Principles of Basic Wound Care
Principles of Basic Wound Care ( 4 Questions)
A nurse is caring for a client who has undergone a skin graft to cover a burn injury on the right arm. Which intervention should the nurse include in the plan of care to promote graft adherence?
This is not necessary for graft adherence, but it may help to reduce edema and pain in the affected arm.
This is contraindicated for skin grafts, as it can cause bleeding, infection, or graft loss. Negative pressure wound therapy is used for wounds that are difficult to heal by primary intention, such as chronic ulcers or open abdominal wounds.
Rationale: Immobilizing the right arm with a splint or sling helps to prevent movement and shear forces that can dislodge or damage the graft. The nurse should also avoid applying pressure or friction to the graft site.
This is not recommended for skin grafts, as it can interfere with graft adherence and increase the risk of infection. The nurse should follow the provider's orders for dressing changes and use sterile technique.
Correct answer: C) Immobilize the right arm with a splint or sling
Rationale: Immobilizing the right arm with a splint or sling helps to prevent movement and shear forces that can dislodge or damage the graft. The nurse should also avoid applying pressure or friction to the graft site.
Incorrect options:
A) Elevate the right arm above the level of the heart - This is not necessary for graft adherence, but it may help to reduce edema and pain in the affected arm.
B) Apply negative pressure wound therapy to the graft site - This is contraindicated for skin grafts, as it can cause bleeding, infection, or graft loss. Negative pressure wound therapy is used for wounds that are difficult to heal by primary intention, such as chronic ulcers or open abdominal wounds.
D) Irrigate the graft site with normal saline twice daily - This is not recommended for skin grafts, as it can interfere with graft adherence and increase the risk of infection. The nurse should follow the provider's orders for dressing changes and use sterile technique.