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

Question

1. Minimize exposure of perineum to soap and water.
2. Apply anti-inflammatory agent to the affected area.
3. Allow adequate time for client to use the bedside commode.
4. Remove incontinence brief and expose skin to air for an hour.

Answer 1

2
2. To maintain skin integrity, reduce inflammation, and prevent deterioration of the affected area, the nurse applies an anti-inflammatory agent after gentle cleansing.
1. The affected area must be cleansed promptly after exposure to urine or fecal mat-ter; to minimize skin trauma, the nurse uses mild soap and rinses thoroughly with a gentle touch.
3. The nurse allows every client adequate time to use the commode, bedpan, or bath-room.
4. 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.