Art & science
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The synthesis of art and science is lived by the nurse in the nursing act
The integumentary system: anatomy,
physiology and function of skin
McLafferty E et al (2012) The integumentary system: anatomy, physiology and function of skin.
Nursing Standard. 27, 3, 35-42. Date of acceptance: April 13 2010.
Abstract
This article, which forms part of the life sciences series, examines
the anatomy and physiology of skin, also termed the integumentary
system. Skin is composed of two main layers, the epidermis and
dermis. The structure of the epidermis and dermis are described
and their functions are discussed. Accessory structures, such as
nails and hair are also considered. Although many diseases of the
skin exist, two common conditions psoriasis and decubitus ulcers
are described in this article.
Authors
Ella McLafferty
Retired, was senior lecturer, School of Nursing and Midwifery,
University of Dundee.
Charles Hendry
Retired, was senior lecturer, School of Nursing and Midwifery,
University of Dundee.
Alistair Farley
Lecturer in nursing, School of Nursing and Midwifery,
University of Dundee.
Correspondence to: a.h.farley@dundee.ac.uk
Keywords
Anatomy and physiology, body systems, integumentary system,
skin and skin disorders
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NURSING STANDARD / RCN PUBLISHING september 19 :: vol 27 no 3 :: 2012 35
If you would like to contribute to the Art & science
Josephine G Paterson
THE SKIN IS a complex arrangement of
structures with a range of different, but important,
functions. The skin is composed of two main
layers, the epidermis and dermis (Waugh and
Grant 2010, Tortora and Derrickson 2009a).
The subcutaneous layer is found beneath the
dermis and is not considered part of the skin
(Tortora and Derrickson 2009a).
Nurses need to be knowledgeable about what
is considered to be healthy skin (Pringle and Penzer
2002). This is important, as the condition of the
skin may often be a sign of underlying disease
(Casey 2002). Changes in the skin may be one
of the first indicators of an underlying health
problem. Many nurses will be familiar with
cyanosis where, because of poor delivery of oxygen
to the tissues, the patients skin appears blue.
Structure of the skin
The skin is the largest organ in the body,
accounting for approximately 16% of the total
body weight of an adult (Tortora and Derrickson
2009a). The skin weighs twice as much as the
brain, approximately 3-5kg (Turkington and
Dover 2007). Skin varies in thickness according
to function and area of the body. On the eyelids,
the skin is only 0.5mm thick, whereas it can be
as much as 3-4mm thick on the soles of the feet
(Brooker 1998). Skin is generally 1-2mm thick
(Tortora and Derrickson 2009a).
The skin consists of thick outer layers, a
widespread system of sweat glands sensitive
to temperature changes and an extensive layer
of fatty tissue under the surface of the skin. The
skin also contains many cells that are sensitive
to touch, pain, pressure, itching and temperature
(Turkington and Dover 2007).
Art & science life sciences: 6
Epidermis
The epidermis is composed of stratified
keratinised squamous epithelium (Tortora
and Derrickson 2009a) and is made up of
many layers near the surface of the skin
(Turkington and Dover 2007). The epidermis
contains four main types of cells, most of which
are keratinocytes, which make up 90% of the
cells found in this layer. Melanocytes make up
8% of epidermal cells and are responsible for
producing the pigment, melanin. Langerhans
cells and Merkel cells are also found within
the epidermis. Langerhans cells are involved
in the immune response and Merkel cells
function in the sensation of touch (Tortora
and Derrickson 2009a). The epidermis is
avascular (without blood vessels) and is
dependent on blood vessels of the dermis for
oxygenation, metabolite provision and removal
of metabolic waste products.
The epidermis is made up of a number
of layers, including (Figure 1):
Stratum
 basale, the deepest layer (also
called the stratum germinativum).
Stratum
 spinosum or prickle cell layer.
Stratum
 granulosum or granular layer.
Stratum
 lucidum (finger tips, palms
and soles).
Stratum
 corneum, which is the top layer.
These layers represent the different stages
of maturation of the cells and their movement
from the stratum basale up to the stratum
corneum, where they are shed. The epidermis
renews itself through cell division in its deepest
layer (Burr and Penzer 2005).
