Nursing diagnosis: risk for impaired Skin/Tissue Integrity
Risk factors may include
Chemical substance—bile salt accumulation in the tissues
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Tissue Integrity: Skin and Mucous Membranes
Display intact skin and tissues free of excoriation.
Report absence or decrease of pruritus and scratching.
NOC
Nursing intervention with rationale:
1. Encourage use of cool showers and baking soda or starch baths. Avoid use of alkaline soaps. Apply calamine lotion, as indicated.
Rationale: Prevents excessive dryness of skin. Provides relief from itching associated with accumulation of bile salts in jaundiced skin.
2. Provide diversional activities.
Rationale: Aids in refocusing attention and reducing tendency to scratch.
3. Suggest use of knuckles if desire to scratch is uncontrollable. Keep fingernails cut short and apply gloves on comatose client or during hours of sleep. Recommend wearing loosefitting clothing. Provide soft cotton linens.
Rationale: Aids in refocusing attention and reducing tendency to scratch. Reduces potential for dermal injury.
4. Provide a soothing massage at bedtime.
Rationale: May be helpful in promoting sleep by reducing skin irritation.
5. Observe skin for areas of redness and breakdown.
Rationale: Early detection of problem areas allows for additional intervention to prevent complications and promote healing.
6. Avoid comments regarding client’s appearance.
Rationale: Minimizes psychological stress associated with skin changes.
7. Administer medications, as indicated, for example: Antihistamines, such as diphenhydramine (Benadryl) and azatadine (Optimine).
Rationale: Relieves itching. Note: Use cautiously in severe hepatic disease.
8. Antilipemic, such as cholestyramine (Questran)
Rationale: May be used to bind bile acids in the intestine and prevent their absorption. Note side effects of nausea and constipation.
No comments:
Post a Comment