RAMSAY SIME DARBY HEALTHCARE COLLEGE

(IPTS NO. B6P8925)

DIPLOMA IN NURSING
SEMESTER 2
FORMATIVE 2
(BOOK ASSIGNMENT)

COURSE NAME: DNU SEPTEMBER 2015

UNIT CODE OF THE SUBJECT & NAME: SURGICAL NURSING (DNNS124)

TUTORS NAME: MS. MAUREEN

ASSIGNMENT: SKIN GRAFTING
SUBMISSION DATE: 09/05/2016
BY: HEMMA RAJENDRA (SD01-1510-001767)

INTRODUCTION TO SKIN GRAFTING

The skin is the largest organ of the human body. It is also known as the integument or
integumentary system because it covers the entire outside of the body. The skin consists of two
main layers: the outer layer, or epidermis, which lies on and is nourished by the thicker dermis.
These two layers are approximately 0.040.08 in (12 mm) thick.
The epidermis consists of an outer layer of dead cells called keratinocytes, which provide a
tough protective coating, and several layers of rapidly dividing cells just beneath the
keratinocytes. The dermis contains the blood vessels, nerves, sweat glands, hair follicles, and
oil glands. The dermis consists mainly of connective tissue, which is largely made up of a
protein called collagen. Collagen gives the skin its flexibility and provides structural support. The
fibroblasts that make collagen are the main type of cell in the dermis.
Skin varies in thickness in different parts of the body; it is thickest on the palms and soles of the
feet, and thinnest on the eyelids. In general, men have thicker skin than women, and adults
have thicker skin than children. After age 50, however, the skin begins to grow thinner again as
it loses its elastic fibers and some of its fluid content.
Skin grafting is a surgical procedure that involves removing the skin from one area of the
body and moving it, or transplanting it, to a different area of the body.
This surgery may be done if a part of your body has lost its protective covering of skin due to
burns, injury, or illness.
Skin grafts are performed in a hospital. Most skin grafts are done using general anesthesia,
which means youll be asleep throughout the procedure and wont feel any pain.
This is often used for burn patients; skin is removed from one area of the body and transplanted
to another. There are two types of skin graft: split-thickness grafts in which just a few layers of
outer skin are transplanted and full-thickness grafts, which involve all of the dermis. There is
usually permanent scarring that is noticeable.

SKIN GRAFTING
This surgery is usually done while you are under general anesthesia. That means you will be
asleep and pain-free.
During a skin graft, a special skin-cutting instrument known as a derma tone removes the skin
from an area (the donor site) usually hidden by clothing such as the buttocks or inner thigh.
Most people who are having a skin graft have a split-thickness skin graft.

Once removed, the graft is placed on the area in need of covering and held in place by a
dressing and a few stitches. The donor site is also covered with a dressing or by staples or a
few small stitches to prevent infection from occurring. The donor-site area is covered with a
sterile dressing for 3 to 5 days.

People with deeper tissue loss may need a full-thickness skin graft. A full-thickness skin graft is
a more complicated procedure. Common donor sites for full-thickness skin grafts include the
chest wall, back, or abdominal wall.
Recovery time from a split-thickness skin graft is generally fairly rapid, often less than three
weeks. For full-thickness skin graft patients the recovery time is a few weeks longer. Aside from
burn patients, skin grafts can also be used during breast or nose reconstruction.

EXAMPLE OF SKIN GRAFTING ON NOSE RECONSTRUCTION

PURPOSE
A skin graft is placed over an area of the body where skin has been lost. Common reasons for a
skin graft include:
Areas where there has been infection that caused a large amount of skin loss
Burns
Cosmetic reasons or reconstructive surgeries where there has been skin damage or skin loss
Skin cancer surgery
Surgeries that need skin grafts to heal
Venous ulcers, pressure ulcers, or diabetic ulcers that do not heal
Very large wounds
A wound that the surgeon has not been able to close properly
Full-thickness grafts are done when a lot of tissue is lost. This can happen with open fractures
of the lower leg, or after severe infections.
Mastectomy

Types of skin grafts

The term "graft" by itself commonly refers to either an allograft or an autograft. An autograft is
a type of graft that uses skin from another area of the patient's own body if there is enough
undamaged skin available, and if the patient is healthy enough to undergo the additional surgery
required.

An allograft uses skin obtained from another human being, Donor skin from cadavers is frozen,
stored, and available for use as allografts. Skin taken from an animal (usually a pig) is called a
xenograft because it comes from a nonhuman species.