FIGURE 1
The skin showing the layers of the epidermis and main structures of the dermis
Hair shaft Opening
of sweat
ducts
Stratum
corneum
Epidermis
Germinative
layer
Sebaceous
gland
Dermis
Sweat gland
Hair follicle
Hair root
Subcutaneous
tissue
36 september 19 :: vol 27 no 3 :: 2012 NURSING STANDARD / RCN PUBLISHING
Stratum basale
The stratum basale is made up of a single row
of columnar keratinocytes. Other types of cells
found within this layer include melanocytes
and Merkel cells (Tortora and Derrickson 2009a).
The stratum basale is the only layer within
the epidermis that consists of cells capable of
division. Keratinocytes in the stratum basale
undergo mitosis and two daughter cells are
produced; one remains in the stratum basale,
while the other migrates up through the other
layers to the surface of the epidermis. This
process takes approximately 28 days in an
average epidermis of 0.1mm thickness (Tortora
and Derrickson 2009a).
The stratum basale is the nearest layer to the
dermis and is located under the epidermis. The
dermis contains a blood supply and provides
nourishment to the stratum basale. However,
as the daughter cells move further away from
the stratum basale, they receive less nutrition. As
a result the cells die. In addition, the cells become
more keratinised they accumulate more keratin,
which is a fibrous protein involved in protecting
the skin from heat, chemicals and microorganisms.
In healthy skin, a balance between the formation
of new keratinocytes in the stratum basale and the
shedding of dead keratinocytes from the stratum
corneum is maintained.
The stratum basale also contains melanocytes,
which produce melanin. Melanocytes account
for one in every six cells in the stratum basale
(Turkington and Dover 2007). Melanin is a
pigment that protects the skin from the harmful
effects of ultraviolet (UV) light. Melanocytes have
Stratum
corneum
Stratum
lucidum
Stratum
granulosum Epidermis
Germinative
layer
Dermis
PETER LAMB
long, slender projections that contain melanin
granules. The projections extend between the
keratinocytes and transfer the granules to them.
Once inside the keratinocytes, the granules gather
to form a protective covering around the nucleus,
protecting the keratinocytes from damage caused
by UV light.
The colour of the skin is genetically determined
and environmentally modified by UV light
exposure. Skin colour is related to the amount
of melanin in epidermal cells. The more melanin
produced, the darker the skin. Nurses should
be able to advise patients of the importance
of avoiding too much UV light, whether from
natural sunlight or sunbeds. They should also
inform patients of the need to cover their skin
when outdoors and to use appropriate UV filter
creams, commonly known as sun blocks. Tortora
and Derrickson (2009a) recommended a sun
protection factor of no less than 15 to protect
against UV light.
Merkel cells are also found in the stratum
basale scattered among the keratinocytes. Merkel
cells make contact with the flattened process of
a sensory neuron called a Merkel disc. Merkel
cells and their discs detect the sensation of touch.
Stratum spinosum
As the daughter cells of the keratinocytes move
into the next layer, the stratum spinosum, they
lose their ability to divide. They also become
rounder and spikier in shape (hence this layers thickened plasma membranes. The stratum
name). The stratum spinosum is five to 12 cells
thick. While in this layer, the single daughter
cells join together via intracellular bridges called
desmosomes. As the cells move through this layer,
the daughter cells continuously break and reform
desmosomes. These intracellular bridges have
thorn-like projections that draw adjacent cells
close together (Thibodeau and Patton 2007).
This arrangement contributes to the tensile
strength and flexibility of the skin.
Langerhans cells, developed from specialised
dendritic cells of the immune system, are found
in the stratum spinosum. They are also found in
the dermis, lymph nodes and thymus (Turkington
and Dover 2007). These cells are produced in the
red bone marrow and then migrate to the stratum
spinosum, where they participate in immune
responses against microorganisms. They function
by attracting and phagocytosing microbes and
presenting their antigens to T lymphocytes,
thereby activating the lymphocytes to destroy
the appropriate cells (Pringle and Penzer 2002).
Langerhans cells are crucial in helping other
cells of the immune system to recognise invading
microorganisms and destroy them.
