Integumentary System
Surface Area : Body Volume Ratio Physiological Implication
A high surface-area-to-body-volume ratio contributes to the risk of greater absorption through the skin. Topical medications should not be used without a health care provider's order.
Introduction
A review of the anatomy and physiology of the integumentary system is essential for nursing practice. The ability to differentiate between pediatric and adult integumentary characteristics are important for accurate assessment and appropriate management. It is essential that the nurse also understand the importance of patient and family history, as well as psychosocial factors, in the overall assessment of the skin.
Which facts explain the anatomical differences between pediatric and adult skin?
Adult epidermis is thicker which decreases water loss through the skin. As children age, photosensitivity decreases as melanocyte number increases. Older children and adults have an increased ability to regulate body temperature due to mature eccrine sweat glands.
Which type of secretory gland produces a thick, milky secretion that is delivered onto hair follicles?
Apocrine sweat glands
The nurse is assessing a 2-month-old dark skinned infant and is not sure whether or not the infant is showing signs of cyanosis. How can the nurse determine cyanosis?
Assess whether the child's skin appears dark bluish (in light-skinned children) or gray or whitish (in dark-skinned children).
While assessing the skin turgor of a six month old, the nurse notices the skin "tents" when released. What does the tenting indicate?
Dehydration
Which skin accessory structure helps regulate body temperature?
Eccrine sweat (sudoriferous) glands
Family members often pay close attention to skin lesions on infants. When performing the skin assessment, what can the nurse to do decrease parental anxiety and increase knowledge regarding skin lesions?
Encourage families to ask questions. Ensure family members are aware of any lesions on the infant. Provide information about the lesion and its progression or resolution. Provide information to correct any misconceptions regarding skin lesions.
In part, the integumentary system helps to maintain a constant body temperature—thermoregulation is important in the neonate population. Excessive heat loss is a stressor for the infant. Heat is lost through:
Evaporation—heat loss through wet skin Convection—heat loss from cooler air circulating around warm, exposed skin Conduction—heat loss through direct contact with cold surfaces (i.e., cold scale) Radiation—heat loss from heat radiating towards a cooler surface Cold can increase oxygen consumption, increase postnatal weight loss, and increase the body's use of glucose. To minimize the potential complications, the nurse must seek to maintain a thermal environment with warmers, warm blankets, and crib location away from walls and windows.
The adolescent integumentary system has unique variations.
Hormonal changes during adolescence increase sebum production, which contributes to acne vulgaris. Hormonal changes during adolescence initiate the development of the secondary sex characteristics including the appearance of terminal hair in the axillary and genitoanal regions. Apocrine sweat glands associated with these terminal hairs become active during puberty.
Identify the correct distinctions between the physiological variations in pediatric skin compared to adult skin.
Insensible fluid loss has a greater effect on the infant's total body water than in the adult. Pediatric skin is not fully mature; production of IgA, melanocyte distribution, and function of eccrine glands require several years before reaching adult levels. Hormonal changes in the pediatric patient are expected during adolescence and with this change it is likely that dermatological lesions will appear as the skin changes.
Eccrine Sweat Glands Physiological Implication
Late maturity of eccrine glands in infants and young toddlers means they are less able to regulate body temperature.
While assessing a pediatric patient, the mother states that her son no longer wants to swim with his friends and prefers to be alone in his room. He states he won't wrestle this year because his skin is "gross". What does this social history indicate?
Negative psychosocial factors Development of a disturbed body image
An adolescent patient visits the clinic because of worsening acne. What information can the nurse share with the patient regarding reasons for the increase in acne during the teenage years?
Oil secretion increases from sebaceous glands. This can clog pores. As sex hormones increase in the body, skin begins to thicken.
Why are infants and toddlers at increased risk for sunburn and sun damage?
Older children and adults have decreased photosensitivity than infants and toddlers due to anatomical differences in the concentration of melanocytes.
A 14-year old female presents with severe acne vulgaris. She shields her face and barely makes eye contact. After a discussion regarding skin care methods, the patient is scheduled to return in two weeks. At the follow-up appointment, the patient makes eye contact and has her hair pulled back into a ponytail. Which statement supports the development of a positive self-image in this patient?
Patient displays actions that indicate she is feeling better about herself.
What is the relationship between age and an increased tendency to blister?
Premature children have fewer cell attachments, such as desmosomes, which increases the tendency to blister. Not all anatomical structures are fully mature at birth. This includes the production of cell-surface proteins, such as desmosomes. Fewer cell-surface protein means less intercellular attachments and the increased tendency to blister.