Allografts and xenografts provide only temporary covering because they are rejected by the
patient's immune system within seven days. They must then be replaced with an autograft.

SPLIT-THICKNESS GRAFTS.

The most important part of any skin graft procedure is proper preparation of the wound. Skin
grafts will not survive on tissue with a limited blood supply (cartilage or tendons) or tissue that
has been damaged by radiation treatment.
The patient's wound must be free of any dead tissue, foreign matter, or bacterial contamination.
After the patient has been anesthetized, the surgeon prepares the wound by rinsing it with
saline solution or a diluted antiseptic (Betadine) and removes any dead tissue by dbridement.
In addition, the surgeon stops the flow of blood into the wound by applying pressure, tying off
blood vessels, or administering a medication (epinephrine) that causes the blood vessels to
constrict.

Following preparation of the wound, the surgeon then harvests the tissue for grafting.
A split-thickness skin graft involves the epidermis and a little of the underlying dermis; the donor
site usually heals within several days.
The surgeon first marks the outline of the wound on the skin of the donor site, enlarging it by 3
5% to allow for tissue shrinkage. The surgeon uses a dermatome (a special instrument for
cutting thin slices of tissue) to remove a split-thickness graft from the donor site.
The wound must not be too deep if a split-thickness graft is going to be successful, since the
blood vessels that will nourish the grafted tissue must come from the dermis of the wound itself.
The graft is usually taken from an area that is ordinarily hidden by clothes, such as the buttock
or inner thigh, and spread on the bare area to be covered. Gentle pressure from a well-padded
dressing is then applied, or a few small sutures used to hold the graft in place. A sterile
nonadherent dressing is then applied to the raw donor area for approximately three to five days
to protect it from infection.

FULL-THICKNESS GRAFTS.

Full-thickness skin grafts may be necessary for more severe burn injuries. These grafts involve
both layers of the skin. Full-thickness autografts are more complicated than partial-thickness
grafts, but provide better contour, more natural color, and less contraction at the grafted site. A
flap of skin with underlying muscle and blood supply is transplanted to the area to be grafted.

This procedure is used when tissue loss is extensive, such as after open fractures of the lower
leg, with significant skin loss and underlying infection. The back and the abdomen are common
donor sites for full-thickness grafts. The main disadvantage of full-thickness skin grafts is that
the wound at the donor site is larger and requires more careful management. Often, a splitthickness graft must be used to cover the donor site.

A composite skin graft is sometimes used, which consists of combinations of skin and fat, skin
and cartilage, or dermis and fat. Composite grafts are used in patients whose injuries require
three-dimensional reconstruction. For example, a wedge of ear containing skin and cartilage
can be used to repair the nose.

A full-thickness graft is removed from the donor site with a scalpel rather than a dermatome.
After the surgeon has cut around the edges of the pattern used to determine the size of the
graft, he or she lifts the skin with a special hook and trims off any fatty tissue. The graft is then
placed on the wound and secured in place with absorbable sutures.

Full-thickness skin graft to nasal dorsum

CRITERIA FOR SKIN GRAFTING

Skin grafting is sometimes done as part of elective plastic surgery procedures, but its most
extensive use is in the treatment of burns.
For first or second-degree burns, skin grafting is generally not required, as these burns usually
heal with little or no scarring.
With third-degree burns, however, the skin is destroyed to its full depth, in addition to damage
done to underlying tissues. People who suffer third-degree burns often require skin grafting.
Wounds such as third-degree burns must be covered as quickly as possible to prevent
infection or loss of fluid. Wounds that are left to heal on their own can contract, often resulting
in serious scarring; if the wound is large enough, the scar can actually prevent movement of
limbs
Non-healing wounds, such as diabetic ulcers, venous ulcers, or pressure sores, can be
treated with skin grafts to prevent infection and further progression of the wounded area.

TREATMENT

Caring for skin grafts

You will need wound care for two sites
Skin grafts are used when there is a large area of your body with damaged skin that needs the
cover of new skin to heal properly, or that requires skin to minimize scarring that could be
physically or psychologically painful. If you receive the most common type of skin graft, it will
mean skin from another part of your body being transplanted to a wound. Naturally, then, you
will have a wound at the donor site too. You must care for your skin graft to ensure it adheres
and heals well, but you must also take care of the donor site and to prevent infection. It is often
the case that the donor site hurts more and produces more exudate, or fluid from the wound
site, as it is a large open wound.