NURSING STANDARD / RCN PUBLISHING september 19 :: vol 27 no 3 :: 2012 37
Stratum granulosum
As the cells move through the epidermal layers
towards the surface of the skin they become
longer and flatten horizontally to form the
stratum granulosum. The stratum granulosum
is composed of three to five layers of flattened
keratinocytes. In this layer, the cells go through
a process known as apoptosis, which is an
orderly, genetically programmed cell death
during which the nucleus breaks up and
the cell dies. The cells are no longer able to
perform any metabolic functions (Tortora
and Derrickson 2009a).
By this stage, the cells lose their nucleus and
become keratinised and are comprised entirely
of a tough pliable protein called keratin (Pringle
and Penzer 2002). Keratohyalin is also present
in this layer. It consists of darkly staining
proteins that convert tonofilaments to keratin.
Odlands bodies may also be seen. These are
membrane-coating, lamellar granules that produce
lipid, which extrudes into the spaces between the
cells and helps them stick together.
Stratum lucidum
The stratum lucidum is only found in areas where
the skin is thick, such as the palms of the hands
and soles of the feet (Tortora and Derrickson
2009a). This layer contains three to five layers
of clear, dead keratinocytes that are flattened
and made up of large amounts of keratin and
lucidum lies between the stratum granulosum
and the stratum corneum and provides some
degree of waterproofing to the skin.
Stratum corneum
The stratum corneum is the uppermost layer.
It consists of 25-30 layers of flattened, dead
keratinocytes (Tortora and Derrickson 2009a).
The cells are arranged in orderly, vertical stacks
and appear to be composed of cell membranes that
are firmly attached to each other. The cells contain
the protein keratin, which helps protect the skin
and underlying tissues from heat, microorganisms
and chemicals. The intracellular lipid from the
lamellar granules in the stratum granulosum
cements the cells together and is vital in preventing
the cells from drying out.
As cells move through the stratum corneum
they lose their stickiness and are shed singly or
in clumps, known as squamae. Most people who
have ever seen or had a plaster cast removed will
recognise the accumulation of dead skin cells on
the surface of the skin. Dandruff and the majority
of house dust are dead, shed skin cells the
favoured food of house dust mites that trigger
Art & science life sciences: 6
asthma in susceptible individuals (Kumar and
Clark 2009).
Each of the layers represents a stage in the life
of an epidermal cell. Since the stratum corneum
is the final layer between the body and the external
environment, it is at risk of considerable wear and
tear. Cells are lost from this layer on a continous
basis. If a part of the skin is exposed to constant
friction a hard callus can form, which is an
abnormal thickening of the stratum corneum
(Tortora and Derrickson 2009a).
Dermis
The dermis lies below the epidermis and above
the subcutaneous layer, and is responsible for
providing nutrients and physical support to the
epidermis (Burr and Penzer 2005). The dermis
contains lymph vessels, nerve endings, hair follicles
and glands (Figure 1) (Pringle and Penzer 2002). It
is anchored to the epidermis by rete ridges, which
are furrows. These furrows stabilise and allow
the exchange of nutrients between the dermis and
epidermis (Turkington and Dover 2007). However,
the two layers may become separated as a result of
shearing forces or friction, allowing fluid to collect
between the epidermis and dermis, forming what
is commonly known as a blister.
The dermis is composed of two layers: the
reticular and papillary layers. The papillary layer
contains the nerves and capillaries that nourish the
epidermis, whereas the reticular layer is made up
of strong connective tissue containing collagen and
elastic fibres (Pringle and Penzer 2002).
Collagen and elastin
Collagen and elastin in the dermis are arranged in a
woven network of fibres that have significant tensile
strength, providing the dermis with the ability
to stretch and contract (Tortora and Derrickson
2009a). Collagen is a protein that contributes
to approximately 70% of the dry weight of the
dermis. When the skin is stretched the collagen
fibres prevent tearing as a result of their high tensile
strength (Pringle and Penzer 2002).
Elastin fibres are synthesised by fibroblasts.
These fibres are finer than collagen and are found,
interwoven, among the collagen bundles. Elastin
also has elastic properties that allow the skin to
return to its normal position after stretching. With
increasing age, there is a reduction in the number
of collagen fibres, which stiffen and break up. This
results in the collagen fibres losing their shape and
becoming tangled. Meanwhile, the elastic fibres
lose some of their elasticity, thicken into bundles
and fray. These changes result in the appearance
of wrinkled skin (Tortora and Derrickson 2009a).
