear.  This condition is treated with topical antifungals (eg, tolnaftate, haloprogin, miconazole, clotrimazole).

Anti-fungal creams and ointments topically applied over the affected skin at least twice a day for 3 weeks can successfully treat the infection. Ketoconazole, Clotrimazole and Miconazole are the usual anti-fungal creams prescribed to treat the infection. A severe form of infection may be prescribed with anti-fungal tablets to be taken orally.

Eczema is a skin rash caused by an immune disorder that is often triggered by an allergy.  Itching is common, but the rash is not contagious. Eczema and psoriasis are chronic skin diseases. They both cause red, dry, scaly skin rashes. While they share similar signs and symptoms, psoriasis and eczema have different causes. They also can have very different treatments.Eczema is the name for a group of skin conditions that cause dry, irritated skin.

Other types of eczema include:

• Discoid eczema – a type of eczema that occurs in circular or oval patches on the skin
• Contact dermatitis – a type of eczema that occurs when the body comes into contact with a particular substance
• Varicose eczema – a type of eczema that most often affects the lower legs and is caused by problems with the flow of blood through the leg veins
• Seborrhoeic eczema – a type of eczema where red, scaly patches develop on the sides of the nose, eyebrows, ears and scalp
• Dyshidrotic eczema (pompholyx) – a type of eczema that causes tiny blisters to erupt across the palms of the hands.

Treatment for atopic eczema can help to relieve the symptoms and many cases improve over time. But there’s currently no cure and severe eczema often has a significant impact on daily life, which may be difficult to cope with physically and mentally.

Many different treatments can be used to control symptoms and manage eczema, including:

• Self-care techniques, such as reducing scratching and avoiding triggers
• Emollients (moisturising treatments) – used on a daily basis for dry skin
• Topical corticosteroids – used to reduce swelling, redness and itching during flare-ups

Oral candidiasis or thrush, often occurs after a course of antibiotics or corticosteroids or can occur in infants with immature immune systems.  An infant who is breastfed can transfer candidiasis to the mother’s breast.  There is also a small risk of transmission when infants place pacifiers or toys in their mouths and subsequently transfer these items to another child’s mouth.  However, oral candidiasis is significantly less contagious than tinea corporis.

Toxic epidermal necrolysis 

Is an acute skin disorder, most commonly associated with a medication reaction, that results in widespread erythema, blistering, epidermal shedding, keratoconjunctivitis, and skin erosion (ie, denuded skin).  It is a severe form of Stevens-Johnson syndrome.  The major cause of death related to toxic epidermal necrolysis is sepsis; therefore, infection prevention is critical. Toxic epidermal necrolysis (TEN) is a rare and serious skin condition. Often, it’s caused by an adverse reaction to medication like anticonvulsants or antibiotics.

Basic supportive care includes:

• Wound care:  Sterile, moist dressings are applied to open areas of skin.
• Infection prevention:  Strict sterile technique and reverse isolation decrease infection risk.  The nurse should also monitor for any signs of infection (eg, fever).
• Fluids and nutrition:  Vital signs and urine output are monitored for signs of hypovolemia.  Oral feeding should be initiated early to promote wound healing; a nasogastric tube may be necessary.
• Hypothermia prevention:  Maintain a room temperature of 85 F (29.4 C) or more, and use passive rewarming methods such as sterile, single-use warming blankets or digitally regulated warming pads.
• Pain management:  Analgesics are administered around the clock and before painful procedures.
• Eye care:  Sterile, cool compresses are applied to relieve discomfort.  Lubricants may relieve dryness and prevent corneal abrasion.

Pressure injuries occur when prolonged pressure, friction, or moisture cause direct trauma to the skin and impair blood flow to the dermis.  Pressure injury staging is a method of identifying how deep a pressure injury has extended into the body, which will affect the duration and intensity of wound care necessary for healing.

Pressure injuries are staged from 1 to 4 to classify the degree of tissue damage and determine the most effective wound treatment. An unstageable pressure injury is characterized by full-thickness tissue loss with a wound base that is partially or completely obscured by eschar or slough. With removal of the eschar and/or slough and visualization of the wound bed, unstageable pressure injuries may then be classified as stage 3 or 4.  Nursing management of an unstageable pressure injury includes:

• Cleansing the wound with a sterile, gentle solution (eg, normal saline)
• Covering the wound with a hydrophilic (ie, “water-loving”) dressing that absorbs moisture.
• Frequently repositioning the client and off-loading the affected area.
• Providing a nutrient-rich, high-calorie diet to provide energy for wound repair and healing .

Evisceration

Total separation of wound layers with protrusion of the internal viscera through the incision is known as evisceration.  Evisceration is a medical emergency that can lead to localized ischemia, peritonitis, and shock.  Emergency surgical repair is necessary.  Clients at risk for poor wound healing (eg, obesity, diabetes mellitus) are at increased risk for evisceration.This client should immediately be made NPO in preparation for possible emergency surgery.  Only IV analgesics should be administered if the client is in pain.

