ANATOMY AND PHYSIOLOGY REVIEW

Structure of the skin

The skin has three layers: fat, dermis, and epidermis. Each layer has unique properties that
constribute to the skin’s ability to maintain its complex functions.

Subcutaneous fat (adipose tissue) is the innermost layer of the skin, lying over musclue and
bone. Fat cells serve as an energy reserve in the event extra calories are needed to power the body.
These cells also act as heat insulators for the body. They absorb shock and protect against injury by
padding internal structures. Many boold vessels go through the fatty layer and extend into dermal
layer, forming capillary networks that supply nutrients and remove wastes.

The dermis (corium) is the layer above the fat layer. It is composed of connective tissue that
contains no cells. The dermis is composed of collagen and elastic fibers that are interwoven to give
the skin both flexibility and strength.

Collagen, the main component of dermal tissue, is aprotein formed by demal cells called
sibroblasts collagen production increases in areas of tissue injury and helps from scartissue.
Fibroblasts also produce ground subtance, a protein lubricant that surrounds the dermal cells and
fibers and contributes to the skin’s normal suppleness and turgor.

The elasticity of the skin depens on both the amount and quality of the elastic fibers, which
are scattered among the collagen fibers. The major component of the elastic fiber is elastin.

The dermis has cappilaries and lymph vessels for the exchange of oxygen and heat. It is rich
sensory nerves that transmit the sensations of touch, pressure, temperature, pain, and itch.

The epidermis is the outermost skin layer. It is anchored to the dermis by finger-like
projections of dermal tissue (demal papillae). The fingers of epidermal tissue that project into the
dermis are called rete pegs. The epidermis is less than 1 mm thick, but it is the protective barrier
between the body and the environment.

The epidermis does not have its own blood supply and receives its nutrients by diffusion from
the blood vessels in the dermal layer through the basement membrane. Attached to the basement
membrane are the keratinocytes. The basal cells (those keratinocytes capable of cell devision and
located closets to the basement membrane) continously divide to from new cells. Older keratinocytes
are pushed upward and flattened to from the stratified layers of the epithelium (malpighian layers).
When these cells reach the outermost skin layer, the stratum corneum (horny layer), they ate no
longer living cells and are shed from the skin. Kreatin, the protein produced by keratinocytes, makes
the horny layer waterproof. A keratinocyte take about 28 to 45 days to move from the basement
membrane to the skin surface.

Vitamin D is activated in the epidermis by ultraviolet (UV) light, such as sunlight. It is then
distributed by the blood to the intestinal tract, where it promotes uptake of dietary calcium.

Melanocytes are pigment-producing cells found at the basement membrane. These cells give
color to the skin and account for the racial differences in skin tone. Darker skin tones are not caused
by increased numbers of melanocytes; rather, the size of the pigment granules (melanin) contained in
each cell determines the color. The purpose of melanin is to protect the skin from damage by UV
light. For this reasons, people with dark skin are less likely to develop sunburn than lighter-skinned
people the same sun exposure. Freckles, birthmarks, and age spot are caused by patches of melanin
whitin the skin. UV light stimulates the production of melanin, which protwcts against the harmful
effects of sun exposure. Melanin production increases in areas that have endocrine charges or
inlamation.

Structue of the skin appendages

Hair, a thick protective pelt worn by most mammals, is mainly a cosmetic feature for modern
humans. Hair growth varies with race, gender, age, and genetic predisposition. Individual hairs can
differ in both structure and rate of growth, depending on body location.

Hair follicles are located in the dermal layer of the skin but are actually extensions of the
epidermal layer (see fig. 26-2). Within each hair follicle, a round column of kreatin forms the hair
shaft. Hair kreatin is tougher than skin kreatin. Hair color is genetically determined by a person’s rate
of melanin production.

Hair growth occurs in cycles, with a growth phase followed by a resting phase. Stressors can
alter the growth cycle and result in temporary hair loss. Permanent baldness, such as male pattern
baldness, is inherited and is seldom influenced by personal or environmental factors.

Nails on fingers and toes have cosmetic value and serve as useful tools for grasping and
scraping. Like hair follicles, the nails are extensions of the keratin-producing epidermal layers of the
skin.

The white, crescent-shaped portion of the nail at the lower end of the nail plate is called the
lunula and is the location of the nail matrix, whwrw nail keratin is formed and nail growth begins
(fig. 26-3). Unlike cyclic hair growth, nail growth is a continuous but slow process. Fingernail
replacement requires 3 to 4 months. Toenail replacement may take up to 12 months.

