• Nursing Diagnosis: Risk for impaired skin integrity related to an alteration in metabolism as evidenced by patients complaints of itchiness.
Risk factors of chemical substance- accumulation of bile salts in the skin and changes in skin turgor evidenced by the 4+ pitting edema.
Goal: Patient will maintain skin integrity
Outcome: Patient will remain free of skin breakdown throughout the shift.
Interventions:
• Explain the side effects that the continued scratching could cause. Provide ways to minimize itching (applying lotion and avoiding harsh soaps) especially during the times when it is most prominent. Rationale: Pruritus affects about two-thirds of client's with primary biliary cirrhosis. The itching often worsens during the evening
Risk factors of chemical substance- accumulation of bile salts in the skin and changes in skin turgor evidenced by the 4+ pitting edema.
Goal: Patient will maintain skin integrity
Outcome: Patient will remain free of skin breakdown throughout the shift.
Interventions:
• Explain the side effects that the continued scratching could cause. Provide ways to minimize itching (applying lotion and avoiding harsh soaps) especially during the times when it is most prominent. Rationale: Pruritus affects about two-thirds of client's with primary biliary cirrhosis. The itching often worsens during the evening