24
Assessment: Integumentary System
Margaret R. Rateau
http://evolve.elsevier.com/Lewis/medsurg/
CONCEPTUAL FOCUS
Health Promotion Tissue Integrity
LEARNING OUTCOMES
1. Describe the structures and functions of the integumentary 5. Perform a physical assessment of the integumentary system
system. using appropriate techniques.
2. Link the age-related changes in the integumentary system to 6. Specify the structural and assessment differences in light-
differences in assessment findings. and dark-skinned persons.
3. Obtain significant subjective and objective data related to 7. Distinguish normal from common abnormal findings of a
the integumentary system from a patient. physical assessment of the integumentary system.
4. Compare the components for describing primary and 8. Describe the purpose, significance of results, and nursing
secondary lesions. responsibilities related to diagnostic studies of the
integumentary system.
KEY TERMS
alopecia, Table 24.8 keloid
dermis keratinocytes
epidermis melanocytes
erythema, Table 24.8 mole (nevus), Table 24.8
hirsutism, Table 24.8 pruritus
intertriginous sebaceous glands
The integumentary system is the largest organ of the body. It is or vascular structures in the epidermis. It is supported by pas-
composed of the skin, hair, nails, and certain glands. The skin sive circulation from the dermis.
has 2 major layers: the epidermis (outer layer) and the dermis The epidermis is divided into 5 distinct but interrelated layers.
(inner layer). The subcutaneous tissue (layer) lies under the der- Two of the layers are the stratum corneum (the surface layer) and
mis (Fig. 24.1). The skin is as complex as any organ, but, unlike the stratum germinativum (deepest, basal layer) (Fig. 24.1).
the others, it is readily visible. Being able to see and touch the Most epithelial cells are keratinocytes (90%). The remain-
skin helps you assess your patients. You can see abnormalities, ing cells are melanocytes, Langerhans’ cells, and Merkel cells.
understand their significance, and intervene early. Keratinocytes form in the basal layer. Initially, they are undiffer-
entiated and shaped like columns. As they mature (keratinize),
STRUCTURES AND FUNCTIONS OF SKIN AND they move to the surface. There they flatten and die, forming
the outer skin layer (stratum corneum). Keratinocytes make a
APPENDAGES
fibrous protein, keratin, which is vital to the skin’s protective
Structures barrier function. The upward movement of keratinocytes from
Epidermis the basal layer to the outermost levels of the stratum corneum
The epidermis, the outer layer of the skin, is relatively thin. Its takes about 14 days. The keratinocytes stay there for another 14
thickness ranges from 0.5 mm on the eyelids to 1.5 mm on the days, allowing the epidermis to regenerate every 28 days. Thus,
palms of the hands and soles of the feet.1 There are no lymphatic each month you have a new layer of skin.
456
, CHAPTER 24 Assessment: Integumentary System 457
Hair shaft
Stratum corneum
(horny cell layer)
Stratum
germinativum Epidermis
(basal cell layer)
Melanocyte
Sebaceous
gland
Eccrine Dermis
sweat gland
Subcutaneous
Apocrine
tissue
sweat gland
Connective
Blood vessels tissue
Arrector
Adipose tissue
pili muscle
Nerves
Hair follicle
Fig. 24.1 Longitudinal view of the skin. (From Jarvis C: Physical examination and health assessment, ed 6,
St Louis, 2012, Saunders.)
Many skin problems result from changes in this cell cycle. epidermis and dermis and (2) structural support for the epi-
If dead cells slough off too rapidly, the skin appears thin and dermis. The basement membrane helps to secure the 2 layers
eroded. If new cells form faster than you shed old cells, the skin together. Inflammation and separation of the epidermal and
becomes scaly and thickened. The epidermis fails to function dermal layers result in the blisters seen with problems such as
normally with skin cancer and psoriasis (discussed in Chapter burns, full-thickness wounds, and mechanical trauma.
25).