The cuticle, a layer of keratin at the nail fold. The nail body is nail plate to the soft tissue of
the nail fold. The nail body is translucent, and the pinkish hue reflects a rich blood supply beneath the
nail surface. Nail growth and appearance altered dueing systemic disease or serious illness.

Sebacceius glands are distributed over the entire skin surface except for the palms of the
hands and soles of the feet. Most of this glands are connected directly to theie follicles (fig. 26-4).
The subaceous glands of the eyelids, nipple areolae, and genitalia are freestanding.

Sebaceous glands produce sebum , a mildly bacteriostatic, fat containing subtance. Sebum
lubricates the skin and reduces water loss from the skin surface.

Sweat gland of the skin are of two types ; eccrine and apocrine. Eccrine sweat gland arise
from the epithelial cells. They are found over the entire skin surface and are not associated with hair
follicle. The oderless, colorless, isotonic secretions of these glands are important in the regulation of
the body temperature. Stimulation of sweat from this gland and the resultant water evaporation can
cause the body to lose as much as 10 to 12 liters of fluid in a single day.

Apocrine sweat glands are in direct contact with the hair follicle. They are found mostly in the
axillae, nipple areolae, and perineal and periumbilical body areas. The interactions of skin bacteria
with the secration of the apocrine glands causes the distinctive body odor.
Function of the skin

Epidermis Dermis Subcutaneous tissue

Protection  Provides fibroblasts for  Mechanical shock
 Kreatin provides wound healing absorber
protrction from injuri  Provides mechanical strength  Energy reserve
by corrosive  Collagen fibers
materials  Elastic fibers
 Inhibites proliferation  Ground substance
of microorganisms
because of dry
external surface
 Mechanical strength
through intercellular
bonds
Homeostasis (water  Lymphatic and vascular
balance) tissues respond to
 Low permeabillity to inflammation, injury and
water and electrolytes infaction
prevents systemic
dehydration and
electrolyte loss
Temperature regulation  Cutaneous vaskulature,  Fat cells act as
 Echine swear glans through dilation or insulators and assist
allow dissipation of constriction, promotos or in retention of body
heat through inhibits heat conduction heat
evaporation of sweat from the skin surface
secreted onto the skin
surface
Sensory organ Encloses an extensive network of  Contains large
 Transmits variety of nerve endings for relaying sensations pressure receptors
sensation through the to the brain
neuroreceptor system
Vitamin synthesis No function No function
 7-dehydrocholesterol
is present in large
concentrations in
malpighian cells;
photoconversion to
vitamin D takes place
Pyshosocial Body image alternations occur with Bpdy image alternations may
 Body image many dermal diseases, such as result from increases,
alterations occur with scleroderma decreases, and redistribution
many epidermal of body fat stores
disease, such as
generalized psoriasis

Nursing focus on the older adult

Changes in the integumentary system related to aging

Physical changes Clinical findings Nursing actions

Epidermis
Decreased thickness in Increased skin transparency and Handle patients carefully.
epidermal layer fragility Avoid taping the skin
Decreased epidermal mitotic Delayed wound healing Protect open areas to promote
activity wound healing
Decreased epidermal mitotic Skin hyperplasia, such as  Assess exposed skin
homeostasis hyperkeratoses and skin cancers areas for sun-induced
(especially in sunexposed areas) changes.
Assess non-sun-
exposed areas to
determine base skin
features.