When an abdominal wound evisceration occurs, the nurse should take the following actions:

• Remain calm and stay with the client.  Have someone notify the HCP immediately and bring sterile supplies.  Instruct the client not to cough or strain.
• Place the client in low Fowler’s position (no more than 20 degrees) with knees slightly flexed to relieve pressure on the abdominal incision and have the client maintain absolute bed rest to prevent tissue injury.
• Assess vital signs (and repeat every 15 minutes) to detect possible signs and symptoms of shock (eg, hypotension, tachycardia, tachypnea).
• Cover the viscera with sterile dressings saturated in NS solution to prevent bacterial invasion and keep the exposed viscera from drying out.
• Document interventions taken and the appearance of the wound and eviscerated organ (eg, color, drainage).  If the blood supply is interrupted, the protruding organs can become ischemic (dusky) and necrotic (black).

Skin cancers are most often caused by damage to the skin’s DNA.  This damage is typically due to exposure to ultraviolet (UV) radiation, primarily from the sun but also from other sources (eg, tanning beds, sunlamps).  The instructions to prevent sunburn and other sun-related damage include:

• Avoid the sun, if possible, especially between 10 AM and 4 PM.  UV rays are not blocked by cloud coverage and can be reflected off water, sand, snow, and concrete.  As a result, clients can burn in the shade or even during outdoor winter activities (eg, skiing) 
• Wear protective clothing (eg, long sleeves, wide-brimmed hats, umbrellas) when possible.
• Avoid the use of tanning beds as they emit UV radiation

Apply sunscreen:

• Use a broad-spectrum sunscreen to block both UVA and UVB rays.
• Choose a sunscreen with SPF ≥15 for daily use or SPF ≥30 for outdoor activities and sun-sensitive individuals.  Sunscreen should be applied 15-30 minutes prior to sun exposure to allow the formation of a protective film on the skin.  Regardless of the type of sunscreen used, it should be reapplied at least every 2 hours, or more often if possible.
• Because sunscreen is washed off with swimming and sweating, it should be reapplied, even for products labeled “water-resistant” or “very water-resistant” 

Poison ivy can cause a contact dermatitis rash in those who are sensitive to the oily resin found on the leaves, stems, and roots of the plant.  About 50% of people who come in contact with the plant develop a rash.  It is often linear in appearance where the plant brushed against the skin.  The rash develops 12-48 hours after exposure and can last for several weeks.  The severity of the rash depends on the amount of resin on the skin.  It is most important to first thoroughly wash the area to remove the resin and prevent its spread to other areas of the body.

Applying cool, wet compresses; applying topical cortisone; and discouraging the child from scratching the area are all appropriate after the rash has developed.  Washing the area has the highest priority and is most important immediately after exposure.

Herpes Zoster

In clients with a history of chicken pox, shingles is caused by reactivation of the varicella-zoster virus; shingles can occur during any immunocompromised state in clients with a history of chicken pox.

Herpes simplex virus is another type of virus; type 1 infection typically causes a cold sore (usually on the lip), and type 2 causes genital herpes typically below the waist (both types are contagious and may be present together).

Methicillin-Resistant Staphylococcus aureus (MRSA) skin or wound becomes infected with methicillin- resistant Staphylococcus aureus (MRSA). MRSA can be community acquired, such as through sports when skin-to-skin contact and sharing of equipment occurs. It can also be hospital acquired, as in the case of a surgical site infection (SSI)

A MRSA screening with a nasal swab may be done for clients who are having surgery, who have been previously hospitalized, or who live in group settings. Clients with positive cultures or with a history of a positive culture are isolated.

Bites and Stings

Spider bites, Almost all types of spider bites are venomous, and most are not harmful, but bites or stings from brown recluse spiders, black widow spiders, and tarantulas (as well as from scorpions, bees, and wasps) can produce toxic reactions in humans. Tetanus prophylaxis should be current because spider bites can be contaminated with tetanus spores.

Brown recluse spider, Bite can cause a skin lesion, a necrotic wound, or systemic effects from the toxin (loxoscelism).

Acne Vulgaris is a chronic skin disorder that usually begins in puberty; lesions develop on the face, neck, chest, shoulders, and back.

Acne requires active treatment for control until it resolves. The types of lesions include comedones (open and closed), pustules, papules, and nodules. The exact cause is unknown but may include androgenic influence on sebaceous glands, increased sebum production, and proliferation of Propionibacterium acnes, the organism that converts sebum into irritant fatty acids.

Instruct the client in prescribed skin-cleansing methods, with emphasis on not scrubbing the face and using only prescribed topical agents. Instruct the client in the administration of topical or oral medications as prescribed. Instruct the client not to squeeze, prick, or pick at lesions. Instruct the client to use products labeled noncomedogenic and water-based cosmetics, and to avoid contact with products with an excessive oil base.

Useful information 

The nurse should consider Maslow’s Hierarchy of Needs to determine the importance of various interventions.  This client in the acute phase of burn management continues to have increased physiological needs.  Clients with burns have increased metabolism and calorie requirements that must be met for healing to occur.  The nutrition needed for healing increases proportionally with the percentage of burned tissue.  Therefore, providing proper nutrition as soon as possible is the highest priority. 

The ABCDE approach is the most recognized tool for rapid patient assessment, it allows us to recognize life-threatening conditions early and provides a systematic method that focuses on identifying problems and implementing critical interventions in a timely manner.

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