Skin Grafts: Care of Graft Site

Notify other appropriate health care professionals who need to assess the graft (e.g., physician) or perform a task (e.g., range-of-motion exercises by physical therapist) of the time of dressing change.

 
Prepare all necessary equipment and supplies.

  1. Wash hands; and don cap, mask, gown, and examination gloves (this applies to each health care provider involved in the procedure).
  2. Remove bulky, outer dressings and discard. Place towel or pad under exposed extremity.
  3. Remove and discard gloves, and don a pair of clean gloves.
  4. If ordered, gently lift nonadherent gauze from grafted site, anchoring graft in place as needed. NOTE:  Surgeon may staple on dressing that is to remain in place until skin graft heals (e.g., Biobrane).
  5. Gently rinse graft site and surrounding tissue with sterile water and gauze.
  6. Notify physician of loose necrotic tissue and any pockets of fluid under the graph.
  7. Assess graft for progression of healing and for complications.
  8. Apply nonadherent dressing (if interstices are open), cover with bulky dressings, and secure; or apply moisturizer to healed adherent graft areas where interstices are closed and cover with thin dressings to promote mobility.
  9. Apply splints and elevate hands with pillows or elastic net sling; elevate head of bed.
  10. Remove and discard gloves. Wash hands.
  11. Continue to monitor patient's vital signs.
  12. Document in patient's record.
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