Jordin is a client with jaundice who is experiencing pruritus. Which nursing intervention would be included in the care plan for the client?
A. Administering vitamin K subcutaneously
B. Applying pressure when giving I.M. injections
C. Decreasing the client's dietary protein intake
D. Keeping the client's fingernails short and smooth
Correct Answer: D. Keeping the client’s fingernails short and smooth
The client with pruritus experiences itching, which may lead to skin breakdown and possibly infection from scratching. Keeping his fingernails short and smooth helps prevent skin breakdown and infection from scratching. Encourage the patient to adopt skin care routines to decrease skin irritation. One of the first steps in the management of pruritus is promoting healthy skin and healing of skin lesions.
Option A: Administering vitamin K subcutaneously is important if the client develops bleeding problems. Instruct the client to bathe or shower using lukewarm water and mild soap or nonsoap cleansers. Long bathing or showering in hot water causes drying of the skin and can aggravate itching through vasodilation.
Option B: Applying pressure when giving I.M. injections is important if the client develops bleeding problems. Instruct the client to allow the skin to air dry or gently pat the skin dry after bathing. Avoid rubbing or brisk drying. Rubbing the skin with a towel can irritate the skin and exacerbate the itch-scratch cycle.
Option C: Decreasing the client’s dietary intake is appropriate if the client’s ammonia levels are increased. The patient who scratches the skin to relieve intense itching may cause open skin lesions with an increased risk for infection. Characteristic patterns associated with scratching include reddened papules that run together and become confluent, widespread erythema, and scaling or lichenification.
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