Regarding perineal care, which nursing action is appropriate? (Select all that apply.)
a. The nurse applies gloves prior to performing perineal care
b. The nurse ignores the erection of a male patient during perineal care
c. The nurse documents the perineal care.
d. The nurse only completes perineal care with daily bathing
ANS: A, B, C
The nurse uses standard precautions (gloves) whenever contact with body fluids is expected. A male patient may have an erection during care, which is a normal response with tactile stimulation. The care provider can ignore the erection and continue with the procedure or return later to complete the care, depending on the comfort level and the situation. Documentation is part of hygienic care. Note any redness, drainage, odor, edema, or skin changes. Perineal care is provided during a bath or shower but may be necessary more frequently, especially in incontinent patients.
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