38 september 19 :: vol 27 no 3 :: 2012 NURSING STANDARD / RCN PUBLISHING
Glands in the dermis
The skin contains three to four million sweat
glands. The function of these glands is to release
sweat into hair follicles or on to the skin surface
through pores. There are two types of sweat glands
eccrine glands and apocrine glands based on
their structure, location and type of secretion
(Tortora and Derrickson 2009a).
Eccrine glands Eccrine glands are simple, coiled
glands that are distributed in many areas
of the skin, but especially in the skin of the
forehead, palms of the hands and soles of the
feet. The eccrine glands produce sweat, which
is predominantly composed of water, but
includes sodium and chlorine ions, urea,
uric acid, ammonia, amino acids, glucose and
lactic acid. A total of 600ml of sweat is produced
daily. Sweat glands have an important role in
thermoregulation through evaporation (Tortora
and Derrickson 2009a).
Apocrine glands Apocrine glands are not active
during childhood, but are activated by sex
hormones during puberty (Pringle and Penzer
2002). The apocrine glands are also simple coiled
tubular glands and are mainly found in the
axillae, groin, areolae of the breasts and bearded
regions of the face in adult males (Tortora and
Derrickson 2009a). Unlike the eccrine glands,
the sweat produced by the apocrine glands is
slightly viscous and has a milky or yellowish
appearance. This sweat has no smell when it
leaves the gland. However, when it meets bacteria
on the surface of the skin, the bacteria metabolise
sweat components to produce a musky odour,
commonly described as body odour (Tortora and
Derrickson 2009a).
Sebaceous glands Sebaceous glands are simple,
branched acinar glands. An acinar gland is
a gland that has a sac-like secretory unit and
an obvious lumen. Most sebaceous glands, but
not all, are connected to hair follicles. They are
most commonly found on the face, neck and
back (Pringle and Penzer 2002). Sebaceous
glands secrete sebum, which is an oily substance
composed of a combination of triglycerides,
cholesterol, proteins and organic salts. Sebum
covers the surface of the hairs and protects them
from drying and becoming brittle. Sebum also
inhibits excessive evaporation of water from the
skin so that the skin remains soft and supple
(Tortora and Derrickson 2009a).
As well as acting as a lubricant, sebum also has
antifungal and antibacterial properties (Pringle
and Penzer 2002). Hormonal activity during
puberty may cause overactivity of sebaceous
glands leading to overproduction of sebum,
which can sometimes lead to the presence of open
comedones (blackheads) and closed comedones
(whiteheads).
Ceruminous glands Ceruminous glands, which
are found in the external ear, are modified sweat
glands. These glands produce a waxy lubricating
secretion, which combines with secretions from
the sebaceous glands to produce a yellowish
substance called cerumen. The function of
cerumen is to provide a sticky barrier, which
together with the hairs in the external auditory
canal inhibits the entrance of foreign bodies
and insects into the ear. Cerumen also prevents
bacteria and fungi from entering the cells
because of its waterproofing ability (Tortora and
Derrickson 2009a).
Blood vessels
There are two main networks of cutaneous
arteries. The deep plexus (a network of blood
vessels) is found where the dermis and the
subcutaneous fat layer join. This network supplies
the dermis and subcutaneous layers of tissue with
blood. Small tributaries run from this plexus,
supplying hair follicles, sweat glands and other
structures within the dermis. At the uppermost
level of the dermis, the superficial plexus branches
off and carries blood vessels to the epidermis and
dermis boundary (Pringle and Penzer 2002).
Hair
Each hair is made up of columns of dead,
keratinised epidermal cells connected together
with extracellular proteins. The shaft of hair is the
segment that projects above the surface of the skin.
The root of the hair is the segment of hair that lies
deep in the shaft and is anchored in the dermis or
subcutaneous layer.
The root of the hair is surrounded by a hair
follicle. This follicle is made up of an external
and internal root sheath, which together make
up the epithelial root sheath. The dermis that
encircles the hair follicle is called the dermal
root sheath. The base of each hair follicle and
the surrounding dermal root sheath is called
the bulb and has a similar shape to an onion.
