Friday, April 5, 2019



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 cardiac function.

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 exercise. 

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.   

Pressure Injuries: previously called “pressure” or “decubitus” ulcers, commonly referred to 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. 

Staging is 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 Injury is “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 Injury is 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 occur. 

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:
1) Sensory perception – is the patient able to recognize pressure on a part of his body? 
2) Moisture – is his skin often wet or usually dry?
3) Activity – is the patient bedridden or physically active?
4) Mobility – is the patient paralyzed and requires assistance for body changes or can he change his body’s position at will?
5) Nutrition – is the patient receiving enough nutrition; are most meals eaten or often does he not eat?
6) 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 Pressure Injuries:
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 breathe. 
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.
5) Turn 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 prominences.
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 it.  Some 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.
10) If 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 professional.


Contact information:
Diane R. Beggin, RN
40 Sycamore Drive
Montgomery, NY 12549

Web site:

Book: HOW TO MANAGE NURSING CARE AT HOME, by Cooper and Beggin


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