INTEGUMENTARY

SYSTEM
 TOPIC OUTLINE
Anatomy and Physiology of the
Integumentary System
Assessment
Skin disorders
Burns
Skin ulcers
 SKIN
 External covering
 Largest organ system
 Functions:
Protection of underlying structures
Insulation
Maintenance of homeostasis
Assist in Vit D production and elimination of
metabolic wastes
Attachment of mm
Cutaneous sensation
LAYERS OF THE SKIN
 LAYERS OF THE SKIN
1. Epidermis

o Outer, most superficial

o Avascular
o Composed of 5 layers
LAYERS OF THE SKIN: EPIDERMIS

Stratum corneum

Stratum lucidum

Stratum granulosum

Stratum spinosum

Stratum basale
 LAYERS OF THE SKIN: DERMIS
2. Dermis (Corium)

– 20 to 30 times thicker than the epidermis

– Contains lymphatics, blood vessels, nerves and
nerve endings,
– Collagen and elastin fibrous connective tissues
– Encloses epidermal appendages and sweat
glands
 DERMIS
LAYER COMPOSITION FUNCTION
Detects light
Meissner’s
touch
PAPILLARY corpuscles
LAYER
Detects heat and
Free nerve endings
pain
Provides
RETICULAR Collagen, elastin
strength and
LAYER and reticular fibers
resilience
 LAYERS OF THE SKIN:
SUBCUTANEOUS TISSUE
3. Subcutaneous tissues

– Loose connective tissues and fat tissues

– Insulation, support and cushion
– Regulation of temperature of the skin itself and
the body.
 APPENDAGES
• Hair
o Terminal hair
o Vellus hair
• Nails
o Nail plate
o Lunula
o Cuticle
o Lateral nail folds
 APPENDAGES
• Sebaceous glands
Secrete fatty substances through hair
follicles

• Sweat glands
Eccrine glands: controls body temp
Apocrine glands: stimulated by emotions
ASSESSMENT
SIGNS AND SYMPTOMS OF
SKIN DISEASE
 Pruritus (itching)
 Rash
 Urticaria
 Xeroderma
 Unusual spots, moles and nodules
 Edema
 Changes in the appearance of nails
 Changes in skin pigmentation, turgor and texture
EXAMINATION OF THE SKIN
Skin mobility and turgor

Edema
o Pitting
o Non-pitting
CHANGE IN SKIN COLOR
 Capillary Refill Test

 Jaundice

 Cyanosis

 Brown

 Cherry lips
CHANGE IN SKIN COLOR
Rubor

Diffuse hyperpigmentation

Pallor
o Temporary pallor
CHANGE IN SKIN COLOR
• Assessing Dark Skin:
– Pallor may be yellow or ashen gray
– Skin rashes may be present as a change in
skin texture
– Edema can be palpated as tightness
– Inflammation may be perceived as change
in skin temp
– Petechiae easier to see in the abdomen,
gluteal area, volar aspect of FA
 CHANGES IN NAILS
Clubbing: thickened and rounded nail end

White spots

Splinter hemorrhage: red brown linear streaks

Koilonychia: spoon nails

Paronychia: red, swollen

EXAMINING MASS OR SKIN
LESION
 Common mole (benign nevus)
- Proliferation of melanocytes, round, or oval
shaped, sharply defined borders, uniform color,
<6mm, flat or raised.
- May change to a melanoma
o Asymmetry – not matching halves
o Border – irregular, poorly defined
o Color – variations, mixtures of black
o Diameter – larger than 6mm/ > width of pencil eraser
o Evolving – change in size, shape, color, elevation
SKIN DISORDERS
 DERMATITIS
 Inflammation of the skin
 Skin is red, brown or gray; sore itchy and swollen
 Causes: 3As
– Allergic/contact dermatitis: poison ivy, harsh
soaps, chemicals
– Actinic: photosensitivity
– Atopic: etiology unknown, associated with
allergic, hereditary, or psychological disorders
DERMATITIS
STAGES OF DERMATITIS
1. Acute: red, oozing, crusting rash, extensive
erosions, exudate, pruritic vesicles
2. Subacute: erythematous skin, scaling,
scattered plaques
3. Chronic: thickened skin, increased skin
marking secondary to scratching, post-
inflammatory pigmentation changes
 Impetigo
Cellulitis
Abscess