You will need to care for the graft site as well as the donor site.
When you come home after surgery, you will have a dressing on your wounds. The dressing
does several things, including
Protect your wound from germs and reduce the risk of infection
Protect the area as it heals
Soak up any fluids that leak from your wound

To care for the graft site:

Rest may be needed for several days after surgery as wound heals.
The type of dressing depends on the type of wound and where it is.
The dressing and area around it needs to be kept clean and free from dirt or sweat.
Dressing should not get wet.
Dressing should not be touched. It should be left in place for as long as the doctor
recommends (about 4 to 7 days).
Medicines or pain relievers should be taken as directed.
Elevating the wound so it's above the heart helps reduce swelling. You may need to do this
while sitting or lying down. You can use pillows to prop up the area.
If your doctor says it's OK, you may use an ice pack on the bandage to help with swelling. Ask
how often you should apply the ice pack. Be sure to keep the bandage dry.
Avoid any movement that might stretch or injure the flap or graft. Avoid hitting or bumping the
area.
If you have a vacuum dressing, you may have a tube attached to the dressing. If the tube falls
off, tell your doctor.
You will probably see your doctor to have your dressing changed in 4 to 7 days. You may
need to have the dressing to your flap or graft site changed by your doctor a couple times over 2
to 3 weeks.
As the site heals, you may be able to care for it at home. Your doctor will show you how to
care for your wound and apply dressings.
The site may become itchy as it heals. Do not scratch the wound or pick at it.

To care for the donor site:

Leave the dressing in place. Keep it clean and dry.

The doctor will remove the dressing in about 4 to 7 days, or give instructions for how to
remove it.
After the dressing is removed, you may be able to leave the wound uncovered. However, if it's
in an area that is covered by clothing, you'll want to cover the site to protect it. Ask your doctor
what type of dressing to use.
Do not apply any lotions or creams to the wound unless your doctor tells you to. As the area
heals, it may itch and scabs may form. Do not pick scabs or scratch the wound as it heals.

Bathing or Showering

The doctor will let you know when it's OK to bathe after surgery. Keep in mind :

You may need to take sponge baths for 2 to 3 weeks while your wounds are in the early
stages of healing.
Once you get the OK to bathe, showers are better than baths because the wound doesn't
soak in water. Soaking your wound could cause it to reopen.
Be sure to protect your dressings while you bathe to keep them dry. Your doctor may suggest
covering the wound with a plastic bag to keep it dry.
If your doctor gives the OK, gently rinse your wound with water as you bathe. Do not rub or
scrub the wound. Your doctor may recommend special cleansers to use on your wounds.
Gently pat dry the area around your wound with a clean towel. Let the wound air dry.
Do not use soaps, lotions, powders, cosmetics, or other skin care products on your wound
unless told to do so by your doctor.
At some point during the healing process, you won't need a dressing anymore. Your doctor
will tell you when you can leave your wound uncovered and how to care for it.

When to Call the Doctor

Call your doctor if:

Pain gets worse or doesn't improve after taking pain relievers

You have bleeding that won't stop after 10 minutes with gentle, direct pressure
Your dressing comes loose
Edges of the graft or flap start to come up
You feel something bulging out of the graft or flap site

Also call your doctor if you notice signs of an infection, such as:

Increased drainage from the wound

Drainage becoming thick, tan, green, or yellow, or smells bad (pus)
Your temperature is above 37.8C for more than 4 hours
Red streaks appear that lead away from the wound

Complications
Failure of the skin graft is often due to:

Inadequate excision of the wound bed.

This leaves non-viable tissue beneath the skin graft (Young and Fowler, 1998).
Inadequate vascular supply to the wound bed.
This compromises the graft (Coull, 1991).
Hematomas and seromas.
These form a barrier between the bed and skin graft and prevent the graft from taking. This can
be reduced by careful haemostasis at the time of surgery (Coull, 1991).
Shearing or displacement of the graft.
This prevents revascularisation of the graft as the capillaries cannot link up. Immobilisation is
important (Francis, 1998).
Infection.
This can lead to disintegration of the graft or excessive exudate that prevents the graft from
adhering to the bed (Beldon, 2003).
Late complications relate to the appearance and function of the graft.
The colour and texture of a healed graft will contrast with the surrounding skin and, usually,
there is some depression of the wound. Hyperpigmentation of the graft can also be a problem
(Young and Fowler, 1998).
Contraction
The main functional problem and can result in joint contracture and restriction of function in the
surrounding tissue. Other problems are caused by the destruction of sebaceous and sweat
glands during transplantation (Wilkinson, 1997), which can lead to dry and flaking skin.
Donor sites
Donor sites are superficial wounds of the epidermis and dermis. In the correct conditions these
heal within 814 days depending on the site, depth and general condition of the patient.