Melanocytes are found in the deep, basal layer. They con- Dermis
tain melanin, a pigment that gives color to the skin and hair The dermis is the connective tissue below the epidermis. Its
and protects the body from damaging ultraviolet (UV) sunlight. thickness ranges from 0.6 mm on the eyelid to 3.0 mm on the
Sunlight and hormones stimulate the melanosome (within the back, palms of the hands, and soles of the feet.1 The dermis is
melanocyte) to increase the production of melanin. People of all very vascular, containing many blood vessels. It also contains
races have similar numbers of melanocytes. In darker skin, the nerves, lymphatic vessels, hair follicles, sebaceous glands, and
melanosomes are larger and more numerous. They make more specialized cells such as mast cells and macrophages that protect
eumelanin, the form of melanin that gives us the coloring of the body from external stimuli.
our skin.2 Increased melanin forms a natural sun shield for dark The dermis is made of 3 types of connective tissue: collagen,
skin and results in a decreased incidence of skin cancer. The dis- elastic fibers, and reticular fibers. Collagen forms the greatest
tribution of melanocytes varies from one area of the body to part of the dermis. It gives the skin toughness and strength.
another. For example, the face has more melanocytes than the Collagen is critical in wound healing. The primary cell type in
abdomen. the dermis is the fibroblast, which makes collagen and elastin.
Langerhans’ cells are a type of dendritic cell. They are immu- The dermis has 2 layers: an upper, thin papillary layer and
nocompetent cells that recognize antigens. When they are a deeper, thicker reticular layer. The papillary layer is arranged
depleted, the skin cannot initiate an immune response. The haphazardly in ridges, or papillae, which extend into the outer
Langerhans cells in bioengineered skin grafts are removed to pre- epidermal layer. These elevated surface ridges form fingerprints
vent graft rejection. We find decreased numbers of Langerhans and footprints. The reticular layer forms the bulk of the dermis.
cells with skin diseases such as psoriasis and sarcoidosis. Merkel It is made up of thick collagen bundles arranged parallel to the
cells are found in the basal layer. They are involved in the sensa- skin’s surface.
tion of light touch. We use them when feeling the texture of an
object and figuring out what it is. Subcutaneous Tissue
The basement membrane zone is between the epidermis and The subcutaneous tissue lies below the dermis. It is made of
dermis. It provides for the (1) exchange of fluids between the loose connective tissue and fat cells that provide insulation,
Assessment: Integumentary System
Margaret R. Rateau
http://evolve.elsevier.com/Lewis/medsurg/
CONCEPTUAL FOCUS
Health Promotion Tissue Integrity
LEARNING OUTCOMES
1. Describe the structures and functions of the integumentary 5. Perform a physical assessment of the integumentary system
system. using appropriate techniques.
2. Link the age-related changes in the integumentary system to 6. Specify the structural and assessment differences in light-
differences in assessment findings. and dark-skinned persons.
3. Obtain significant subjective and objective data related to 7. Distinguish normal from common abnormal findings of a
the integumentary system from a patient. physical assessment of the integumentary system.
4. Compare the components for describing primary and 8. Describe the purpose, significance of results, and nursing
secondary lesions. responsibilities related to diagnostic studies of the
integumentary system.
KEY TERMS
alopecia, Table 24.8 keloid
dermis keratinocytes
epidermis melanocytes
erythema, Table 24.8 mole (nevus), Table 24.8
hirsutism, Table 24.8 pruritus
intertriginous sebaceous glands
The integumentary system is the largest organ of the body. It is or vascular structures in the epidermis. It is supported by pas-
composed of the skin, hair, nails, and certain glands. The skin sive circulation from the dermis.
has 2 major layers: the epidermis (outer layer) and the dermis The epidermis is divided into 5 distinct but interrelated layers.
(inner layer). The subcutaneous tissue (layer) lies under the der- Two of the layers are the stratum corneum (the surface layer) and
mis (Fig. 24.1). The skin is as complex as any organ, but, unlike the stratum germinativum (deepest, basal layer) (Fig. 24.1).
the others, it is readily visible. Being able to see and touch the Most epithelial cells are keratinocytes (90%). The remain-
skin helps you assess your patients. You can see abnormalities, ing cells are melanocytes, Langerhans’ cells, and Merkel cells.