BACTERICIDAL
INFECTIONS
 IMPETIGO
Superficial skin infection caused by staphylococci
or streptococci
Inflammation, small pus-filled vesicles, itching
Contagious
Common in children and the elderly
IMPETIGO
 CELLULITIS
Suppurative inflammation of cellular or
connective tissue in or close to the skin
Poorly defined and widespread
By streptococcal or staphylococcal infection
Can be contagious
Skin is red, hot and edematous
Can lead to lymphangitis, gangrene, abscess
and sepsis
CELLULITIS
 ABSCESS
Cavity containing pus and surrounded by inflamed
tissue

Result of localized infection

Commonly a staphylococcal infection

ABSCESS
VIRAL INFECTIONS

Herpes simplex
Herpes zoster
Warts
Fungal infections
 HERPES 1 (HERPES SIMPLEX)
Itching and soreness followed by vesicular
eruption on the face or mouth,
cold sore or fever blister
HERPES 2
Common cause of vesicular genital eruption
Spread by sexual contact
 HERPETIC WITHLOW
Painful infection of the terminal phalanx caused by
Herpes Simplex 1 and 2

Tingling pain or tenderness of the affected digit

followed by throbbing pain, swelling and redness
 HERPES ZOSTER (SHINGLES)
Caused Varicella-zoster virus (chicken pox)
Pain and tingling affecting spinal or cranial nerve
dermatome
Red papules progressing to vesicles
Accompanied by fever, chills, malaise, GI
disturbances
(+) Post herpetic neuralgic pain
HERPES ZOSTER (SHINGLES)
 WARTS
Benign infection by human papilloma virus (HPV)
Transmission: direct contact and autoinoculation
Location: hands and fingers
Plantar wart: on pressure points of the feet
WARTS
 Ringworm
Athlete’s foot

FUNGAL INFECTIONS
FUNGAL INFECTIONS
Ringworm (Tinea Corporis)
– Forms ring-shaped patches with vesicles or
scales
– Transmission is direct contact
– Treatment: Topical or antifungal drugs

Athlete’s foot (Tinea Pedis)

– Erythema, inflammation, pruritis, itching, pain
– Can progress to cellulitis if untreated
– Treatment: Antifungal creams
FUNGAL INFECTIONS
IMMUNE DISORDERS
OF THE SKIN
Psoriasis
Lupus erythematosus
sclerodermra
 PSORIASIS
Chronic disease of skin with erythematous plaques
covered with silvery scales
Common in ears, scalp, knees, elbows, genitalia,
extensor surfaces
Associated with psoriatic arthritis, joint pain

Topical meds may be used

PT Intervention: UV light with psoralens
PSORIASIS
 LUPUS ERYTHEMATOSUS
Chronic, progressive inflammatory disorder of
connective tissues
Characteristic red rash with raised red, scaly
plaques

 Discoid Lupus Erythematosus (DLE)

 Systemic Lupus Erythematosus (SLE)
 DISCOID LUPUS
ERYTHEMATOSUS (DLE)
Affects only skin; flare-ups with sun
exposure
Causes atrophy, permanent scarring,
hypo/hyperpigmentation
 SYSTEMIC LUPUS
ERYTHEMATOSUS (SLE)
Chronic, systemic inflammatory disorder affecting
multiple organ systems
Can be fatal
Symptoms:
Fever, malaise, butterfly rash across bridge of
nose, skin lesions, chronic fatigue, arthritis,
photosensitivity, hairloss, Raynaud’s
Phenomenon
 SYSTEMIC LUPUS
ERYTHEMATOSUS (SLE)
 SCLERODERMA
Chronic, autoimmune diffuse disease of
connective tissues causing fibrosis of skin,
joints, blood vessels, GI tract, lungs, heart,
kidneys
Associated with CREST Syndrome
Skin is taut, firm, edematous, firmly bound to
subcutaneous tissues
PT Mgt: delay development of contracture
and deformity
SCLERODERMA
 DERMATOMYOSITIS
Affecting the connective tissues
Inflammation of the muscle and skin
Skin rash and proximal mm weakness
(+) Gottron's sign
(+) Heliotrope rash
(+) Shawl sign
(+)Mechanic’s Hands
DERMATOMYOSITIS
DERMATOMYOSITIS
SKIN TRAUMA
CONTUSION
ECCHYMOSIS
PETECHIAE
ABRASION
LACERATION
 SKIN TRAUMA
Contusion
– Skin is not broken
– Pain, swelling and discoloration