The bulb contains the layer of cells called the
hair matrix. The hair matrix cells arise from
the stratum basale, which is the layer where cell
division occurs. Therefore the hair matrix cells
are responsible for the growth of existing hairs.
They also produce new hairs when old hairs are
shed (Tortora and Derrickson 2009a).
The growth cycle for each hair follicle has
three stages:
Growth.
 Thermoregulatory function
Regression.
 Receptors in the skin monitor temperature and
Resting.
 transmit impulses to central control mechanisms
NURSING STANDARD / RCN PUBLISHING september 19 :: vol 27 no 3 :: 2012 39
The cells of the hair matrix divide during the
growth stage. New cells are added at the base
of the hair so that existing cells are pushed up
through the shaft and the hair grows longer.
During this process the hair becomes keratinised
and dies. The hair stops dividing during the
regression stage and the hair follicle atrophies
and the hair no longer grows. Finally, the hair
follicle enters a resting stage. Scalp hair remains
in the growth stage for two to six years, while
the regression stage lasts for two to three
weeks and the resting stage lasts for about
three months. Normal hair loss in the adult
scalp is 70-100 hairs per day (Tortora and
Derrickson 2009a).
Nurses should note that, for most patients,
care of the hair is important. Nurses should assist
patients to wash and style their hair because
poor hair care causes oils from sebaceous glands
to collect on the hair and scalp, making the
hair look and feel greasy. Patients may find it
physically and psychologically distressing not
to have their hair washed.
The arrector pili muscle is connected to the
follicle and is responsible for the appearance of
goose bumps, which are experienced when in a
cold environment or when frightened or excited.
Nails
The finger and toe nails are made of sheets of
keratin and are tough. Their function is to protect
the ends of the digits and to allow the performance
of intricate movements. Nails grow from germinal
cells called the nail root. The tip of the finger, lying
beneath the distal end of the nail, is known as
the hyponychium, which is an area of thickened
epidermis that allows for greater protection of the
digit ends. Nail beds are usually pink in colour
because there is an extensive network of capillaries
beneath the nail (Pringle and Penzer 2002).
Functions of the skin
The skin has several important functions,
including sensation, thermoregulation, protection
and synthesis of vitamin D.
Sensory function
The skin is able to react to external stimuli
such as cold, heat, pain, touch and pressure.
It is supplied with approximately one million
nerve fibres, most of which end in the face and
extremities (hands and feet).
Art & science life sciences: 6
in the hypothalamus. The hypothalamus is
a region of the forebrain that co-ordinates the
autonomic nervous system, including the control
of body temperature, thirst, hunger and other
homeostatic systems.
Thermoregulatory mechanisms occurring
in the skin include insulation, sweating and
control of blood flow. The body is insulated by
subcutaneous adipose tissue, which is found
under the dermis. Eccrine glands are stimulated
to produce sweat when the core temperature
rises above 37C. Sweat, in turn, cools the
body through the process of evaporation
(McLafferty et al 2009).
The skin is also provided with an abundant
blood supply, which aids thermoregulation. The
bodys core temperature has to remain constant to
maintain homeostasis. When the core temperature
rises, the body cools itself by increasing blood flow
to the skin. Heat is removed from the body by the
process of radiation. Heat is also lost through the
skin by conduction and convection (Tortora and
Derrickson 2009a).
If the body is becoming too cold, heat loss
is reduced by the process of vasoconstriction,
which reduces the flow of warm blood to the
extremities from the bodys core (McLafferty
et al 2009). Thermoregulatory mechanisms
are immature in children and their large body
surface area increases the risk of hypothermia
(Hockenberry and Wilson 2011). As people age,
their thermoregulatory mechanisms become less
efficient, which makes it more difficult for older
people to detect and respond to temperature
variations (Farley et al 2011).
Protective function
The skin is a physical, protective barrier for the
internal organs. It prevents loss of fluids so that
the internal organs do not dry out. Acidic
secretions from the skin prevent colonisation by
harmful microorganisms (Pringle and Penzer
2002). The epidermis is efficient at holding water,
which helps to maintain the elasticity of the skin
and has a role in the bodys fluid and electrolyte
balance (Turkington and Dover 2007).
