Integumentary

Mark Ebony C. Sumalinog

Outline
• Effects of Aging on the Integument
• Integumentary Health Promotion
• Selected Integumentary Conditions
• General Nursing Considerations
Effects of Aging on the Integument
• Flattening of the dermal-epidermal junction
• Reduced thickness and vascularity of the dermis
• Decrease rate of epidermal turnover
• Degeneration of elastic fibers
• Increased coarseness of collagen
• Reduction in melanocytes (grey hair)
• Atrophy of hair bulbs
• Decline of rate in hair and nail growth
Effects of Aging on the Integument
Heightened risks for: Effect:
• skin tears • visible signs of aging
• bruising • body image
• ulcer formation • self-concept
• skin infection • reaction from others
• socialization
• other psychosocial
factors
Integumentary Health Promotion
• Avoid drying agents, rough clothing, highly
starched linens, and other irritating to the skin

• good skin nutrition and hydration: activity, bath

oils, lotions and massages

• skin cleanliness is important but excessive bathing

may be haardous to skin
Integumentary Health Promotion
• Daily partial sponge baths and complete baths
every third or fourth day are sufficient for the
average older person

• attention and treatment of pruritus and skin

lessions to prevent irritation, infection and other
problems
Integumentary Health Promotion
• UVR damages the skin causing solar elastosis or
photoaging
-loss of elasticity and wrinkling of the skin
- high risk: fair-skinned who easily burns when
when under the sun; sunbathing during youth
- sun screening lotions are beneficial (with SPF
or sun protection factor)
Integumentary Health Promotion
• Skin cancer in late life is prevalent therefore inspection for
abnormalities is a beneficial action

- A- Assymetry: if a mole is not round or symmetrical ,

or half of the mole is not similar to the other half, it could
be a sign of MELANOMA

-B- Border Irregularity: Cancerous moles have irregular

borders that may be uneven, ragged, notched, or blurred.
Integumentary Health Promotion
- C- Color: The typical color of a mole is
consistently brown throughout. A change in color
overtime or is varied in a shade of brown, tan, and
black may be cancerous.

Melanoma- red, blue or white

Integumentary Health Promotion
- D- Diameter: Cancerous moles can be more
than 6 mm in diameter (about 1/4 inch or the size of a
pencil eraser

Other indication of melanoma: elevation of height

both horizontally and vertically; a change in feeling
(itchiness, tenderness or pain; tendency to bleed if
scratched)
Integumentary Health Promotion
• Nurse should emphasize to persons young and old
that no cream, lotion, or miracle drug will remove
wrinkles and lines or return youthful skin

- money that could be applied to more basic needs

is sometimes invested in attempts to defy reality
Integumentary Health Promotion
• The nurse can encourage the use of cosmetics to
promote the skin and maintain an attractive
appearance

• Gerontological nurses to be informed of the

different surgical interventions (inc. number of
aging individuals who seek cosmetic surgery)
Integumentary Health Promotion
• Nurses can also help in locating a competent
cosmetologist/ cosmetic surgeon (unfortunate
complications have resulted from from unskilled
physicians performing cosmetic surgery; injecting
collagen or silicone)

• explore for underlying reason behind seeking

cosmetic surgery to ensure its a rational decision
rather than a sign of depression or neurotic disorder
Integumentary Health Promotion
• counseling and therapy may be more pressing than
a surgical intervention

• as society achieves a greater acceptance and

understanding of the aging process, the masking of
the effects of aging with cosmetics and surgery will
be replaced by an appreciation of natural beauty of
age.
 Nursing diagnosis r/t Dermatologic problems
Causes or Contributing Factors Nursing Diagnosis
Altered body appearance anxiety

Pruritus, infection, ulcer acute pain

Ulcer, fragile skin risk for infection

More fragile skin risk for injury

 Nursing diagnosis r/t Dermatologic problems
Causes or Contributing Factors Nursing Diagnosis
Age-related changes to skin, hair, and nails; disturbed body image
pain

