Short essays by Douglas Winslow Cooper, Ph.D., the author of TING AND I: A Memoir of Love, Courage and Devotion, published in September 2011 by Outskirts Press (Parker, CO, USA), available from outskirtspress.com/tingandi, Barnes and Noble [bn.com], and Amazon [amazon.com], in paperback or ebook formats. Please visit us at tingandi.com for more information.
Friday, April 5, 2019
MANAGE NURSING CARE AT HOME, Ch. 17 Skin
CHAPTER 17 INTEGUMENTARY (SKIN) SYSTEM
Often the forgotten
child, the skin system makes up more of the body than any other system. From its uppermost tissue layer (epidermis) to
the various layers beneath it, the skin is involved in many functions.
Besides the skin, this system also includes oil (sebaceous)
and sweat (sudoriferous) glands, and nerve receptors. It also gives rise to hair and nails. However,
the primary function of skin is defense.
It provides the boundary to prohibit or discourage foreign substances
from entering the body. When compromised
with a cut or scrape, it utilizes defenses to repair the impaired barrier to
protect and promote healing.
While covering and protecting the body in multiple layers,
the integumentary system regulates temperature (thermoregulation) during
perspiration or shivering. Temperature
regulation and excretion are performed by means of sweat. The skin also plays an integral role in the vitamin D synthesis necessary for
calcium absorption essential for skeletal formation and maintenance, and
Derived from the Latin word “integumentum” meaning
“covering”, the integumentary system is comprised of the skin and all its
associated elements, such as nails, hair, and glands. While the skin furnishes an outer form to
house the internal works of the body, it provides so much more.
The chief organ in this system is the skin. Organs are often perceived as being internal
structures. They may be individual and
located in one part of the body, such as the heart or brain. Other times, organs appear in pairs but are
found near each other, such as the kidneys and lungs. Organs may be small and held in the palm of
a hand, such as an eye which is about one inch in size, or large, as exampled
by the small intestine which may exceed 19 feet.
The skin’s primary function is as a physical barrier
between the environment and the body. It is
the rock walls that guard the perimeter of the kingdom. When unharmed and unbroken by cuts or
abrasions, it prevents most infectious agents (pathogens), such as bacteria,
from entering the body. This is accomplished
by the many layers of tissues that compose it.
However, when harmed by infection for example, the skin initiates repair
by means of an inflammatory process.
The outermost or top layer (epidermis) of the skin is four
or five layers in thickness. It is
constantly renewed and replaced, and essentially “dead” at the outermost
surface. The cell turnover in a year can
be eight pounds. Yet, it provides
immunity, heat, prevention or promotion of water loss, and UV light
protection. It also contains various
cell types at lower levels to provide water-proofing and touch sensation. In addition, there are pores for hair
follicles and sweat (sudoriferous) gland surface. Structures, such as fingernails, are also
created by the epidermis.
The inner layer (dermis) usually has two layers which
contain collagen and elastin fibers for strength, hair follicles with attached
oil (sebaceous) glands, nerve roots and endings, and blood vessels. Variances in thickness occur depending on the
location; they may be very thin, such as on the eyelids, or thick, such as on
the soles of the feet.
There are two types of skin, which differ in their
thickness, amount of blood vessels, nerve supply, gland types, skin strength,
and absence of hair. Most of the body is
made of skin that is considered thin and contains hair, such as the face, arms,
legs, trunk, and pubic area. While the
amount or coarseness of this hair may vary, they all contain hair. Hair
is protective: the scalp protects from
sun and injury; eyebrows and eyelashes protect from foreign particles, and
nostril hair protects from inhaling foreign particles and insects, for example. Along with hair are oil (sebaceous) glands
connected to hair follicles. Sebaceous glands protect the hair from
drying by preventing excess water evaporation from the skin surface and protect
from bacterial growth while keeping skin soft and resilient. Skin that is thick and hairless appears on
the palms of the hand and soles of the feet, for example, where friction and
wear are greatest.
In addition to protection, however, another major function
of the skin is temperature regulation (thermoregulation). This is accomplished by blood vessels and
sweat (sudoriferous) glands which have receptors in the dermis to regulate
secretion. During high temperatures,
water and internal heat are released via sweat glands. The evaporation of fluid (sweat,
perspiration) cools the body. When
temperatures are low, sweat production is decreased and heat is conserved. The skin’s blood supply, which is quite
extensive, works in a similar manner.
The small arterial vessels (arterioles) expand to help dissipate heat
and during levels of moderate exercise.
However, the vessels will also constrict during cold periods to protect
the internal organs, as well as direct blood flow into muscles during strenuous
Sudoriferous glands empty onto the skin surface via pores, and besides providing
sweat for evaporation and cooling, small amounts of wastes are excreted. Waste material includes salt, urea, glucose,
lactic acid, and other organic compounds.
