NURSING DIAGNOSIS: Skin Integrity, risk for impaired
Risk factors may include
- Altered circulation/metabolic state
- Accumulation of bile salts in skin
- Poor skin turgor, skeletal prominence, presence of edema, ascites
- Maintain skin integrity.
- Identify individual risk factors and demonstrate behaviors/techniques to prevent skin breakdown.
Nursing Interventions & Rationale
|Inspect skin surfaces/pressure points routinely. Gently massagebony prominences or areas of continued stress. Use emollient lotions; limit use of soap for bathing.||Edematous tissues are more prone to breakdown and to the formation of decubitus. Ascites may stretch the skin to the point of tearing in severe cirrhosis.|
|Encourage/assist with repositioning on a regular schedule, while in bed/chair, and active/passive ROM exercises as appropriate.||Repositioning reduces pressure on edematous tissues to improve circulation. Exercises enhance circulation and improve/maintain joint mobility.|
|Recommend elevating lower extremities.||Enhances venous return and reduces edema formation in extremities.|
|Keep linens dry and free of winkles.||Moisture aggravates pruritus and increases risk of skin breakdown.|
|Suggest clipping fingernails short; provide mittens/gloves if indicated.||Prevents patient from inadvertently injuring the skin, especially while sleeping.|
|Encourage/provide perineal care following urination and bowel movement.||Prevents skin excoriation breakdown from bile salts.|
|Use alternating pressure mattress, egg-crate mattress, waterbed, sheepskins, as indicated.||Reduces dermal pressure, increases circulation, and diminishes risk of tissue ischemia/breakdown.|
|Apply calamine lotion, provide baking soda baths. Administer medications such as cholestyramine (Questran), hydroxyzine (Atarax), diphenhydramine (Benadryl), ifindicated.||May be soothing/provide relief of itching associated with jaundice, bile salts in skin.|