A client with a perineal carbuncle and an abscess is being given morning care by a newly hired nurse who is being mentored by another staff nurse. The client had an incision and drainage of the wound three days ago
Current orders include bedrest; diet and fluids as desired; warm, moist compresses every four hours; and topical and systemic antibiotics. Which observation of the newly hired nurse giving care should be interrupted and clarified by the mentoring nurse? 1. The nurse cleanses the area with warm water before applying the compress.
2. The nurse encourages the client to do active range of motion to all extremities.
3. The nurse uses sterile gloves and gauze to change the compresses.
4. The nurse places a bed cradle on the bed.
2
Rationale: Active ROM of the legs can irritate the perineal wound, cause tears in the wound, or cause hemorrhaging. Cleansing the area with warm water using sterile gloves and gauze is a correct action. Placing a bed cradle on the bed to keep sheets and blankets from irritating the wound is also an acceptable action by the nurse.
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