Increased epidermal Increased susceptibility to Teach patients how to avoid

permeability irritant reaction exposure to skin irritants
Decreased number of Decreased cutaneous Do not rely on redness and
langerhan’s cells inflamatory response swelling to indicate skin
damage
Decreased number of active Increased sensitivy to sun Teach patients to wear hats and
melanocytes exposure protective clothing and to use
sunscreen when outside
Hyperplasia of melanocytes at Mottied hyperpigmentation and Teach patients to keep track of
the dermal-epidermal junction hypopigmentation (e.g., liver such spots, but help them to
(especially in sunexposed areas) spots, age spots) differentiate these “noemal”
spots from those that need
evaluation for malignancy
Decreased vitamin D Increased susceptibility to Urge patients to take a multiple
production osteomalacia vitamin or acalcium supplement
that contains vitamin D
Flattering of the dermal- Increased susceptibillity to Avoid pulling or dragging
epidermal junction shearing forces with resultant patients. Assist patients
blisters, purpura, skin tears, and confined to bed or chairs to
pressure related skin problems change positions or least every
2 hour
Dermis
Decreased dermal blood flow Increased susceptibillity to dry Teach patients to use
skin (xerosis) moisturaizers or the skin and to
avoid agents that promote skin
dryness
Decreased vasomotor Increased thermoregulatory Teach patients to dress for the
responsiveness alterations (predisposition to environmental temperatures and
heat stroke and hypotermia) not to rely on skin sensations to
tell them they are too hot or too
cold
Decreased dermal thickness Paper-thin, transparent skin Handle patients gently, and
with an increased susceptibillity avoid to use of tape or tight
to trauma dressings
Degeneration of elastic fibers Decreased tone and elasticity Use lift sheets when positioning
(wrinkles) patients
Beningn proliferation of Cherry hemangiomas Teach patients that these are
capilaries benign
Reduced number and function Alterations in sensory Instruct patients to use bath
of nerve endings perception thermometer and to lower the
the water heater temperature to
prevent scalds
Subcutaneous layer
Thining of subcutaneous fat Increased susceptibillity to Teach patients to dress warmly
layer hypotermia in clod weather and to wear hats
and gloves when outdoors

Decreased resistance to Assist patients confined to bed

mechanical injury (especially or chairs to change prositions at
pressure necrosis) least every 2 hours
Hair
Decreased number of hair Increased hair thinning Suggest wearing hats in cold
follicles and rate of growth weather to prevent body heat
loss and when in the sun preven
burning the scalp
Decreased number of active Gradual loss of hair color Although associated with aging,
melanocytes in follicle (graying) inform patients that hair volor
loss can occur at any age
Nails
Decreased rate of growth increased susceptibillity to Inspect the nails (including
fungal infections toenails) of all older adults.
 Instruct patients to wear
socks and to keep the
feet clean, warm, and
dry
Decreased blood flow beneath Longitudinal nail ridges Use the oral mucosa to assess
the nail bed for cyanosis
Thickening of the nail Toenails (especially) thicken  Use fingernails to assess
and may overhang the toes caillary refill
 Cut toenails straight across
rather than on a curve
 Do not use nail appearance
alone alone to determine
whether the thick nail is
irritating it
Glands
Decreased sebum production Increased size of pores Teach patients not to squeeze
despite sebaceous gland (especially on nose); large the pores or comedones to
hyperplasia comedones in malar region prevent traumatizing the skin
Decreased eccrine and apocrine increased susceptibillityto dry Urge patients to avoid
gland activity skin deodorant soaps and to use
soaps with a high fat content

decreased perspiration, leading Do not use sweat production as

to decreased cooling effect an indicator of hypertermia

Individual differences exixt in how quickly and to what degree the skin ages. Althogh genetic
background, hormonal changes, and systemic disease may change the appearance of the skin over
time, chronicsun exposure is the single most important factor leading to degeneration pf the skin
components.
Skin assessment

Inspection

Skin changes may be related to specific skin diseases and may also reflect a systemic
disorder. By using skin assessment skills, you are in a unique position to identify clues about a
patient’s state of health.

A thorough assessment of the skin is best performed with the patient partially or completely
undressed. Incorporate skin examination for actual or potensial problems into the routine part of daily
care while bathing him or her or assisting with hygiene.

Inspect the patient’s skin surfaces in a well lighted room; natural or bright fluorescent lighting
enhances the visibility of subtle skin changes. Although no special equipment is needed, use a
penlight to closely inspect lesions and to iluminate the mouth.

Assesee each skin systematically, including the scalp, hair, nails, and mocous, membranes.
Give particular attention to the skinfold areas. The moist, warm environment of skinfold can harbor
organisms, such as yeast or bacteria. Observe and document these features :

 Obvious changes in color and vascularity

 Presence or absence of moisture
 Edema
 Skin lesions
 Skin integrity

Check the cleanliness of the various body areas to determine whether the patient’s self-care
avtivities need to be evaluated.

Skin color is affected by a number of factors, including blood flow, oxygenation, body
temperature, and pigment production. The wide variation in natural skin tones may require different
techniques for patients who have darker skin ( see cultural awareness, pp. 474-476, for suggestions for
assessing patients with darker skin).