Ecchymosis
– Bluish discoloration of skin caused by
extravasation of blood into subcutaneous tissues

Petechiae
– Tiny red or purple hemorrhagic spots on the skin
 SKIN TRAUMA
Abrasion
– Scraping away of skin as a result of injury or
mechanical abrasion

Laceration
– Irregular tear of the skin producing torn, jagged
wound
OTHER SKIN LESIONS:
Vitiligo: lack of pigmentation
ousually on sun-exposed areas, body
folds, and around openings
Café-au-lait (coffee with milk): light brown
macules
oDiagnosis: >5 lesions or 1 lesion but >1.5
cm
Hemorrhagic Rash: requires medical
evaluation
MONGOLIAN SPOT
BURNS
 BURNS
Tissue injury or destruction

Results from thermal, chemical, electrical,

or radioactive agents

3 zones
BURN ZONES
LUND AND BROWDER
LUND AND BROWDER
 Depth Characteristics Healing/Scarring
Epidermal/Superfi Epidermis 3-7 days
cial Burn (first Pink/red, no blistering No scarring
degree) Minimal edema, tenderness
Superficial Partial- Epidermis and upper layers of dermis 7-21 days minimal
thickness Burn Bright red/pink, intact blister scarring
Moderate edema, painful
Deep Partial- Severe damage to epidermis and dermis Healing is slow
thickness Burn Nerve endings, hair follicles, sweat glands Excessive scarring
(second degree) Mixed red or waxy; Broken blisters
(moist/weeping)
Marked edema, sensitive to pressure but
insensitive to light touch or soft pin prick
Full-thickness Burn Complete destruction of epidermis, dermis and Removal of eschar
(third degree) subcutaneous tissues, may extend into muscles and skin grafting is
White, gray, charred, black, poor distal circulation, necessary
parchment-like, dry leathery surface Hypertrophic scars
Little pain, destroyed nerve endings
Subdermal Burn Complete destruction of epidermis, dermis and Heals with grafting
(fourth degree) subcutaneous tissues, with muscle damage and scarring
May lead to necrosis Extensive surgery
SEVERITY OF BURN
COMPLICATIONS OF BURN
INJURY
1. Infection
2. Shock
3. Pulmonary Complications
4. Metabolic Complications
5. Cardiac and Circulatory complications
6. Integumentary scars and contractures
 DERMAL HEALING
Phase Description Duration
Inflammatory Redness, edema, 3-5 days/1-7 days
Phase warmth, pain,
decreased range of
motion
Proliferative Fibroblasts form scar 7-21 days
Phase tissue (deeper tissues);
characterized by wound
contraction;
reepithelialization
Maturation Phase Scar tissue remodeling Up to 2 years
 SCARS
Hypertrophic scar
– Raised scar that stays within the boundaries of
the burn wound
– Red, raised, firm

Keloid scar
– Raised scar extends beyond the boundaries of
the original burn wound and is red, raised, firm
– Common in young women, dark skinned
SCARS
BURN MANAGEMENT
 TOPICAL MEDICATIONS
TOPICAL AGENT ADVANTAGES DISADVANTAGES
Effective against
Does not penetrate
SILVER SULFADIAZINE yeast, Pseudomonas
eschar
infections
Poor penetration,
Antimicrobial against
SILVER NITRATE discolors, can cause
gram + and gram -
electrolyte imbalance
yeasts, molds, fungi,
Not effective for
POVIDONE-IODINE viruses, and
pseudomonas
protozoans
MAFENIDE ACETATE May cause Metabolic
Penetrates eschar
(SULFAMYLON) acidocis
May lead to overgrowth
NITROFURAZONE Bactericidal of fungus and
pseudomonas
 GRAFTS
Autograft

Allograft (homograft)

Xenograft (heterograft)

Biosynthetic grafts

Cultured skin
 GRAFTS
Split-thickness graft

Full-thickness graft

Z-plasty (resection of scar)

– Surgical incision in the
form of the letter Z
used to lengthen a
burn scar
 MANAGEMENT
Edema control
Deep friction massage
Resistive and strengthening exercises
CV endurance
Promote ADL independence
Management of chronic pain
Emotional support
COMMON DEFORMITIES
 DEFORMITY POSITIONING
ANTERIOR
Flexion
NECK
SHOULDER Adduction, IR

