The nurse is caring for a client with a burn wound on the left knee and an autograft and skin grafting was performed. Which of the following activities will be prescribed for the client post-op?
A. Elevation and immobilization of the affected leg.
B. Placing the affected leg in a dependent position.
C. Dangling of legs.
D. Bathroom privileges.
Correct Answer: A. Elevation and immobilization of the affected leg.
Autograft placed on the lower extremity requires elevation and immobilization for at least 3-7days. This period of immobilization allows the autograft time to adhere to the wound bed. Clinically, skin grafts are secured into place and often bolstered until postoperative day 5 to 7 to allow the skin graft to go through the above steps, ensuring the best skin graft take.
Option B: Do not place the affected leg in a dependent position. Any buildup of fluid between the split-thickness skin graft and wound bed will jeopardize skin graft take, including seroma, hematoma, and infection. Shear or traction injury also disrupts skin graft healing.
Option C: Dangling of legs puts the affected site into a dependent position, which can cause a build-up of fluid that jeopardizes the skin graft. The graft can have incomplete (less than 100%) take or complete nontake.
Option D: Split-thickness skin grafts typically become adherent to the recipient wound bed 5 to 7 days following skin graft placement. The dressings placed intraoperatively are kept in place until 5 to 7 days postoperatively to minimize shear and traction to the healing skin graft.
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