After completing perineal care, what should you do with observations such as redness, irritation, discharge, or pain?

• A. Report observations such as redness, irritation, discharge, or pain.
• B. Ignore minor symptoms if the resident says fine.
• C. Document only if there is fever.
• D. Leave notes at the end of your shift.

Answer: (D)

Noting and documenting changes right after care is essential. Observations such as redness, irritation, discharge, or pain can signal skin breakdown, infection, or other issues that need attention from the nurse and may affect the resident’s care plan. Recording these findings helps ensure the information is preserved and available to the next caregiver and the supervising nurse, supporting continuity of care and timely follow-up actions. The notes become part of the resident’s chart, guiding future assessments and treatments and helping prevent problems from going unnoticed. While clinical actions and verbal reporting are important, documenting the observations at the end of your shift ensures a complete record is in the chart for ongoing monitoring and decision-making.