understand their significance, and intervene early. Keratinocytes form in the basal layer. Initially, they are undiffer-
entiated and shaped like columns. As they mature (keratinize),
STRUCTURES AND FUNCTIONS OF SKIN AND they move to the surface. There they flatten and die, forming
the outer skin layer (stratum corneum). Keratinocytes make a
APPENDAGES
fibrous protein, keratin, which is vital to the skin’s protective
Structures barrier function. The upward movement of keratinocytes from
Epidermis the basal layer to the outermost levels of the stratum corneum
The epidermis, the outer layer of the skin, is relatively thin. Its takes about 14 days. The keratinocytes stay there for another 14
thickness ranges from 0.5 mm on the eyelids to 1.5 mm on the days, allowing the epidermis to regenerate every 28 days. Thus,
palms of the hands and soles of the feet.1 There are no lymphatic each month you have a new layer of skin.
456
, CHAPTER 24 Assessment: Integumentary System 457
Hair shaft
Stratum corneum
(horny cell layer)
Stratum
germinativum Epidermis
(basal cell layer)
Melanocyte
Sebaceous
gland
Eccrine Dermis
sweat gland
Subcutaneous
Apocrine
tissue
sweat gland
Connective
Blood vessels tissue
Arrector
Adipose tissue
pili muscle
Nerves
Hair follicle
Fig. 24.1 Longitudinal view of the skin. (From Jarvis C: Physical examination and health assessment, ed 6,
St Louis, 2012, Saunders.)
Many skin problems result from changes in this cell cycle. epidermis and dermis and (2) structural support for the epi-
If dead cells slough off too rapidly, the skin appears thin and dermis. The basement membrane helps to secure the 2 layers
eroded. If new cells form faster than you shed old cells, the skin together. Inflammation and separation of the epidermal and
becomes scaly and thickened. The epidermis fails to function dermal layers result in the blisters seen with problems such as
normally with skin cancer and psoriasis (discussed in Chapter burns, full-thickness wounds, and mechanical trauma.
25).
Melanocytes are found in the deep, basal layer. They con- Dermis
tain melanin, a pigment that gives color to the skin and hair The dermis is the connective tissue below the epidermis. Its
and protects the body from damaging ultraviolet (UV) sunlight. thickness ranges from 0.6 mm on the eyelid to 3.0 mm on the
Sunlight and hormones stimulate the melanosome (within the back, palms of the hands, and soles of the feet.1 The dermis is
melanocyte) to increase the production of melanin. People of all very vascular, containing many blood vessels. It also contains
races have similar numbers of melanocytes. In darker skin, the nerves, lymphatic vessels, hair follicles, sebaceous glands, and
melanosomes are larger and more numerous. They make more specialized cells such as mast cells and macrophages that protect
eumelanin, the form of melanin that gives us the coloring of the body from external stimuli.
our skin.2 Increased melanin forms a natural sun shield for dark The dermis is made of 3 types of connective tissue: collagen,
skin and results in a decreased incidence of skin cancer. The dis- elastic fibers, and reticular fibers. Collagen forms the greatest
tribution of melanocytes varies from one area of the body to part of the dermis. It gives the skin toughness and strength.
another. For example, the face has more melanocytes than the Collagen is critical in wound healing. The primary cell type in
abdomen. the dermis is the fibroblast, which makes collagen and elastin.
Langerhans’ cells are a type of dendritic cell. They are immu- The dermis has 2 layers: an upper, thin papillary layer and
nocompetent cells that recognize antigens. When they are a deeper, thicker reticular layer. The papillary layer is arranged
depleted, the skin cannot initiate an immune response. The haphazardly in ridges, or papillae, which extend into the outer
Langerhans cells in bioengineered skin grafts are removed to pre- epidermal layer. These elevated surface ridges form fingerprints
vent graft rejection. We find decreased numbers of Langerhans and footprints. The reticular layer forms the bulk of the dermis.
cells with skin diseases such as psoriasis and sarcoidosis. Merkel It is made up of thick collagen bundles arranged parallel to the
cells are found in the basal layer. They are involved in the sensa- skin’s surface.
tion of light touch. We use them when feeling the texture of an
object and figuring out what it is. Subcutaneous Tissue
The basement membrane zone is between the epidermis and The subcutaneous tissue lies below the dermis. It is made of
dermis. It provides for the (1) exchange of fluids between the loose connective tissue and fat cells that provide insulation,
