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The integumentary system is the largest organ in the body and is important to our survival in many ways. The skin is an organ which acts as a barrier between the internal system and the external environment as well as plays a role in temperature regulation.

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Capillary refill

Press down on one of the patient’s nails until it pales. Release the nail and observe for the pink color to return. The normal color should return in less than 3 seconds.

Note: Capillary refill can be affected by room and body temperature, vasoconstriction from smoking, or peripheral edema.


Normal concave nail bases will create a small, diamond-shaped space when the nails of the index fingers of each hand are placed together. Clubbed fingers are convex at the bases and will touch without leaving a space.

Note: Finger clubbing, a sign of chronic tissue hypoxia, occurs when the angle between the fingernail and where the nail enters the skin increases.


Dark bluish or purplish discoloration of the integument and mucous membranes.

Note: May indicate hypoxia or hematologic pathology.


Increased temperature.

Note: May indicate localized or systemic infection, inflammation, thermal injury; hyperthyroidism or fever is generalized.


Decreased temperature.

Note: May indicate arterial insufficiency or shock.


Yellowish discoloration of skin and sclera.

Note: May indicate liver disease or hemolytic pathology.

Tzanck smear Scraping of an ulcer base to look for Tzanck cells (acantholytic cells). It is sometimes also called the chickenpox skin test or the herpes skin test.
Dermatitis Inflammation of the skin.
Total body surface area Used to estimate the total fluid and caloric requirements and is a predictor of mortality.
Hypertrophic scar A raised scar that stays within the burn wound’s boundaries; characteristically red, raised, firm.
Keloid scar A raised scar extends beyond the original burn wound; red, raised, firm.
Pruritus Itching.


Also known as drainage, exudate is a liquid produced by the body in response to tissue damage.

Primary intention

Wound edges are approximated with sutures, staples, or adhesives. Minimal scarring and heal quickly (blisters and abrasions may fall into this quick healing).

Secondary intention

The wound closes on its own with a layer of granulation tissue filling in lost tissue space followed by wound contraction and scar tissue formation resulting in larger scars.

Tertiary intention

A delayed primary intention for cases in which a wound has been left open or the event of dehiscence (opening of the wound).

The integumentary system has two major components: the cutaneous membrane (skin), which is divided into three layers: the epidermis, the dermis, and subcutaneous tissue, and the accessory structures, which include the hair, nails, vascular supply, sweat glands, and sebaceous glands (Figure 6-1). The skin serves as a protective barrier, has immunologic functions for first-line defenses, and is involved in melanin production, vitamin D synthesis, sensation, temperature regulation, protection ...

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