Clinical meaning
The integumentary system is the largest organ of the body, comprising approximately 16% of total body weight and covering an average surface area of 1.5 to 2 square meters in adults. The skin consists of three primary layers: the epidermis (outermost layer), the dermis (middle layer), and the hypodermis or subcutaneous tissue (deepest layer). The epidermis is an avascular, stratified squamous epithelium that provides the primary barrier against infection, fluid loss, and environmental injury. Keratinocytes make up approximately 90% of epidermal cells and produce keratin, which waterproofs the skin. Melanocytes produce melanin, which protects against ultraviolet radiation damage. The Fitzpatrick Skin Type classification system categorizes skin into six types (I through VI) based on the skin's response to ultraviolet exposure, ranging from Type I (very fair, always burns, never tans) to Type VI (deeply pigmented, never burns). This classification is clinically important because it influences assessment techniques -- in darker skin tones, color changes such as erythema, cyanosis, and jaundice are assessed differently. Erythema in darker skin appears as increased warmth and a deeper brown or purple hue rather than redness. Cyanosis is best assessed in the oral mucosa, conjunctivae, and nail beds rather than the skin surface. The dermis contains blood vessels, nerve endings, hair follicles, sweat glands, sebaceous glands, and collagen fibers that provide structural support and elasticity. With aging, dermal collagen decreases by approximately 1% per year, leading to thinning, wrinkling, and increased fragility. The Braden Scale is the most widely used validated tool for predicting pressure injury risk in clinical settings. It evaluates six subscales: sensory perception (ability to respond to pressure-related discomfort), moisture (degree of skin exposure to moisture), activity (degree of physical activity), mobility (ability to change and control body position), nutrition (usual food intake pattern), and friction/shear (assistance required for movement). Scores range from 6 (highest risk) to 23 (lowest risk), with scores of 18 or below generally indicating risk for pressure injury development.