Lastly, the skin serves to provide tactile stimulation as
well as absorption, synthesis and storage of vitamin D. The sense of touch is accomplished by the
skin via nerve endings and receptors.
These detect stimuli such as pain, pressure, touch, and heat, causing automatic
reflexes to pull away or change an action, if it is a negative stimulus. Touch, providing an ability to grasp, hold,
and discern textures, especially in the hands, along with fine motor skills,
allows for dexterity and use for numerous circumstances and actions. From sun exposure (UVB rays) the skin
produces vitamin D, and the derivatives needed by the body are synthesized by
the liver and kidneys. Ultimately, this
substance is changed to a product that aids in calcium absorption, essential
for the skeletal system and various calcium-sensitive mechanisms that regulate
internal functions via ion exchanges, such as heart beats.
While the skin is a
very large and multi-functioning organ of the body, nursing services do not
usually dictate long-term requirements.
The exception to this is pressure
ulcers. Although discussed in other
sections of this book, they will also be addressed here.
called “pressure” or “decubitus” ulcers, commonly referredto as “bedsores,” these
are defined as areas where skin death
occurs because it is compressed between an internal bony projection and another
external surface, such as a chair or bed, for a period. The injury results from the pressure exerted
on the skin which lies between the two objects.
As the internal bone pushes against a hard, external surface, the skin
covering the bone becomes damaged. This is due to loss of oxygen because a
constant flow of blood is restricted. Besides a deficiency of blood flow to the
tissues, the patient’s underlying health condition, such as nutrition and
sensory perception, as well as additional factors such as moisture, friction,
and shear are also contributing factors causing skin damage.
The bony projections, or prominences, that most often
initiate this damage include the sacrum (which lies at the base of the spinal
column), the heel of the foot, elbow, outer ankle bone (lateral malleolus),
outer hip bone (greater trochanter), and projections of the hip bone (ischial
tuberosity). The patient’s position could be that of
sitting in a chair or lying in bed. Skin damage could result in two or three
hours or as little as 90 minutes depending on the force of pressure force in
addition to the patient’s pressure tolerance and tissue health.
Stagingis used to
characterize the extent of the injury and to dictate protocols for healing. Staging is evaluated visually by using the
National Pressure Ulcer Advisory Panel (NPUAP) per their 2016 guidelines. If eschar (dead, dried, brown-blackish crust)
or slough (dead, mucus-like, yellow, gray, green material) is present, the
wound cannot be accurately staged until the substance is removed. In addition, location of the wound is
pivotal. Some areas of the body, such as
the bridge of the nose or the ankles, do not have a lot of subcutaneous
tissue. In such locations, the wound
beds themselves may be shallow in comparison with other areas of the body.
Stage 1 Pressure Injury is “non-blanchable
erythema of intact skin.” It indicates
an area of redness (erythema) in light-pigmented skin or an area that is darker
in dark-pigmented skin. When a finger is
pressed against this tissue and quickly released, the fingerprint area returns
immediately to the original skin color; if it does not, it is non-blanchable. Edema and tissue hardness may also
present. But the skin is intact and
there is no outward injury except for redness.
Stage 2 Pressure Injuryis
“partial-thickness skin loss with exposed dermis.” Tissue damage to the layers of the epidermis
and/or dermis is evident. It is
superficial and may look like an abrasion, blister, or shallow crater. Actual injury to the skin is apparent.
Stage 3 Pressure Injuryis
much more severe and termed “full thickness with skin loss”. There is full skin damage and loss extends to
tissues that lie under the skin (subcutaneous tissue) including fat (adipose)
tissue. Evident injury is without
question. At times the edges of the
wound roll back (epibole) creating undermining of the pressure wound that is
hidden by the upper rolled back skin, making the wound appear smaller than it
actually is. The wound bed may have
tunneling, when open passages extend further into the tissue. Often deep craters are formed.
Stage 4 Pressure Injury,
“full-thickness skin and tissue loss” is the most severe stage of pressure
wound. Tissue loss and death are
extensive continuing into the deep tissues.
Muscle, bone, and supporting structures such as tendons are often
visible. Epibole (undermining) and
tunneling are often present. Osteomyelitis, a severe skeletal infection, may
A patient’s risk for pressure wounds can be assessed using
various scales. One often used to be the
Braden Scale. It measures six specific areas that may
predict the potential occurrence of a pressure wound. Categories include:
– is the patient able to recognize pressure on a part of his body?
is his skin often wet or usually dry?
– is the patient bedridden or physically active?
– is the patient paralyzed and requires assistance for body changes or can he
change his body’s position at will?
is the patient receiving enough nutrition; are most meals eaten or often does he
Friction and shear
– in caring for and positioning the patient, is sliding on the sheets an
occurrence, does the patient frequently slide down in the bed due to gravity
and often needs positioning, or does he have the muscle strength to lift his
body to position himself and usually maintains a position that does not result
in sliding down?
Each category is given a value of one to four (except
category six which has a total of three).
