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    Skin Integrity

    Uploaded by

    Jonica Campos
    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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    Skin Integrity

    Uploaded by

    Jonica Campos
    2K views2 pages
    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.

    Original Description:

    nursing care plan

    Original Title

    skin integrity

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    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.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    2K views2 pages

    Skin Integrity

    Uploaded by

    Jonica Campos
    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.

    Copyright:

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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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