Integumentary System: Quick Bedside Refresher

Skin Structures – What Matters Clinically

Heather Murphy: Hi everyone, this is Heather Murphy, and welcome back to the NSG3046 Adult Medical Surgical 2 podcast. Today we’re gonna do a quick, really practical bedside refresher on the integumentary system. This is the stuff you actually use in clinical, not just on an exam. We’re going to keep it simple and focused on three things: first, the layers and structures of the skin and why they matter at the bedside; second, how aging changes the skin and increases risk; and third, how to do a focused skin assessment and what basic diagnostics you’re likely to see. So if you’re listening on your way to clinical, this episode is for you. Let’s jump into the skin layers first.

Heather Murphy: I want you to picture the skin in three main layers, from top to bottom: epidermis, dermis, and subcutaneous tissue. The epidermis is the outermost layer. It doesn’t have blood vessels or lymphatics. It’s made mostly of keratinocytes, which produce keratin and form that protective barrier, and melanocytes, which make melanin for pigment and UV protection. Why do you care at the bedside? When the epidermis is damaged—think abrasions, blisters, superficial burns—your barrier is compromised. That means higher risk for infection and increased fluid loss through the surface. So when you see missing or damaged epidermis, your brain should go: infection risk and fluid balance.

Heather Murphy: Under that is the dermis, a thicker connective tissue layer with blood vessels, nerves, hair follicles, sebaceous glands, and sweat glands. It’s rich in collagen, which gives strength and elasticity. Clinically, the dermis is a big player in wound healing and scarring. Pressure injuries that extend into the dermis are automatically more serious. You’ve got more bleeding potential, more pain because of the nerves, and slower healing. So when you’re staging wounds or describing depth, you’re basically describing how far into the dermis or beyond that injury goes.

Heather Murphy: The deepest layer is the subcutaneous tissue. That’s fat and loose connective tissue. It provides insulation, energy storage, and padding over bony prominences. We also use it for subcutaneous injections. When this layer is thin or missing—like in very thin patients or many older adults—there’s less cushioning. That means bones are closer to the surface and the risk for pressure injuries goes way up. So when you’re turning a frail patient and you’re seeing prominent elbows, heels, sacrum, I want you thinking: “They don’t have much subcutaneous tissue here; I need extra protection here.”

Heather Murphy: Now let’s talk quickly about skin appendages: hair, nails, and glands. Hair and nails are specialized keratin. Changes here can be early clues to systemic issues. For example, brittle nails, ridges, or thickened toenails can be related to aging, trauma, or sometimes circulation or nutritional problems. Hair loss patterns or very dry, coarse hair might prompt you to think about endocrine issues or chronic illness. You’re not diagnosing, but you are noticing and reporting.

Heather Murphy: Sebaceous glands secrete sebum into hair follicles, helping prevent excessive dryness. When they’re overactive or blocked, you can see acne or folliculitis. Apocrine glands are in the axillae, breast, and genital areas. They secrete a thicker fluid that bacteria act on, which gives body odor. So if a patient has changes in odor or increased moisture there, you’re thinking hygiene, possible infection, or skin breakdown risk in those folds. Eccrine glands are almost everywhere and help with cooling, waste excretion, and skin moisture. If a patient is diaphoretic, that tells you about their temperature regulation and maybe pain or anxiety, not just “they’re sweaty.”

Heather Murphy: Big picture, the integumentary system has a few core jobs: protection, temperature regulation, vitamin D synthesis, and sensation. At the bedside, protection means you’re always asking, “Is this barrier intact?” Any break—IV sites, wounds, rashes, tape damage—raises infection risk. Temperature regulation shows up in how you interpret warm vs cool skin, sweating vs dry skin, and whether the patient can maintain their temperature. Vitamin D synthesis depends on skin and sun exposure, and while you’re not measuring that in the room, it’s part of why long‑term indoor patients or older adults are at risk for deficiency. Sensation—pain, touch, temperature, pressure—is why you care about numbness, tingling, or reduced sensation in feet and hands, especially in patients at risk for pressure injuries. So every time you assess skin, I want you to think: How well is this patient’s skin doing these four jobs right now?

Aging Skin and Clinical Risk

Heather Murphy: Let’s shift into aging skin, because a lot of your patients in med‑surg are going to be older adults. If you understand what “normal aging” does to the skin, the risks you see on the unit will make a lot more sense. With aging, a few big changes happen. First, we lose dermal volume and collagen. The dermis gets thinner, less elastic, and more fragile. That’s what gives us wrinkling, but from a nursing standpoint it means the skin tears more easily and heals more slowly.

Heather Murphy: Second, there’s a decrease in subcutaneous fat. So that nice cushy padding over the heels, hips, and sacrum? It’s reduced. That makes older adults much more vulnerable to pressure injuries, even from short periods of unrelieved pressure. You can have a patient who “looks fine” at 8 a.m. and by 4 p.m. they’ve got non‑blanchable redness on the sacrum if they haven’t been turned and their nutrition or perfusion isn’t great.

Heather Murphy: Hair changes too. Fewer melanocytes in the hair follicles lead to gray or white hair. You may also see thinning hair on the scalp and body. Nails can become thin and brittle, or sometimes thick and hard to cut, especially toenails. They might be yellowed, split, or ridged. Some of this is just aging, but it also makes basic care—like trimming nails or keeping feet clean—more challenging. And remember, thick, misshapen toenails and poor foot care can turn into mobility issues and infection risk.