Flexion and
ELBOW pronation

Claw hand (intrinsic

HAND minus position)

Flexion and
HIP adduction

KNEE Flexion

ANKLE Plantar flexion

COMPRESSION STOCKINGS
16-18: pressure per stocking

10-30 (Low): prevent varicosities and DVT

20-30: Flatten Scar

30-40: (High): Edema Mgt

SKIN ULCERS
 ULCERS ARTERIAL VENOUS
Etiology ASO, Arterioembolism Valvular Incompetence,
Venous Hypertension

Appearance Reg, smooth edges, min to no Irreg: dark pigmentation,

granulation sometimes fibrotic
Usually DEEP Good Granulation
Usually SHALLOW
Location Distal lower leg: toes, feet Distal lower leg
Lat. Malleolus Med. Malleolus
Ant. Tibia area
Pedal Pulses Decreased or Absent Present
Pain Painful, especially if legs Little pain, comfortable with
elevated legs elevated
Drainage Moderate to large amount of
exudate
Associated Gangrene May be present Absent
Associated Signs Trophic changes Edema
Pallor on foot elevation
Dusky rubor on dependency
 DIABETIC ULCER
 Etiology: repetitive trauma on insensitive skin
 Location: Where arterial ulcer usually appears
(plantar aspect of the foot)

 Features:
Not painful
(+) SENSORY LOSS
Pulses: may be present or absent
Sepsis common; GANGRENE may develop
Semmes-Weinstein
SAMPLES:
PRESSURE ULCER
 PRESSURE ULCER/DECUBITUS
ULCER
 Lesion caused by unrelieved pressure resulting in
ischemic hypoxia and damage to underlying tissue
 Usually over bony prominences
 Common in: elderly, debilitated, or immob individuals,
cognitive impairment, decrease sensation
 Interventions: patient education and physical
intervention
Stage Characteristics
Stage I Non-blanchable erythema of intact skin; (+) change in
tissue temp, tissue consistency, sensation

Stage II Partial thickness skin loss; Involves epidermis, dermis or

both. Presents as abrasion, blister or shallow crater
Stage III Full thickness skin loss; May extend down to, but not
through, underlying fascia. Presents as deep crater
Stage IV Full thickness skin loss; involves extensive destruction or
damage to mm, bone or supporting structures.
Undermining and sinus tracts may be present
Unstageable Tissue depth is obscured d/t slough or eschar and extent
of damage cant be determined
Deep tissue Discolored area of tissue (bruise) that is not reversible
Injury and will likely progress to a full thickness injury
_______
______
_______
______
______
______
 WAGNER ULCER GRADE
CLASSIFICATION SCALE
Grade Desciption
0 No open lesion but may possess pre-ulcerative
lesions; healed ulcers; presence of bony deformity
1 Superficial ulcer not involving subcutaneous tissue

2 Deep ulcer with penetration through the

subcutaneous; potentially exposing bone, tendon,
ligament or joint capsule
3 Deep ulcer with osteitis, abscess or osteomyelitis
4 Gangrene of digit

5 Gangrene of foot requiring disarticulation

 EXAMINATION OF WOUND
Assess size (length, width, depth, wound area)
oClear film grid superimposed: size
oCotton tip: depth

Examine tunneling (rimming or undermining)

Evaluate for sinus tracts (communication
with deeper structures)

Determine wound drainage

TYPES OF WOUND DRAINAGE
TYPE DESCRIPTION
Clear, shiny exudate; can have
SEROUS
slightly yellow appearance

SANGUINEOUS Red, blood drainage

SEROSANGUINEOUS Pinkish- red colored exudate

Brighter yellow drainage, slightly

SEROPURULENT thicker exudate than serous; slightly
malodorous

Containing pus; Thick, cloudy or

PURULENT
opaque exudate; mal odorous
 WOUND COLOR
Clean red wounds
– Healthy granulation wounds

Yellow wounds
– Slough, fibrous tissue

Black wounds
– Eschar
EXAMINATION OF WOUND
Determine temperature: use thermistor

Determine girth: use circumferential or

volumetric measurements

Examine viability of periwound:

oErythema, warm, swelling: infection
oMaceration: d/t moisture
oCyanosis: arterial insufficiency
WOUND CARE
 WOUND CARE
Infection Control
oWounds are cultured; antibiotics are
prescribed

