Asuhan Keperawatan Aplikasi NANDA, NOC, NIC: Nursing Diagnosis: Impaired Comfort

Nursing Diagnosis: Impaired Comfort—pruritis
Betty J. Ackley

NANDA Definition: State in which an individual experiences an uncomfortable sensation in response to a noxious stimulus (Carpenito, 1993)

Defining Characteristics: Verbalization or demonstration of discomfort, itching, reddened irritated skin

Related Factors: Chemical irritants, dry skin

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels

· Comfort Level

Client Outcomes

· States he or she is comfortable, itching relieved

· Explains methods to decrease itching

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels

· Pruritis Management

Nursing Interventions and Rationales

· Determine cause of pruritus (e.g., dry skin, contact with irritating substance, medication side effect, insect bite, infection, symptom of systemic disease). The etiology of pruritus helps direct treatment. Pruritus may be caused by serious illnesses such as renal failure, liver failure, malignancy, or diabetes (Eaglestein, McKay, Pariser, 1994), as well as by dry skin and various skin conditions.

· Apply soaks with washcloths wrung out in cool water or ice water as needed. The application of cool or cold washcloths can depress the itching sensation.

· Keep client's fingernails short; have client wear mitts if necessary. Scratching with fingernails can excoriate the area and increase skin damage.

· Leave pruritic area open to the air if possible. Covering the area with a nonventilated dressing can increase itching sensation and warmth in the area.

· Use nonallergenic mild soap and use it sparingly. Many soaps can be irritating to the skin and increase the itching sensation.

· Keep skin well lubricated. After bathing while the skin is still moist, apply nonallergenic moisturizers such as Medilan that are alcohol free and available in cream or ointment form. Apply moisturizers daily. These agents lubricate the skin surface and make the skin feel smoother and less dry (Hardy, 1996). Medilan is a hypoallergenic lanolin that has soothing and hydrating properties. It can be helpful for the treatment of eczema and other dry skin conditions (Stone, 2000). Creams and ointments are more effective than lotions because they contain less water (Frantz, Gardner, 1994). Daily application of moisturizers can have the persistent clinical effect of relieving dry skin (Tabata et al, 2000).

· Provide distraction techniques such as music, television, or massage. These activities help to temporarily distract the client from the itching sensation. Massage has been helpful for some people with atopic dermatitis (Koblenzer, 1999).

· Consult with physician for medication to relieve itching. Medications such as topical steroids or antihistamines can be helpful (Koblenzer, 1999).

Geriatric

· Limit number of complete baths to one every other day. Use a tepid water temperature of 90° to 105° F for bathing. Excessive bathing, especially in hot water, depletes aging skin of moisture and increases dryness.

· Use a superfatted soap such as Dove, Tone, Basis, or Caress. Superfatted soaps help retain moisture in dry, elderly skin (Hardy, 1996).

· Increase fluid intake within cardiac or renal limits to a minimum of 1500 ml/day. Dry skin is caused by loss of fluid through the skin; increasing fluid intake rehydrates the skin. Adequate hydration helps decrease itching (Koblenzer, 1999).

· Use a humidifier or a container of water on heat source to increase humidity in the environment, especially during winter. Increasing moisture in the air helps to keep moisture in the skin (Hardy, 1996). During times of cold weather and low humidity, dermatitis of the hands is common (Uter, Gefeller, Schwanitz, 1998).

Multicultural

· Assess for the influence of cultural beliefs, norms, and values on the client’s perceptions of skin and/or hair status and practices. What the client considers normal and abnormal skin and hair condition may be based on cultural perceptions (Leininger, 1996).

· Identify and clarify cultural language used to describe skin and hair.

· Assess skin for ashy appearance. Black skin and the skin of other people of color will appear ashy as a result of the flaking off of the top layer of the epidermis (Smith, Burns, 1999; Jackson, 1998).

· Encourage use of lanolin-based lotions for black clients with dry skin. Vaseline may clog the pores and cause cellulitis or other skin problems (Jackson, 1998).

· Offer hair oil and lanolin-based lotion for dry scalp and skin. Black skin seems to produce less oil than lighter colored skin; therefore blacks may use more lubricants as a normal part of skin hygiene (Smith, Burns, 1999).

· Use soap sparingly if the skin is dry. Black skin tends to be dry, and soap will exacerbate this condition (Jackson, 1998).

Home Care Interventions

· Assist client and family with identifying and avoiding irritants that exacerbate pruritus (e.g., wool). Avoiding irritants decreases discomfort of pruritus (Koblenzer, 1999).

· Teach family to use mild, nonscented, and nonbleach laundry products. Chemical irritants increase discomfort of pruritus.

· Keep temperature of home moderated. Use a humidifier. Overheated home environments increase sweating, which adds salts to the skin and increases irritation. Increasing moisture in the air helps to keep moisture in the skin (Hardy, 1996).

Client/Family Teaching

· Teach techniques to use when client is uncomfortable, including relaxation techniques, guided imagery, hypnosis, and music therapy. Interventions such as progressive muscle relaxation training, guided imagery, hypnosis, and music therapy can effectively decrease the itching sensation.

· Teach client with pruritus to substitute rubbing, pressure, or vibration for scratching when itching is severe and irrepressible.

· Teach client to see primary care practitioner if itching persists and no cause is found. Itching can be a symptom of other conditions (Eaglestein, McKay, Pariser, 1994; Koblenzer, 1999).