Vitamin D synthesis
Vitamin D is synthesised by the skin as a
consequence of the exposure of the skin to UV
light. Vitamin D is necessary for controlling
the amount of calcium and phosphorus that is
absorbed through the small intestine and mobilised
from the bone. A deficiency of vitamin D can lead
to rickets in children and osteomalacia in adults
(Tortora and Derrickson 2009b). Subcutaneous
adipose tissue acts as a fat reserve, which is useful
40 september 19 :: vol 27 no 3 :: 2012 NURSING STANDARD / RCN PUBLISHING
in thermoregulation and as an energy source
to meet the energy needs of the body.
Psychological function
The skin has an important role in psychological
wellbeing. The skin is highly visible and has high
cosmetic, aesthetic and cultural significance when
it functions normally (Pringle and Penzer 2002).
Skin disorders
There are several common disorders associated
with the skin. Only psoriasis and decubitus
ulcers are considered in this article, as both
conditions affect one or more layers of the skin,
and knowledge of physiology of the skin and its
functions are important to provide appropriate
nursing management.
Psoriasis
Psoriasis occurs as a result of increased turnover
of keratinocytes, so that cells take only three to
five days to move from the stratum basale to the
stratum corneum to be shed, a process that usually
takes 28 days. The exact cause of psoriasis has
not been identified, although there is a variety
of factors that can trigger and/or exacerbate the
condition (Alexander et al 2006).
Psoriasis commonly presents with plaques
on the elbows, knees and scalp. According to
Paige (2005), a plaque is a large flat-topped,
elevated, palpable lesion. Scalp scaling can
affect 50% of patients and can be very thick,
especially around the hairline, but it can cover
the whole scalp (Buxton and Morris-Jones 2009).
The nails show pits and also thickening with
separation of the nail from the nail bed. The
development of a particular type of psoriasis
called guttate psoriasis, where the plaques
are shaped as drops, is associated with a
history of a streptococcal throat infection
(Alexander et al 2006).
Pustular psoriasis commonly appears on the
hands and feet and features sterile pustules.
Erythrodermic psoriasis is a generalised form of
inflammatory psoriasis affecting all sites of the
body, including the face, hands, feet, nails, trunk
and extremities, and is a dermatological emergency.
Two of the functions of the skin are to
maintain thermoregulation and prevent
colonisation by harmful microorganisms.
Erythrodermic psoriasis can be life-threatening
if psoriasis affects a large skin surface area and
disrupts the two functions mentioned above.
Increased blood flow to the skin results in
heat and water loss, and dehydration and
hypothermia can cause death (Buxton and
Morris-Jones 2009). In addition, there is
a risk of overwhelming infection.
Treatments for psoriasis include:
Phototherapy,
 which can be administered
using UV light. UVB is a wavelength of UV
light that occurs in natural sunlight. It
penetrates the epidermis and is responsible
for causing sunburn. UVA also occurs in
natural sunlight and may be administered,
but it has to be preceded by the administration
of the drug psoralen two hours before exposure
to UVA. Psoralen increases the sensitivity of
the skin in preparation for the treatment.
UVA is the wavelength that will penetrate
through to the dermis and is responsible for
the ageing effects of sunlight. The therapeutic,
controlled administration of psoralen and
UVA slows down production of skin cells
(NHS Choices 2007).
Topical
 ointments, including emollients such
as emulsifying ointment added to baths, soap
substitutes, for example aqueous cream, and
coal tar ointments. Other topical therapies
include the use of dithranol (an aqueous cream),
vitamin D analogues topical applications that
reduce dermal proliferation (McCance and
Huether 2006) and scalp therapy, including
warmed olive oil to soften and remove psoriatic
scales on the scalp. Emollients soothe and
hydrate the skin and can be prescribed for all
dry or scaling disorders. They may also have an
anti-proliferative effect in psoriasis (British
National Formulary 2012). Coal-tar-based
ointments suppress cell proliferation (Buxton
and Morris-Jones 2009).
Systemic
 medication, including methotrexate.
Vitamin A derivatives are used to slow the
epidermal turnover of cells and retinoids,
which reduce scaling of the skin and the
thickness of plaques associated with psoriasis
(Alexander et al 2006).
