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Skin Integrity

The patient has elevated bilirubin levels which has caused crystals to deposit in their skin, leading to impaired skin integrity and lesions. They complain of constant itching that they cannot resist scratching. On examination, the patient's skin is yellowed and they have lesions on their right arm and left leg. Their bilirubin level is high and liver enzymes are elevated. The short-term goal is to decrease the patient's itching and prevent scratching, while the long-term goal is healing of the lesions. Nursing interventions include assessing for jaundice, monitoring liver tests, keeping the skin clean and moisturized, discouraging scratching, and keeping the room cool.

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Jonica Campos
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2K views

Skin Integrity

The patient has elevated bilirubin levels which has caused crystals to deposit in their skin, leading to impaired skin integrity and lesions. They complain of constant itching that they cannot resist scratching. On examination, the patient's skin is yellowed and they have lesions on their right arm and left leg. Their bilirubin level is high and liver enzymes are elevated. The short-term goal is to decrease the patient's itching and prevent scratching, while the long-term goal is healing of the lesions. Nursing interventions include assessing for jaundice, monitoring liver tests, keeping the skin clean and moisturized, discouraging scratching, and keeping the room cool.

Uploaded by

Jonica Campos
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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Assessment

Background Knowledge
Bilirubin is a chemical that is released into blood which results from breakdown of RBC. It is used by the liver to make bile.

Nursing Diagnosis
Impaired skin integrity related to disruption of skin surface (lesions) secondary to crystal deposit in skin

Planning

Intervention

Subjective: parati akong nangangati at hindi ko mapigilan kamutin, kapag kinamot ko may parang nararamdaman akong maliit na bato bato sa balat ko. Objective: -Patient frequently scratches skin - yellowing of the skin - elevsted live enzymes SGPT -110 units/ml Bilirubin 25 g -foul smelling odor of skin - lesions in right upper extremities & left lower extremities

Short term: After 8 hours of nursing interaction the patient will be able to: verbalize decrease itching or ability to tolerate itching without scratching Long term: Patients lesion will be healed.

-Assess for jaundice (yellow staining of skin by bilirubin). - monitor findings of liver function tests, especially bilirubin levels. -Assess itchiness & scratching -Emphasize importance of keeping skin clean & well moisturized. Used tepid water Avoid alkaline soaps Apply enrolment lotions -Discourage scratching; keep nails short. Suggest that the patient wear hand mitts if scratching cannot be discouraged by other means . -Keep room temperature cool.

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