Risk for Impaired Skin/Tissue Integrity | Nursing Care Plan Liver Cirrhosis

Nursing diagnosis: risk for impaired Skin Integrity

Risk factors may include
Altered circulation and metabolic state
Accumulation of bile salts in skin
Poor skin turgor, skeletal prominence, presence of edema, ascites

Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)

Desired Outcomes/Evaluation Criteria—Client Will
Risk Control
Maintain skin integrity.
Identify individual risk factors and demonstrate behaviors or techniques to prevent skin breakdown.

Nursing intervention with rationale:
1. Discuss itching with client, addressing areas involved and time of day when client is most uncomfortable.
Rationale: Pruritus affects about two-thirds of clients with primary biliary cirrhosis; the cause is unknown. The itching often worsens during the evening and improves during the day. It typically begins in the palms and soles, and then spreads to the rest of the body. Prolonged, repeated scratching can result in excoriations and thickening and darkening of the skin (Heathcote, 2000).

2. Inspect skin surfaces and pressure points routinely. Gently massage bony prominences or areas of continued stress. Use emollient lotions and limit use of soap for bathing.
Rationale: Edematous tissues are more prone to breakdown and to the formation of decubitus ulcers. Ascites may stretch the skin to the point of tearing in severe cirrhosis.

3. Encourage and assist with repositioning on a regular schedule, while in bed or chair, and active or passive range-of-motion (ROM) exercises, as appropriate.
Rationale: Repositioning reduces pressure on edematous tissues to improve circulation. Exercises enhance circulation and improve or maintain joint mobility.

4. Recommend elevating lower extremities.
Rationale: Enhances venous return and reduces edema formation in extremities.

5. Keep linens dry and free of wrinkles.
Rationale: Moisture aggravates pruritus and increases risk of skin breakdown.

6. Suggest clipping fingernails short and provide mittens or gloves, if indicated.
Rationale: Prevents client from inadvertently injuring the skin, especially while sleeping.

7. Encourage, or provide, perineal care following urination and bowel movement.
Rationale: Prevents skin excoriation breakdown from bile salts.

8. Use alternating pressure mattress, egg-crate or foam mattress, waterbed, or sheepskins, as indicated.
Rationale: Reduces dermal pressure, increases circulation, and diminishes risk of tissue ischemia and breakdown.

9. Apply calamine lotion and provide baking soda baths.
Rationale: May be soothing and provide relief of itching.

10. Administer medications, such as cholestyramine (Questran), colestipol (Colestid), hydroxyzine (Atarax), and dronabinol (Marinol), if indicated.
Rationale: Although the cause of pruritus is unknown, it may be associated with jaundice or bile salts in skin and may respond to these treatments.