The nurse is caring for an infant with bladder exstrophy. As part of the infant's preoperative plan of care, the nurse monitors for abdominal skin excoriation
Which action would be most appropriate for promoting healing and preventing further skin breakdown? A) Cleaning the area well with a scented diaper wipe
B) Applying a barrier/healing cream or paste on skin
C) Keeping the bladder moist and covered with a sterile bag
D) Covering the area with sterile gauze pads after tub baths
B
Feedback:
The nurse should use a barrier/healing cream or paste on surrounding skin to promote healing and prevent further skin breakdown. Diaper wipes that contain fragrance or alcohol can sting if used on nonintact skin and can worsen skin breakdown. It is important to protect the bladder, but this will not address the skin excoriation. Meticulous attention to cleanliness is important, but the nurse should sponge-bathe the infant rather than immerse him in water to prevent pathogens from the water possibly entering the bladder.
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