The lower the number, the more prone the patient may suffer injury. For example, a score of “one” in the categories
of “moisture” and “mobility” would be assigned to a patient that is “constantly
moist” and “bedfast.” Conversely, a score of “four” would be given if the
patient is “rarely moist” and “walks frequently.” Scores
for all six areas are totaled. The
highest possible score is 23. If the
patient’s score is 17 to 23, the patient is at little to no risk. A score less than or equal to 16 indicates
there is certain risk for the patient. A
patient at high risk has a total score less than or equal to nine.
Using this scale is simply an indication of risk. If the patient has a high score, pressure
wounds could still occur. However, they
are just less likely to happen. These
are merely tools to help assess the patient’s needs and requirements to prevent
formation of pressure ulcers.
Care Considerations for
1) The best care is that in which a pressure
injury does not develop. Unfortunately,
sometimes even though superlative care is provided, a pressure injury will
result. However, there are steps that
can be taken to minimize possible occurrence of these wounds.
2) When bathing, use mild soap and warm water. Harsh perfumed soaps and hot water can be
drying, irritate skin, or cause damage.
3) Use a moisturizer after cleansing. These help seal skin to prevent moisture
loss. Avoid products that are thick and
do not absorb well, as these tend to prohibit the skins’ natural ability to
4) Keep the patient dry. If the patient is incontinent, perform
frequent (disposable) undergarment changes every 3 or 4 hours, or more often if
needed. Use a skin-protecting barrier,
such as A&D ointment to provide a shield between caustic urine and stool,
as well as protecting from moisture in general.
Specialized water-proof pads are available to provide an additional
barrier. Use those made from cloth, not
plastic, so the skin’s ability to breathe is maintained.
and position the patient every two hours.
Use variations of all four possible positions as can be tolerated: side-lying
(lateral, left and right), on back (supine), and on stomach (prone). The more positions used, the more time a
patient has to enhance blood flow to rested areas. Rather than have the patient be at a right
angle to the mattress when on his side, utilizing a 30-degree lateral position
using pillows for support and protection minimizes direct contact with bony
6) Keep head of bed at a thirty-degree angle as
much as possible. If the head is higher, shearing forces caused
by sliding greatly increase.
7) Range of motion exercises aid in blood flow
as well as prevent contractures.
8) Ensure sufficient nutrition and fluids. Offer a variety of easy-to-digest, healthy
foods, including protein to sustain muscle mass and promote healthy skin. Provide more frequent and smaller meals
throughout the day; this can be less intimidating to the patient. More may be consumed in many small meals than
in three larger ones. If the patient is
unwilling or unable to eat a sufficient amount, numerous liquid supplements are
available on the market to bridge the protein/nutrition gap. In addition, for patients that are unable to
eat orally and utilize a gastric tube for nutrition, consult a medical
professional. Many formulas are
available via prescription, and a medical professional will be able to suggest
one that is best for the patient’s needs.
9) Check skin often, especially in areas of bony
prominences. If injury is suspected but the skin remains
blanchable, other skin assessments and evidence may suggest breakdown. Compare that area to the skin that surrounds
danger signs: The skin itself may be taut or shiny. The temperature may be warmer initially, but
later stages may present as cooler. The
texture may be different and appear rippled like an orange peel. The area may feel more spongy or, perhaps,
firm and hard. Looking for subtle
changes in the skin can promote immediate corrective action to halt the progression
of the wound and limit further injury.
injury should appear, it is best to consult with a medical professional, such
as a specialized Wound Care Nurse, to treat the wound. Depending on the stage of the wound, various
protocols and equipment will be utilized.
Specific determinations need to be made concerning the best method for
healing. For example, a clean wound base
is essential for healing. Cleaning
solutions generally include normal saline, but other commercial products are
also available. One that is effective
but not damaging to the tissue is required.
Medications may be applied to the wound, such as ointments that debride
dead tissue or slough. Besides ointments
and creams, wound beds may sometimes require mechanical or chemical
debridement. Dressing will be applied to
the pressure injuries. There are many
types of dressings as well as many methods of application and use. For example, a dry dressing is used when
drainage is minimal, to inhibit bacteria, and to prevent further injury. Moist dressings aid in full-thickness, crater
like wounds. Wet-to-dry dressings are
used for debridement. A wet dressing is
placed directly on the wound bed. It
draws out and picks up pus (exudate) and other debris present in the wound. As the dressing dries, the wound material
adheres to the dressing. When the dressing
is removed, it pulls the wound contents out with it. A dry dressing is placed over the wet one to
merely protect from bacteria. In
addition, as the injury begins healing, so will the course of treatment. Lastly, most usually, all wound beds are
colonized with bacteria. Swabbing the
wound bed will provide a diagnosis of the organisms to ensure the efficacy of
prescribed antibiotics, if necessary, will be appropriate. As the complexity of
this section illustrates, wound care requires involvement of a medical