Heather Murphy: All these changes add up to higher risk. Fragile skin plus less padding equals more pressure injuries, more skin tears, and more damage from tape, friction, and shear. Even something as simple as removing a dressing can cause a skin tear if you’re not careful. Long‑term sun exposure over the years also means older adults are at increased risk for basal cell and squamous cell skin cancers. So any non‑healing lesion, any spot that bleeds easily, or something that changes in shape, color, or size needs to be taken seriously.

Heather Murphy: So what are your nursing priorities with aging skin? Prevention, prevention, prevention. First, pressure injury prevention. That means regular repositioning—usually every two hours if the patient can’t move independently—using pillows or wedges, and making sure heels are offloaded. Support surfaces matter: specialty mattresses, cushions, heel protectors. If you see a bony prominence with redness, don’t just document it and move on. Ask yourself, “What can I change right now?”

Heather Murphy: Next priority is protecting fragile skin from adhesives, friction, and shear. Use skin prep or barrier film under tapes when you can. Consider paper tape or non‑adhesive dressings. Be gentle when you’re sliding the patient up in bed—lift rather than drag whenever possible, and use draw sheets. This is one of those things where your technique can literally prevent a skin tear.

Heather Murphy: Moisture and incontinence management are also huge. Constant moisture from sweat, urine, or stool breaks down skin quickly, especially in the perineal area and skin folds. Use moisture barriers, keep linens dry, change incontinence products promptly, and avoid harsh soaps that strip oils. For patients with incontinence, a scheduled toileting program and appropriate products make a big difference.

Heather Murphy: Finally, you want to be really vigilant about surveillance for suspicious or non‑healing lesions. During your bath or assessment, take a few extra seconds to look at the scalp, back, and behind the ears—areas patients often don’t see. If a lesion looks different from the others, is growing, is irregular, or just doesn’t heal, document clearly and report it. You’re often the first line of defense in catching potential skin cancers or chronic wounds early. So when you see an older adult, your mindset should be: “Their skin is higher risk. What can I do this shift to protect it?”

Focused Assessment and Basic Diagnostics

Heather Murphy: Now let’s pull it all together with a focused integumentary assessment and some basic diagnostics you’ll see in clinical. I like to start with a quick, targeted history before I even put hands on the patient. A few key questions go a long way. Ask about UV and radiation exposure: “Do you spend much time in the sun or use tanning beds? Have you ever had radiation treatments?” That gives you context for skin cancer risk and chronic damage.

Heather Murphy: Next, medications. Some drugs cause photosensitivity or rashes. Even if you don’t remember the whole list yet, if a patient says, “I started this new med and then got this rash,” that’s a red flag to share with the provider. Ask about hygiene and self‑care: what kinds of soaps or lotions they use, any home remedies. Then ask specifically about pruritus—itching. Persistent itching can be related to dry skin, but also to fluid issues or systemic disease, so don’t brush it off as just “annoying.”

Heather Murphy: You also want a quick family history of skin disease or cancers, and any body image concerns related to skin conditions. That might sound small, but rashes, scars, or hair loss can really affect how people feel about themselves. And with obese patients, remember to ask about chafing or rash in skin folds—under breasts, in the axillae, and groin. Those areas are prime spots for yeast and bacterial infections.

Heather Murphy: Then you move into your physical exam. I always start with inspection: overall color and pigmentation, looking for erythema, pallor, or any unusual discoloration. Note vascularity and bruising. Tattoos and piercings should be documented too, but also checked—those can hide infections or skin changes. Look carefully at any lesions. Describe them specifically: size, color, shape, border, location, and whether they’re raised or flat.

Heather Murphy: On palpation, you’re checking temperature with the back of your hand—warm, cool, or any localized differences. Assess turgor and mobility, but remember age; older adults normally have less elastic skin, especially over the hands, so you may check over the sternum or clavicle instead. Note moisture—dry, oily, or diaphoretic—and texture: smooth, rough, thickened, or thin. All of that feeds into your picture of hydration, circulation, and overall health.

Heather Murphy: It also helps to know the difference between primary and secondary lesions. Primary lesions appear on previously normal skin—things like macules, papules, vesicles, plaques, wheals, and pustules. Secondary lesions result from a primary lesion or from injury—fissures, scales, scars, ulcers, excoriations, atrophy. A nevus, or mole, is usually a benign collection of melanocytes, but changes in color, border, or size are concerning. A keloid is an overgrowth of collagen at a site of skin injury—you’ll see those more in some populations.

Heather Murphy: For patients with darker skin tones, you have to adapt your assessment a bit. Color changes like erythema or cyanosis can be subtle. Assessment is often easier in less pigmented, thinner areas: lips, oral mucosa, nail beds, and the conjunctiva. Palms and soles are usually lighter and can show rashes more clearly. Don’t just rely on what you see; use palpation. Feel for warmth, induration, or texture changes. For cyanosis, look at mucous membranes and nail beds, but also pay attention to the patient’s overall condition and their pulse ox reading.

Heather Murphy: To wrap up, remember these three big takeaways: know your layers and appendages so what you see makes sense; recognize how aging skin increases vulnerability; and use a focused history plus a systematic assessment to catch problems early, especially in patients with darker skin tones where changes can be harder to spot. On your next shift or clinical day, I want you to pick one patient and deliberately do a full skin, hair, and nail assessment. Document it using precise terms for lesions and describe at least one area of risk and what you did to address it. That’s how you build your assessment muscle. I’m Heather Murphy. Thanks for spending a few minutes with me, and I’ll talk with you next time in NSG3046 Adult Medical Surgical 2.