Cell Attachments in a Premature Infant Physiological Implication
Premature infants also have fewer cell attachments, which increases the tendency to blister.
What is the function of the epidermis?
Protects and waterproofs The many strata of the epidermis, along with the keratin protein, function in the protection and waterproofing of the skin. The epidermis also contains melanocytes for UV protection.
Which skin accessory structure will become increasingly active in response to sex hormones during adolescence?
Sebaceous glands
Match the accessory structure with the correct function.
Secretion of sweat (water, electrolytes, & waste). Eccrine sweat glands. Secretion of thick, milky sweat. Apocrine sweat glands Secretion of sebum. Sebaceous gland Pulls skin taut and hair stands on end. Erector muscle (arrector pili)
Why are infants more susceptible to mucous membrane infections?
Several aspects of integumentary physiology (such as IgA levels) do not reach maturity for several years after birth.
IgA Physiological Implication
Since IgA production is low, the infant is less resistant to organisms such as those occurring on the hands or other objects the infant might place into the mouth.
Summary
Skin assessment requires the knowledge of basic integumentary anatomy and physiology. Differentiating between pediatric and adult integument specifically facilitates the understanding of skin pathology. Patient, family, and social history are important in the skin assessment and the nurse should be aware of psychosocial factors that are influenced by skin conditions. Differences in pediatric skin anatomy result in differences in the physiological functions of the skin. Pediatric patients may require specific care based on the anatomical differences.
Which structure is not part of the integument, but lies beneath the dermis and is composed of adipose tissue?
Subcutaneous layer (hypodermis/superficial fascia)
There are two types of sweat glands (sudoriferous glands): eccrine and apocrine.
The eccrine sweat glands open directly onto the skin surface and produce sweat, which evaporates to reduce body temperature. Eccrine sweat glands are widely distributed over the body and are functionally mature by two months of age. Sweat contains water, electrolytes, and waste products. The apocrine sweat glands produce a thick, milky secretion. The apocrine sweat glands open onto terminal hair follicles located mainly in the axillary and genital areas and become active during puberty.
Surface Area: Premature Infants Physiological Implication
The increased surface area leads to increased evaporative fluid losses.
An infant is admitted for dehydration that occurred while attending an outdoor event. The mother states that none of her teenaged children have signs of dehydration. Why do you think the infant developed dehydration before the other siblings?
The infant has a greater surface area to body volume ratio which results in increased water loss from the body.
The pediatric integumentary system differs from the adult integumentary system in many ways. Some of these ways include:
The newborn's epidermis is thinner than that of adults. The ratio of skin surface area to body volume is greater in infants and small children than in adults. Premature infants have a proportionately greater body surface area than older infants and children. Eccrine glands do not reach mature function until age 2 or 3 years. Infants have fewer melanocytes than adults. IgA, secreted by the epithelial cells of the mucous membranes, does not reach adult levels until age 2 to 5 years.
Melanocytes Physiological Implication
There is an increase in photosensitivity when the child has fewer melanocytes.
Epidermis Physiological implication
Thin epidermis of the newborn results in increased permeability to topical agents and increased water loss through the skin.
Select the major functions of the integumentary system.
To aid in excretion of water. To regulate body temperature. To aid in production of vitamin D. To initiate the sensations of touch, pain, and itch. To protect the deeper tissues from injury, drying, and invasion by foreign matter.
The integumentary system has five major functions:
To protect the deeper tissues from injury, drying, and invasion by foreign matter. To regulate temperature. To aid in excretion of water. To aid in production of vitamin D. To initiate the sensations of touch, pain, heat, and cold. Understanding the anatomical structures that provide these physiological mechanisms facilitates assessment and formation of nursing management.
Why is it important to obtain information regarding maternal history when performing a pediatric integumentary assessment?
To provide information that can eliminate, or lead to, a diagnosis in the pediatric patient Obtaining maternal history can provide details regarding the mother's health and activities that may be useful in diagnosis and treatment of the pediatric patient.
Erector smooth muscles, which are controlled by the
autonomic nervous system, are associated with hair. When these smooth muscles contract, the skin is pulled taut and the hair stands on end
The reaction between natural bacteria on the skin and the fluid released from the apocrine glands is what produces
body odor in older children. The nurse should educate the child and parent that one sign of puberty is the onset of body odor.
Nerve structures are found throughout the
dermis and detect changes in and on the skin. Free nerve endings can sense changes in touch, temperature, pain, and itch. These nerve receptors provide sensory information regarding the both the external and internal environments.
Anatomy and physiology—structure and function—are interrelated; if the anatomy is different, changed, or absent, the physiology will also be
different, changed, or absent. Use the information in the table to learn more about how anatomical differences in pediatric skin lead to physiological differences as well.
