A client diagnosed with chronic cirrhosis who has ascites and pitting peripheral edema also has hepatic encephalopathy. Which of the following nursing interventions are appropriate to prevent skin breakdown? Select all that apply.
A. Range of motion every 4 hours
B. Turn and reposition every 2 hours
C. Abdominal and foot massages every 2 hours
D. Alternating air pressure mattress
E. Sit in chair for 30 minutes each shift
Correct Answers: B & D
Edematous tissue must receive meticulous care to prevent tissue breakdown. An air pressure mattress, careful repositioning can prevent skin breakdown. Inspect pressure points and skin surfaces closely and routinely. Gently massage bony prominences or areas of continued stress. Use of emollient lotions and limiting use of soap for bathing may help.
Option A: Range of motion exercises preserve joint function but do not prevent skin breakdown. Encourage and assist the patient with reposition on a regular schedule. Assist with active and passive ROM exercises as appropriate.
Option B: Repositioning reduces pressure on edematous tissues to improve circulation. Exercises enhance circulation and improve and/or maintain joint mobility. Edematous tissues are more prone to breakdown and to the formation of decubitus. Ascites may stretch the skin to the point of tearing in severe cirrhosis.
Option C: Abdominal or foot massage will not prevent skin breakdown but must be cleaned carefully to prevent breaks in skin integrity. Keep linens dry and free of wrinkles. Moisture aggravates pruritus and increases the risk of skin breakdown.
Option D: Use an alternating pressure mattress, egg-crate mattress, waterbed, sheepskins, as indicated. Reduces dermal pressure, increases circulation, and diminishes the risk of tissue ischemia.
Option E: The feet should be kept at the level of the heart or higher so Fowler’s position should not be employed. Recommend elevating lower extremities. Enhances venous return and reduces edema formation in extremities.
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