Describe changes in skin color by their appearance (table 26-2). Document changes in color, and
describe whether the changes are general or confined to one body region. Color changes can be seen
most easily in the areas of least pigmentaion, such as the oral mucosa, sclera, nail beds, and palms
and soles. Inspect these areas to help confirm more subtle color changes of general body areas.

Lesions in skin disease are clinically described in terms of primary and secondary lesions (fig. 26-
13). Bprimary lesions are an initial reaction to a problem that alters one of the structural components
of the skin. Secondary lesions are changes in the appearance of the appearance of the primary lesion.
These changes occur with progression of an underlying disease or in response to a topical or systemic
therapeutic intervention. For example, acute dermatitis often occurs as primary vescles with
associated pruritus (itching). Secondary lesions in the from of crusts occur as the patient scratches,
the vesicles are opened, and the exudate dries. With chronic dermatitis, the skin often becomes
lichenified (thickened) because of the patient’s continual rubbing of the area to relieve itching.

Describe lesions by color, size, location, and shape. Note whether they occur as isolated changes
or are grouped and from a distinct pattern. Table 26-3 on p. 471 defines terms used to describe
lesions.
Assess each lesion for the following ABCD features that are associated with skin cancer :

Asymmetry of shape

Border irregularity

Color variation within one lesion

Diameter greater than 6 mm

A patient who has a lesion with one or more of the ABCD features should be evaluated by a
dermatologist or surgeon. Teach patients these signs, and encourage them to perform total skin self-
examination (TSSE) on a monthly basis.

Common alternation in skin color

Alternati Underlying cause Location significance

on
White  Decreased  Conjunctivae  Anemia
(pallor) hemoglobin level
 Decreased blood  Mucous membranes  Shock or blood
flow to the skin  Nail beds loss
(vasoconstriction  Chronic vascular
) compromise
 Palms and soles  Sudden emotional
upset
 Edema
 Lips
 Albinism
 Generalized

 Geneically
determined defect
of the melanocyte
(decreased  Vitiligo, tinea
pigmentation)  localized versicolor

 Acquired patchy
loss of
pigmentation
Yellow-  Increased total  Generalized  increased
orage serum  Mucous membranes hemolysis of red
bilirubin level  Sclera blood cells
(jaundice)  liver disorders
 Perioral
 increased ingestion
 Increased  Palms and soles of caratorie-
serum containing foods
carotene level (carrots)
(carotenemia)
 Ears and nose  pregnancy

 Absent in sclera and  thyroid deficiency

mucous memranes
 diabetes

 Generalized  chronic kidney

 Localized ( to area of disease (uremia)
involvement)

 Increased
urochrome
level
Red  increased  Generalized  Generalized
(erythema blood flow to inflammation (e.g.,
) the skin erytroderma)
(vasodilation)
 Localized
 Localized ( to area of inflammation (e.g.,
involvement) sunburn, cellulitis,
trauma, rashes)

 Fever, increased
 Face, cheeks, nose upper alcohol intake
chest
 Exposure to cold

 Area of exposure
Blue  Increased in  Nail beds  cardiopulmonary
deoxygenated disease
blood  Mucous membranes  methemoglobinemi
(cyanosis)  Generalized a

 Bleeding from
vessels into
tissue :
 Petechiae(1-3  Localized  thrombocytopenia
mm)  Localized  increased blood
 Ecchymosis(> vessel fragility
3mm)
Reddish  increased  generalized  polycythemia vera
blue overall
amount of
hemoglobin
 decreased  distal extremities, nose  inadequate tissue
peripheral perfusion
circulation
Brown  increased  Localized ( to area of  Choronic
melanin involvement) inflammtion
production  Exposure to
sunlight
 Pressure points, aroelae,  Addison’s disease
palmar creases, and  Pregnnancy; oral
genitalia contraceptives(mel
asma)
 cafe au lait
spots (tan-
brown
patches)
 <6 spots  Localized  Nonpathogenic
 >6 spots  Generalized  Possible
neurofibromatosis

 Melanin and  Distal lower extremities  Choronic venous

hemosiderin statis
deposits
(bronze or  Exposed areas or  Hemochromatosis
grayish tan generalized
color)

In describing the location of lesions, determine whether they are generalized or localized. If the
lesions are localized, identify the specific body areas involved. This information is important because
some diseases have a specific pattern of skin lasions. Involvement of only the sun-exposed areas of
the body is important information when a possible cause is being considered. Rashes limited to tje
skinflod areas (e.g., on the axillae, beneath the breasts, in the groin) may reflect problems related to
friction, heat, and excessive moisture.