altered self-concept due to age-related sexual dysfunction

changes; more fragile vaginal epithelium

Fragile skin, immobility impaired skin integrity

Altered self-concept due to age-related impaired social interaction

changes in the integument
 Nursing diagnosis r/t Dermatologic problems
Causes or Contributing Factors Nursing Diagnosis
Pressure sites, ulcer risk for ineffective peripheral tissue
perfusion
Assessment Guide: Skin Status
General observation
• skin color, moisture, and cleanliness
• presence of lesions
• hair condition and grooming
• condition of nails
• pallor or flushing
Assessment Guide: Skin Status
Interview
• ask about itching, burning sensations on skin
• ask for hair loss, increased fragility of skin
• ask for other symptoms associated with
integumentary system problems
• review bathing and shampooing practices
Assessment Guide: Skin Status
Physical Examination
• Skin surface: examin head to toe (ears, skin folds,
breast, between toes)
• bathing and massages are good opportunities to
inspect the skin in the course of patient care
• note moles, skin tears, bruises, discoloration and
other unusual finding
Assessment Guide: Skin Status
Lesions
• Color (black, purple or hypopigmented)
• configuration (linear, separate, confluent, annular)
• size (depth and diameter)
• drainage
• types
Assessment Guide: Skin Status
Types
• macule: small nonpalpable spot or discoloration
• papule: discoloration <1/2 cm in diameter with palpable
elevation
• plaque: group of papules
• nodule: 1/2 to 1 cm in diameter with palpable elevation;
skin may not be discolored
• tumor: >1 cm with palpable elevation, skin may not be
discolored
Assessment Guide: Skin Status
Types
• wheal: red or white palpable elevation with variable
sizes
• vesicle: <1/2 c in diameter that contains fluid and has
palpable elevation
• bulla: a >1/2 cm in diameter that contains fluid and has
palpable elevation
• pustule: containing purulent fluid of variable size and
palpable elevation
Assessment Guide: Skin Status
Types
• Fissue: a groove in the skin
• Ulcer: open depression in the skin that may occur
in variable sizes
Assessment Guide: Skin Status
Mongolian spots
• irregular, dark areas
(resembling bruises)
that may be found in the
buttocks, lower back,
and to a lesser extent on
the arms and thighs
Assessment Guide: Skin Status
Skin turgor
• test skin turgor by pinching areas of skin
• area over sternum and forehead do experience less
of an age related reuction in turgor (good areas for
assessment)
Assessment Guide: Skin Status
Pressure tolerance
• inspecting a pressure point after the patient has
been in the same position for half an hour
• if redness is present, the patient must be in turning
schedule every half an hour
• if not, remain in same position for 1 hour and
inspect
Assessment Guide: Skin Status
Temperature
• Use back of hands and touching various areas
• note coldness or temperature inequalities between
extremities
Assessment Guide: Skin Status
Pruritus
• most common
• precipitated by any circumstances that dries the
skin (excessive bathing and dry heat)
• other factors: DM, arteriosclerosis,
hyperthyroidism, uremia, liver disease, cancer,
pernicious anemia, and certain psychiatric
problems
Assessment Guide: Skin Status
Pruritus
• if not controlled, may result to traumatizing
scratching, leading to breakage and infection of
skin
• underlying cause should be corrected: ex. scabies
• ttt: bath oils, moisturizing lotions, and massage
• diet: vitamin supplements and vitamin-rich diet
Assessment Guide: Skin Status
Pruritus
• topical: zinc oxide
• antihistamines and topical steroids for relief
Assessment Guide: Skin Status
Keratosis
• actinic or solar keratosis
• small, light colored lesions, usually gray or brown,
on exposed areas of the skin
• keratin may be accumulated in these lesions,
causing the formation of cutaneous horn with a
slightly reddened and swollen base
Assessment Guide: Skin Status
Keratosis
• ttt: freezing agents and acids can be used
• electrodesiccation or surgical excision ensures a
more throrough removal
• close monitring because it is pre-cancerous
Assessment Guide: Skin Status
Seborrheic keratosis
• dark, wartlike projections of the skin
• can be small as a pinhead or as large as a quarter
• increase in size and number as we age
• areas: trunk, face, neck, and in persons with oly
skin
• oily skin: they appear dark and oily
Assessment Guide: Skin Status
Seborrheic keratosis
• in less sebaceous areas, they are dry in appearance
and of a light color
• normally, base is not swelling or no reddening
• abrasive activity with a gauze pad containing oil will
remove seborrheic keratosis
• freezing agents or by curretage and cauterization
can remove it
Assessment Guide: Skin Status
Seborrheic keratosis
• benign; but medical evaluation is important to
differentiate from precancerous lesions
Skin Cancer (3 major types)
Skin Cancer (3 major types)
A. Basal cell carcinoma
• most common form
• grows slowly and rarely metastasizes
• risk factors: advancing age, exposure to sun, UVR,
and therapeutic radiation
• most common: face; but can erupt anywhere
Skin Cancer (3 major types)
A. Basal cell carcinoma
• growth tend to be small, dome-shaped elevations
covered by small blood vessels
• resemble benign , flesh colored moles with a pearly
surface
• the surface sometimes is dark, rather than shiny
(cotains melanin pigments)
Skin Cancer (3 major types)
B. Squamous cell carcinoma
• arises from the squamous cells (skin, hollow
organs of the body, passages of the respiratory and
digestice tract
• sun exposure most prevalent factor
• other factors: exposure to hydrocarbons, arsenic
and radiation
Skin Cancer (3 major types)
B. Squamous cell carcinoma
• may develop in scar tissue and is associated with
suppression of the immune system
• typically appear as firm, skin-colored or red nodules
• usually stays in the epidermis but may metastasize
(lower lip)
Skin Cancer (3 major types)
C. Melanoma
• tends to metastasize, or spread more easily
• deadly if not caught earlier
• due to sun exposure, fair skinned, increases with
age
Skin Cancer (3 major types)
Classifications
i. Lentigo maligna melanoma- black, brown, white or red
pigmented flat lesion occurs predominately in sun
exposed areas of the body

