A nurse is caring for a 4-year-old boy who has sustained second-degree burns on his left leg. A skin graft has been used to cover the area of the burn. Nursing management of the skin graft site includes what?
A) Assisting with AROM of the skin graft site to prevent contractures
B) Keeping the affected area immobilized as much as possible
C) Applying heat to the grafted area to decrease edema
D) Using lanolin to moisten the graft site on postop day 2
Ans: B
Feedback: The nurse should instruct the patient to keep the affected part immobilized as much as possible. When ambulation is permitted, the patient wears an elastic stocking to counterbalance venous pressure. There may be loss of feeling or sensation in the grafted area for a prolonged period; the application of heating pads and exposure to the sun are avoided to prevent burns and further skin trauma. In donor site care, the patient is instructed to keep the donor site soft and pliable with cream, such as lanolin.
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