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    Burns - Skin Integrity, Impaired

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    makyofrancis20
    1) The patient has impaired skin integrity due to a partial- or full-thickness burn requiring skin grafting. 2) Interventions include pre- and post-operative wound care such as documenting the wound, providing infection control, and maintaining dressings over the grafted area. 3) Additional interventions include assisting with surgical grafting using various graft types like homografts, heterografts, and cultured epithelial autografts to cover the wound until the patient's own skin is ready.

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    Burns - Skin Integrity, Impaired

    Uploaded by

    makyofrancis20
    265 views2 pages
    1) The patient has impaired skin integrity due to a partial- or full-thickness burn requiring skin grafting. 2) Interventions include pre- and post-operative wound care such as documenting the wound, providing infection control, and maintaining dressings over the grafted area. 3) Additional interventions include assisting with surgical grafting using various graft types like homografts, heterografts, and cultured epithelial autografts to cover the wound until the patient's own skin is ready.

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    Burns- Skin Integrity, Impaired

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    Burns- Skin Integrity, Impaired

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    1) The patient has impaired skin integrity due to a partial- or full-thickness burn requiring skin grafting. 2) Interventions include pre- and post-operative wound care such as documenting the wound, providing infection control, and maintaining dressings over the grafted area. 3) Additional interventions include assisting with surgical grafting using various graft types like homografts, heterografts, and cultured epithelial autografts to cover the wound until the patient's own skin is ready.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    265 views2 pages

    Burns - Skin Integrity, Impaired

    Uploaded by

    makyofrancis20
    1) The patient has impaired skin integrity due to a partial- or full-thickness burn requiring skin grafting. 2) Interventions include pre- and post-operative wound care such as documenting the wound, providing infection control, and maintaining dressings over the grafted area. 3) Additional interventions include assisting with surgical grafting using various graft types like homografts, heterografts, and cultured epithelial autografts to cover the wound until the patient's own skin is ready.

    Copyright:

    Attribution Non-Commercial (BY-NC)
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    NURSING DIAGNOSIS: Skin Integrity, impaired [grafts] May be related to Disruption of skin surface with destruction of skin layers

    (partial-/full-thickness burn) requiring grafting Possibly evidenced by Absence of viable tissue DESIRED OUTCOMES/EVALUATION CRITERIAPATIENT WILL: Wound Healing: Secondary Intention (NOC) Demonstrate tissue regeneration. Achieve timely healing of burned areas.

    ACTIONS/INTERVENTIONS
    Wound Care (NIC)

    RATIONALE

    Independent
    Preoperative Assess/document size, color, depth of wound, noting necrotic tissue and condition of surrounding skin. Provide appropriate burn care and infection control measures. (Refer to ND: Infection, risk for.) Provides baseline information about need for skin grafting and possible clues about circulation in area to support graft. Prepares tissues for grafting and reduces risk of infection/graft failure.

    ACTIONS/INTERVENTIONS
    Wound Care (NIC)

    RATIONALE

    Independent
    Postoperative Maintain wound covering as indicated, e.g.: Biosynthetic dressing (Biobrane); Nylon fabric/silicon membrane containing collagenous porcine peptides that adheres to wound surface until removed or sloughed off by spontaneous skin reepithelialization. Useful for eschar-free partial-thickness burns awaiting autografts because it can remain in place 23 wk or longer and is permeable to topical antimicrobial agents. Hydroactive dressing that adheres to the skin to cover small partial-thickness burns and that interacts with wound exudate to form a soft gel that facilitates debridement. Thin, transparent, elastic, waterproof, occlusive dressing (permeable to moisture and air) that is used to cover clean partial-thickness wounds and clean donor sites. Reduces swelling/limits risk of graft separation. Movement of tissue under graft can dislodge it, interfering with optimal healing. Areas may be covered by translucent, nonreactive surface material (between graft and outer dressing) to eliminate

    Synthetic dressings, e.g., DuoDerm;

    Opsite, Acu-Derm.

    Elevate grafted area if possible/appropriate. Maintain desired position and immobility of area when indicated.

    Maintain dressings over newly grafted area and/or donor site as indicated, e.g., mesh, petroleum, nonadhesive.

    shearing of new epithelium/protect healing tissue. The donor site is usually covered for 424 hr, then bulky dressings are removed and fine mesh gauze is left in place. Keep skin free from pressure. Promotes circulation and prevents ischemia/necrosis and graft failure. Evaluates effectiveness of circulation and identifies developing complications. Newly grafted skin and healed donor sites require special care to maintain flexibility.

    Evaluate color of grafted and donor site(s); note presence/absence of healing. Wash sites with mild soap, rinse, and lubricate with cream (e.g., Nivea) several times daily after dressings are removed and healing is accomplished. Aspirate blebs under sheet grafts with sterile needle or roll with sterile swab.

    Fluid-filled blebs prevent graft adherence to underlying tissue, increasing risk of graft failure.

    Collaborative
    Prepare for/assist with surgical grafting or biological dressings, e.g.: Homograft (allograft);

    Skin grafts obtained from living persons or cadavers are used as a temporary covering for extensive burns until persons own skin is ready for grafting (test graft), to cover excised wounds immediately after escharotomy, or to protect granulation tissue.

    ACTIONS/INTERVENTIONS
    Wound Care (NIC)

    RATIONALE

    Collaborative
    Heterograft (xenograft, porcine); Skin grafts may be carried out with animal skin for the same purposes as homografts or to cover meshed autografts. Skin graft obtained from uninjured part of patients own skin and prepared in a laboratory; may be full-thickness or partial-thickness. Note: This process takes 2030 days from harvest to application. The new CEA sheets are 16 cell layers thick and thus are very fragile. Wound covering approved by the Food and Drug Administration (FDA) for full-thickness and deep partialthickness burns. It provides a permanent, immediate covering that reproduces the skins normal functions and stimulates the regeneration of dermal tissue.

    Cultured epithelial autograft (CEA);

    Artificial skin (Integra).

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