Surgical Intervention: for stage III and IV ulcers

 WOUND CARE
Hyperbaric Oxygen Therapy
o Patient breathes 100% oxygen in a sealed, full
body chamber with an elevated atmospheric
pressure

o Hyperoxygenation reverses tissue hypoxia

and facilitate wound healing

o CI: untreated pneumothorax, anti-neoplastic

medications
 WOUND CARE
Wound Cleansing
o Normal saline (0.9% NaCl)
o Cleansing topical agents: ANTISEPTICS
a) POVIDONE-IODINE SOLUTION
• Staphylococcus aureus (yellow)
b) DAKIN’S SOLUTION (Na Hypochloride)
• purulent exudate
c) ACETIC ACID
• P. Aeruginosa (light green)
d) HYDROGEN PEROXIDE
• Least effective
 WOUND CARE
Wound Debridement
o Removal of necrotic or infected tissue that
interferes with wound healing
o Allows examination of ulcer
o Decreases bacterial concentration
o Improves wound healing
o Decreases spread of infection
WOUND DEBRIDEMENT
 Delivery Systems
o Minimal mechanical force :
• Gauze, cloth, sponge

o Irrigation:
• Syringe, battery-powered irrigation system
(pulsatile lavage)

o Hydrotherapy
• For ulcers with large amount of exudate
• Discontinue whirlpool when wound is clean
METHODS OF DEBRIDEMENT
 SELECTIVE
1. Autolytic
• Most selective
• Used if granulation tissues are greater than
necrotic tissues

2. Sharp debridement
• With the use of scalpel, scissors and tweezers
• This is contraindicated for patients taking anti-
coagulants
METHODS OF DEBRIDEMENT
3. Enzymatic
• Use of fibrinolytic and proteolytic enzymes
a) ELASE
• Glassy edematous wounds
• Venous insufficiency ulcers with fibrous
exudates
b) TRAVASE
• Used for ESCHAR
4. Maggot therapy
METHODS OF DEBRIDEMENT
NON-SELECTIVE
1. Hydrotherapy – whirlpool bath
2. Wet-to-dry
3. Forceful irrigation – pulsed lavage
4. Radical surgery
METHOD DEFINITION INDICATION C/I
Autolytic Selective Solubilization of Necrotic wounds Infected wounds,
necrotic tissue by immunosupresse
phagocytic d individual
cells/proteolytic Dry gangrene

Enzymatic Selective Liquefication of All moist necrotic Ischemic wounds

necrotic tissue by wounds Gangrenous
proteolytic/collagen Eschar after cross- wound, clean
olytic enzymes hatching granulated
wound
Mechanical Nonselective Removes Moist necrotic Clean, granulated
devitalized/contamin tissue or foreign wound
ated tissue by materials present
mechanical force
Sharp Selective Removal of tissues scoring/excision of Clean wounds,
using sterile leathery eschar, DRY GANGRENE
instruments without moist necrotic advancing
anesthesia tissue cellulitis/sepsis
Surgical Nonselective Operative procedure Cellulitis/sepsis Indiv. with short
surgical wound life expectancy
closure
 WOUND DRESSINGS
1. For dry desiccated wound (need hydration)
a) Wet-to-wet gauze
b) Hydrogel products
• Curasol gel
• Hydrogel impregnated gauze
• Hydrogel sheet

2. For minimal exudating wound

a) Wet-to-dry gauze
b) Hydrocolloid wafer dressing (THIN TYPE)
 WOUND DRESSINGS
3. For moderate to heavy exudating wound
a) Dry-to-dry gauze
b) Calcium alginate (maximum absorptive
capacity)
c) Semi-permeable foam
d) Collagen dressing
e) Hydrocolloid wafer dressing (THICK TYPE)
• For moderate exudating wound only
• Not for infected wound
• Transparent Films • Hydrocolloids
• Hydrogels • Foams
• Alginate • Gauze Dressing
 NUTRITIONAL
CONSIDERATIONS
Malnutrition and poor hydration can cause delayed
wound healing
High-calorie/high-protein diet
Patients with trauma stress and burns require
higher intakes
 INJURY PREVENTION
Daily skin inspection
Therapeutic positioning
o Every 2 hours
o Wheelchair push ups every 15 minutes
Lifting, not dragging
Use of draw sheets
Use pressure relieving devices
Prevent maceration
THANK YOU FOR LISTENING! 