The skin is visible and its disorders can even be disfiguring for a child which can cause
emotional and psychological stress for the child and family. For this reason, patients with dermatological conditions may have issues with self-image and self-esteem. It is important for the nurse to be aware of these issues and facilitate discussions to help generate a positive outlook
Appendages (accessory structures) from the
epidermis—sebaceous glands and sweat glands—are embedded in the dermis. The sebaceous glands arise from the hair follicles and produce sebum, which lubricates the epidermis and is slightly bacteriostatic.
Sebaceous glands are particularly abundant on the
face and scalp. During adolescence, hormones influence the activity of the sebaceous gland. Testosterone increases secretion of sebum and estrogen suppresses it.
Social history is important in the
full assessment of the patient. Changes in social interactions can occur when skin conditions worsen or if the patient is experiencing social exclusion. Nurses should be prepared to identify behavioral, cognitive, emotional, social, and medical factors that play a role in psychosocial changes. The nurse can then provide coping strategies and psychosocial interventions to improve self-image and self-esteem.
Skin assessment should include
history (pigment changes, rashes, bruising and bleeding, dryness/sweating, and previously diagnosed skin diseases), color, turgor, moisture, birthmarks/moles, masses, and lesions. For example, assessment of skin turgor is utilized to determine hydration. The skin is gently pinched into a tent and the "tent" should immediately flatten for normal hydration. If an individual is dehydrated, the "tent" remains for a few seconds and supplemental hydration is indicated. Skin color is also very important as it can provide evidence of cyanosis, erythema, jaundice, and pressure ulcers. It is important to note these conditions may present differently in light-skinned patients compared with dark-skinned patients. Cyanosis, for example, appears as a dark bluish tint to the skin and mucous membranes in light-skinned patients. However, in dark-skinned patients it is likely that the skin around the mouth may be gray or whitish (not bluish).
The epidermis is made of
nonvascular, stratified epithelium. There are two major layers.
Obtaining the patient and family history is important in any
nursing assessment. The information obtained during this part of the assessment is critical in analysis of new lesions or conditions and can help to facilitate appropriate nursing management. For neonatal pediatric patients, it is critical that the maternal history information is included to aid in the skin evaluation. Additionally, social history can provide insight regarding skin infections, infestations, and opportunities for prevention.
Each hair is composed of a
shaft and a root, which lie in a deep cavity of dermal cells called the hair follicle. There are several types of hair. Lanugo is the fine first hair that covers the body during fetal life and generally disappears before or shortly after birth. It is replaced by fine, nonpigmented, vellus hair. Terminal hair covers all the ordinarily hairy parts of the body; it is coarse, long, and pigmented.
Nurses caring for children are in a unique position to assess the condition of children's
skin and to help children and families cope with skin disorders. Nurses can play an important role in teaching parents and children strategies to maintain healthy skin and prevent future skin problems.
Parents typically inspect every inch of their newborn infant's skin and continue to attend closely to variations in the skin of older infants. Regardless of whether the parent mentions it, the nurse must be sure the family is aware of
spots, bumps, or rashes on the infant. Families frequently worry about skin lesions on infants, and the nurse can ease anxieties by pointing out and explaining the meaning and natural history of common skin variations. Common cultural misconceptions can be addressed as well, including myths regarding the origin and meaning of the lesions. Encouraging the parents to ask questions will help direct the information the nurse provides.
Stratum basale
the deep layer—anchors the epidermis to the dermis. It contains dividing, undifferentiated cells that migrate upward toward the stratum corneum, differentiating into keratinocytes on their way. Epidermal replacement is relatively rapid; the epidermis is completely replaced about every four weeks. The stratum basale also contains melanocytes—the source of melanin, the pigment that gives skin its color.
The skin (cutaneous membrane) is composed of two principal layers
the outer epidermis and the inner supportive dermis. Beneath these layers is the subcutaneous layer, which is composed largely of adipose tissue.
Stratum corneum
the outermost layer—is a tough, horny collection of dead keratinized cells that have migrated up from the underlying layers. Keratin, a fibrous protein, is also the principal component of nails and hair and acts as a mechanism for protecting and waterproofing the skin. Skin cells are constantly being shed and replaced with new cells from the layers below.
The dermis, composed of
tough connective tissue, contains lymphatics and nerves. The highly vascular dermis nourishes the epidermis. The subcutaneous layer (not actually part of the integument) is composed of fat cells, underlying the dermis. Adipose tissue helps cushion and insulate underlying structures