Edema causes the skin to appear shiny, taut (tightly stretched), and paler than univolved skin.
During skin inspection, document the location, distribution, and color of any areas of edema.

Skin elasticity is also affected by edema. Using moderate pressure, place the tip of the index
finger against edematous tissue to determine the degree of indentation, or pitting.

Moisture content is assessed by noting the thickness and consistency of secretions. Normally,
increased moisture in the from of sweat occurs with increased activity or elevated environmental
temperatures. Dampness of skinflod areas occurs as a result of decreased air circulation where the
skin surfaces tpuch. Excess moisture can cause skin breakdown in bedridden and debilitated patients.

Overly dry skin can be caused by factors such as a dry environment, poor skin lubricantion,
inadequate fluid intake, and the normal processes og aging. Dry skin usually has scaling of the outer
surface. Dry skin may be especially marked in areas of limited circulation, such as the feet and lower
legs. It is a problem for most adults during the winter month when the air contains less moisture,
living in geographic areas with little humidity, and in the hospital environment where humidity is
offen low.

Vascular changes or markings are classified as normal or abnormal, depending on the cause.
Normal vascular markings include birthmarks, cherry angiomas (see fig. 26-11), spider angiomas, and
venous stars. Bleeding into the tissue is abnormal and results in purpuric lesions (bleeding under the
skin that may progress from red to purple to brownish yellow), petechiae, and ecchymoses.

Petechiae are small, reddish purple lesions (<0,5 mm in diameter) that do not fade or blanch
when pressure is applied (fig. 26-14). They often indicate increased capillary fragility. Petechiae of
the lower extremities often occur with stasis dermatitis, a condition frequenly seen in patients who
have chronic venous insufficiency.
Echymoses (bruises) are large areas of hemorrhage that range on size from several millimeters to
many centimeters. In older adults, bruising is common after minor trauma to the skin, especially on
sun expoised areas of the body. Certain drugs (e.g. aspirin, warfarin). And low platelet counts lead to
easy or excessive bruising. Anticoagilants and decreased numbers of platelets disrupt clotting action,
resulting in ecchymosis.

Integrity of the skin is assesed by first thoroughly examining areas with actual breaks or open
areas. For example, skin tears are a common finding in older people as a result of a flattening of the
dermal-epidermal junctiom with aging. The thin, fragile skin is easily damaged by friction or shearing
forces, especially if bruising is already present. Look for skin tears in these areas:

 Where constricting clothing rubs against the skin

 On the upper extremities, where the skin is grasped when assisting a patient to ambulate
or change position
 Where adhesive tapes or dressings have been applied and removed

Check for the presence of multiple abrasions or early pressure related skin changes. These
findings may indicate previously unrecognized problems in mobility or sensory perception.

Describe breaks, in skin integrity by their location, size, color, and distribution, as weel as by
the presence of drainage or any signs og infection. The evaluation of partial thickness and full-
thickness wounds, including objective criteria that describe progress toward healing is discussed in
chapter 27.

Cleanliness of rhe skin is evaluated to gain information about self-care need. Inspect the hair,
nails, and skin closely for excessive dsoiling and offensive odor. Depending on a patient’s degree of
self-care deficit, hard-to-reach areas my (e.g., perirectal and inginal skinflods, axillae, feet) may be
less clean but stained as a result of exposure to chemicals during work or leisure activities.

Patients who have cognitive poblems may not pay attention to hygiene measure. Asses the
cognitive function of any patient whose hygiene of the skin, hair, or nails appears inadequate.

Tattoos and piercings can cause or mask skin problems and should be carefully examined.
Bruises and rashes can occur in tattooed areas but may be difficult to see. Examine newly pierced
areas for signs of inflammation or infection. Scars may be present in old tattoos or pierced areas and
should be documented. Any areas where tattoes have been removed should be examined for skin
changes that may indicate cancer.

Hair assessment

During the skin assessment, inspect and palpate the hair for cleanliness, distribution, quantity,
and quality. Hair is normally found in an even distribution over most of the body surfaces, with the
hair on the scalp, in the public region, and in the axillary fold thicker and coaser than hair on the
trunk, arms, and legs. Although color and growth patterns vary, sudden or marked changes in hair
characteristics may reflect an underlying disease proces. As with skin changes, check any abnormal
findings by obtaining an in-depth history of the circumstances sorrounding any changes.