With time, it becomes larger and becomes

progressively irregularly pigmented

age of diagnosis: 67 years old

Skin Cancer (3 major types)
Classifications
ii. Superficial spreading melanoma: most common
melanoma;

variable pigmented plaque with an irregular border

and can occur at any parts of the body

incidence peaks at middle age and continues to be

high in the 8th decade (80 years old)
Skin Cancer (3 major types)
Classifications
iii. Nodular melanoma: can be found in any parts of
the body

darkly pigmented papule that increase in size

overtime
Skin Cancer
• Suspicious lesions should be evaluated and
biopsied
• excision of melanomas and its surrounding tissues
and subcutaneous fat
• physicians recommend removal of ALL palpable
lymph nodes
• prognosis: depends on the depth of the melanoma
rather than type
Skin Cancer
• Nurse should teach older adults to inspect
themselves for melanomas, identify moles that
demonstrate changes in pigmentation or size.

• Early detection means better prognosis

Vascular Lesions
• Age-related changes can weaken the walls of the veins
and reduces the ability of the vein to respond to
increased venous pressure.
• factors: obesity and heriditary
• can cause varicose veins to develop
• poor venous return and congestion leads to edema of
lower extremities
• poorly nourished legs accumulate debris and gains a
pigment, cracked and exudative appearance
Vascular Lesions

• results to stasis dermatitis (inflammatory condition)

• subsequent scratching, irritation or other trauma
(ex. elastic bond stockings) develops to leg ulcers
• leg ulcers or stasis ulcers appears on the medial
aspect of the tibia above the malleolus and appears
as dark discoloration before breakdown
Vascular Lesions

• stasis ulcers need special attention

• infection must be controlled and necrotic tissue
must be removed to promote healing
• good nutrition is an important component
• diet high in protein and vitamins is recommended
Vascular Lesions

• once healed, avoiding situations that promote stasis

dermatitis is of concern
• weight reduction
• elevate legs several times a day
• avoid standing for long periods, sitting with legs
crossed, and wearing garters (interferes with circulation)
Vascular Lesions

• elastic support stockings may be prescribed but

challenging for older adults to wear
• assess for ability to wear elastic support stockings
• some may need ligation and stripping of veins to
prevent further episodes of stasis dermatitis
Pressure Ulcers

• Tissue anoxia and ischemia resulting from pressure can

cause the necrosis, sloughing and ulceration of tissue
• also known as decubitus ulcer
• any part can develop a pressure ulcer but the most
common parts are the sacrum, greater trochanter, and
ischeal tuberosities
Pressure Ulcers

• elderly at high risk:

- have fragile skin
- poor nutritional state
- reduced sensation to pain and pressure
- frequently affected by immobile and edematous
conditions
Pressure Ulcers

• pressure ulcers requires a longer time to heal in

older adults
Pressure Ulcers

Stages:
I- a persistent area of skin redness; no skin breakdown

II- a partial thickness loss of skin layers involving the

epidermis that presents as abrasion, blister or shallow
crater
Pressure Ulcers

Stages:
III- full thickness of skin lost extending through the
epidermis and exposing the subcutaneous tissues;
presents as deep crater with or without underminig
adjacent tissues
Pressure Ulcers

Stages:
IV- full thickness of skin and subcutaneous tissue is
lost, exposing muscles, bones, or both; presents as
crater that may include necrotic tissue, exudate,
sinus tract formation and infection
Pressure Ulcers

