Impaired Skin Integrity — Liver Cirrhosis

NURSING DIAGNOSIS: Skin Integrity, risk for impaired

Image: http://nurseslabs.com

Risk factors may include

• Altered circulation/metabolic state
• Accumulation of bile salts in skin
• Poor skin turgor, skeletal prominence, presence of edema, ascites

Desired Outcomes

• Maintain skin integrity.
• Identify individual risk factors and demonstrate behaviors/techniques to prevent skin breakdown.

Nursing Interventions & Rationale

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.

 Source: http://ncplist.blogspot.com/2012/05/impaired-skin-integrity-liver-cirrhosis.html