A patient, with a draining enterocutaneous fistula, is developing skin breakdown around the opening of the fistula. Which of the following should the nurse do to reduce this patient's risk of further skin injury?
1. consult an enterostomal nurse for wound and skin care
2. use gauze pads to wick the drainage away from the fistula opening
3. use an abdominal binder to secure gauze pads over the fistula opening
4. keep the wound open to air and permit the draining to air dry
1
Rationale: Management of skin integrity in patients with an enterocutaneous fistula is extremely complex and a wound ostomy nurse should be consulted to help manage these complex wounds. The nurse should not use gauze pads to wick the drainage away from the fistula opening nor use an abdominal binder to secure gauze pads over the fistula opening. The wound should not be kept open to air and permit the drainage to dry on the skin. This would encourage further skin breakdown.
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