• The most important measure is to prevent the

formation
• avoid unrelieved pressure
• turning schedule (varies)
• shearing forces that causes two layers of tissue to
move across each other should be prevented
Pressure Ulcers

• do not elevate head of bed more than 30 degrees, not

allowing patient to slide in bed, and lifting instead of
pulling patients wh moving them

• use pillows, flotation pads, alternating pressure

mattresses and water beds can disperse pressure from
bony prominences
Pressure Ulcers

• devices do not eliminate the need for frequent

position changes
• when sitting, urge to move around
• heel protectors are useful
• sheets are wrinkle free
• check bed for foreign objects (syringes and utensils)
Pressure Ulcers

• diet: high protein, vitamin-rich diet to maintain and

improve tissue health
• good skin care is essential
• skin should be kept dry and clean
• do not rub when wiping patient; blot instead
• bath oils and lotions
Pressure Ulcers

• massage of bony prominences

• ROM exercises to promote circulation
• incontinent patients- thouroughly cleansed with
soap and water and dried after each episode to
prevent skin irritation from excreta
Treatment measures depend on the
state of the pressure ulcer as identified:
Hyperemia
• redness of the skin appears quickly and can disappear if
pressure is removed
• remove pressure by the use of a square of adhesive foam
• products: DuoDerm (Squibb) or Tegasorb (3M) before
applying the adhesive
Treatment measures depend on the
state of the pressure ulcer as identified:
Ischemia
• redness of the skin develops from up to 6 hours of
unrelieved pressure and is often accomapnied by
edema and induration
• takes days before the area return to its normal
color, during which the epidermis may blister
Treatment measures depend on the
state of the pressure ulcer as identified:
Ischemia
• Protect skin with Vigilon, which contains water and
is soothing to the area
• if skin is broken, cleanse daily with normal saline
solution
Treatment measures depend on the
state of the pressure ulcer as identified:
Necrosis
• Unremitting pressure extending over 6 hours can cause
ulceration with a necrotic base
• this requires a transparent dressing that protects it from
bacteria but is permeable to oxygen and water vapor
• thorough irrigation during dressing changes
Treatment measures depend on the
state of the pressure ulcer as identified:
Necrosis
• topical antibiotics
• may take weeks to months before full healing to
occur
Treatment measures depend on the
state of the pressure ulcer as identified:
Ulceration
• if pressure is not relieved, necrosis will extend to
through the fascia and potentially to the bone
• eschar: thick, coagulated crust
• debridement is essential to promote healing
ounderlying tissues
Treatment measures depend on the
state of the pressure ulcer as identified:
Assessment tool:
• Braden Scale and Norton Scale- to assess risk of having
pressure ulcers upon admission
• Pressure Sore Status Tool (PSST) offers a means of
assessing and monitoring existing pressure ulcers using
13 indexes (ex. size, exudate, necrotic tissue, edema and
granulation
General Nursing Considerations

• Psychological support: skin problems are visibly

unpleasant to patient and to others
• Visitors and staff may unnecessarily avoid touching and
being with the patient
• Reassure visitors regarding safety of contact with the
patient and instruct for any special precautions that must
be followed
General Nursing Considerations

• Emphasize that the patient is still normal, with

normal needs and feelings, and will appreciate
normal interaction and contact
• Wrinkles can not be avoided
• advise persons of all ages to avoid excessive sun
exposure and use sunscreen
General Nursing Considerations

• Topical products (b-hydroxy acids) that can reduce

wrinkling
• advise individuals to only seek reputable providers
who are experienced in cosmetic procedures
General Nursing Considerations

Alternative Therapies
• External application of chamomile extract is used for skin
inflammation
• Witch hazel is used for its astringent effect and applied on
bruise and swelling
• Essential oils like thyme oil (antiseptic), thyme linalol and
rosewood oil for topical acne
General Nursing Considerations

Alternative Therapies
• Rosemary oil for cell regeneration
• Oils of basil, cinnamon, garlic, lavender, sage,
savory, and thyme for insect bites or stings
• peppermint oil (anti-inflammatory) speed the
healing of wounds and mild burns
General Nursing Considerations

Alternative Therapies
• homeopathic and naturopathic remedies
• acupuncture
• biofeedback, guided imagery, relaxation exercise
• supplements: zinc, magnesium, essential fatty acids,
vitamin A, B complex, B6, and E
Integumentary
Mark Ebony C. Sumalinog