The nurse assesses the incontinent patient's perineal skin and notes redness. What does the nurse include in the patient's plan of care to individualize nursing care?

Question

a. Minimize exposure of the perineum to soap and water.
b. Apply an anti-inflammatory agent to the affected area.
c. Allow adequate time for the patient to use the bedside commode.
d. Remove the incontinence brief and expose the skin to air for an hour.

Answer 1

B
To maintain skin integrity, reduce inflammation, and prevent deterioration of the affected area, the nurse applies an anti-inflammatory agent after gentle cleansing. The affected area must be cleansed promptly after exposure to urine or fecal matter; to minimize skin trauma, the nurse uses mild soap and rinses thoroughly with a gentle touch. Removing the incontinence brief is usually impractical; it can remain in place to contain urine and fecal matter, with prompt perineal care after exposure to urine or fecal matter. The risk of skin breakdown from incontinence does not improve with exposure to air because the basic problem is frequent skin exposure to irritating waste products and not an anaerobic environment. The nurse allows every patient adequate time to use the commode, bedpan, or bathroom, but, since this patient is incontinent, toileting time is not an issue.