Decubitus ulcers
Decubitus ulcers are also known as pressure
ulcers (Waugh and Grant 2010). They are caused
by shearing forces and prolonged or repeated
pressure over skin, soft tissue, muscle and/or
bone, occluding the capillaries within the
compressed tissue and causing ischaemia
(Alexander et al 2006). Ischaemia causes
hypoxia and malnourishment in the compressed
soft tissues and a build-up of toxic metabolites
locally, increasing the rate of cell death. These
processes lead to necrosis of the skin and
underlying tissue and the formation of pressure
ulcers. Pressure ulcers commonly develop over
bony prominences, although they can develop
NURSING STANDARD / RCN PUBLISHING september 19 :: vol 27 no 3 :: 2012 41
on any area of the body where there is prolonged
pressure (Bansal et al 2005).
Decubitus ulcers are classified according to the
depth of visible tissue damage. Therefore, the use
of any classification for such ulcers needs to be
interpreted with caution, as further damage may be
occurring at a deeper level, which is not necessarily
visible at the time of assessment. The National
Pressure Ulcer Advisory Panel and European
Pressure Ulcer Advisory Panel (2009) pressure
ulcer classification system is shown in Box 1.
Conclusion
In this article, the structure and functions of
the skin have been examined and the layers of
the skin and its accessory structures have been
described. The skin protects underlying tissue from
microbial invasion. It provides a barrier against
most chemicals and also protects the underlying
tissues from mechanical injury. It is involved in
BOX 1
International pressure ulcer classification system
Category/stage 1: non-blanchable redness of intact
skin usually over a bony prominence. Discolouration
of the skin, warmth, oedema, hardness or pain may
be present.
Category/stage 2: partial-thickness skin loss
or blister presenting as a shallow ulcer that may
include the epidermis and dermis with pigmentation
changes. It may present as an abrasion, blister or
superficial ulcer.
Category/stage 3: full-thickness skin loss.
Subcutaneous fat may be visible. Bone,
tendon or muscle are not exposed. Some slough
may be present.
Category/stage 4: full thickness tissue loss with
exposed bone, tendon or muscle. Slough or eschar
may be present. The depth of the pressure ulcer
depends on the anatomical location.
(Adapted from European Pressure Ulcer Advisory Panel and
National Pressure Ulcer Advisory Panel 2009)
POINTS FOR PRACTICE
Use your knowledge of the skin to identify the
changes that occur as a result of the ageing process.
Reflect on what advice you would give to the
mother of a young child in relation to sun exposure
and protection.
Consider the physical and psychological effects
on patients of using emollients every day to
manage psoriasis.
Consider the advantages and disadvantages of
using assessment tools in the prevention and early
detection of pressure ulcers.
Art & science life sciences: 6

thermoregulation through convection, conduction, wellbeing. Understanding the normal structure

radiation and evaporation. It also synthesises and function of the skin is a prerequisite to
vitamin D and functions as a sophisticated sense understanding and managing skin disorders
organ. Intact, healthy skin is essential for patient such as psoriasis and decubitus ulcers NS

GLOSSARY
Conduction
Heat lost to, or gained from, objects in direct
contact with the body.
Convection
When air makes contact with exposed parts of
the body it is warmed. It then rises away from
the body surface. Cooler air replaces the rising
air and convection currents are initiated.
Evaporation
The conversion of a liquid to a vapour, such as
when heat is used to convert water in sweat to
water vapour and in the process cools the body.
Hypodermis
Sometimes referred to as the subcutaneous tissue.
It is not part of the skin, but the skin rests on
this layer, which attaches it to underlying bone
and muscle.
Keratinocyte
This is the primary cell found in the epidermal layer.
Langerhans cells
These cells are found in the stratum spinosum and
function in the immune response.
Melanocyte
This is a pigment-producing cell found in the epidermal
layer.
Merkel cells
Merkel cells function in the sensation of touch.
Mitosis
A form of cell division where the parent cell replicates
to produce two daughter cells that are genetically
identical to the parent.
Radiation
The transfer of heat between a warmer object and
a cooler one without any direct contact.
Tonofilament
A tonofilament is a proteinaceous fibre found in
epithelial cells. Bundles of tonofilaments form
a tonofibril, which has a supporting function.

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42 september 19 :: vol 27 no 3 :: 2012 NURSING STANDARD / RCN PUBLISHING