Porter (1991) suggests that the delay in wound healing of a split-thickness skin graft donor
site is a complication that can cause the patient more inconvenience than the skin graft
or the condition for which the grafting was indicated.

Problems with the donor site include leakage of exudate and pain.

Delayed healing and prolonged treatment times are associated with patients who very old or
very young who are nutritionally compromised as well as patients taking steroids (Edwards,
1998).

The lack of appropriate dressings leads to donor sites being one of the less satisfactory aspects
of skin grafting, and mismanagement can lead to drying out of the wound, increased healing
times and deeper scarring (Wilkinson, 1997).

NURSING INTERVENTIONS ON SKIN GRAFTING

Nursing diagnoses: Anxiety related to threat to health status caused by graft rejection or death
of graft; Body image disturbance related to biophysical factor, scarring, disfigurement caused by
skin grafts; and High risk for impaired skin integrity related to internal factors of altered
circulation, infection, fluid accumulation under graft resulting in floating of graft.

Nursing intervention and rationale

1. Assess the client for anxiety, expression of feelings regarding possible scarring or
change in appearance.
Rationale: anxiety varieties from mild to severe depending on situation.
2. Assess the graft for fluid, blood purulent drainage under graft.
Rationale: discharges that accumulate may end up with death of graft.
3. Perform or provide assistance with aspiration of fluid from under graft with needle
and syringe or roll fluid to wound edge with sterile applicator.
Rationale: removes fluid that wound prevent contact of graft with tissue and result in
graft floating away.
4. Elevate graft site, protect from movement and pressure.
Rationale: prevents disturbance of graft and possible damage.
5. Ensure that dressings are secure; avoid loosening them or lying on dressings
Rationale: provides proper amount of pressure.
6. Warm sterile compresses of Normal Saline.
Rationale: promotes blood supply to the area.
7. Heat lamp, bad cradle to donor site after dressings removed.
Rationale: dries and protects donor site.

8. Environment conducive to expression of concerns with patience and caring

attitude.
Rationale: offers opportunity to vent feelings and reduce anxiety.
9. Assist to identify strength, use coping mechanisms and problem solving.
Rationale: provides assistance in adapting to any change in appearance.

10. Assist to be realistic about expectations of graft results.

Rationale: prevents disappointment and depression if graft fails.

RECOMMENDATION
Before the Procedure
Tell your surgeon or nurse:
What medicines you are taking, even drugs or herbs you bought without a prescription.
If you have been drinking a lot of alcohol.

During the days before surgery:

You may be asked to stop taking medicines that make it hard for your blood to clot. These
include aspirin, ibuprofen, warfarin (Coumadin), and others.
Ask your surgeon which drugs you should still take on the day of your surgery.
If you smoke, try to stop. Smoking increases your chance of problems such as slow healing. Ask
your doctor or nurse for help quitting.

On the day of the surgery:

Follow instructions about when to stop eating and drinking.
Take the drugs your surgeon told you to take with a small sip of water.

After the Procedure

You should recover quickly after split-thickness skin grafting. Full-thickness grafts need a longer
recovery time. If you received this kind of graft, you may need to stay in the hospital for 1 to 2
weeks.
After you are discharged from the hospital, follow instructions on how to care for your skin graft,
including:
Wearing a dressing for 1 to 2 weeks. Ask your provider how you should care for the dressing,
such as protecting it from getting wet.
Protecting the graft from trauma for 3 to 4 weeks. This includes avoiding being hit or doing any
exercise that might injure or stretch the graft.
Getting physical therapy, if your surgeon recommends it.

CONTENTS

1.

Tittle

Introduction to Skin Grafting

Page

2.

Skin Grafting & Skin structure

3.

Types of Skin Grafting

4.

Criteria of Skin Grafting

5.

Purpose of Skin Grafting

6.

Recommendations ( Before/After Procedure )

7.

Treatment after Skin Grafting

8.

Complication of Skin Grafting

9.

Nursing Intervention on Skin Grafting

10
.

Skin Graftings Latest Update on its Procedure

11.

Reference

SKIN GRAFTINGs NEW PROCEDURE

Skin grafting is a procedure that has been used for years to help heal wounds so damaged they
are unable to regenerate on their own.
The procedure, which consists of transferring epidermal tissue from a healthy site of skin to the
wound, is often painful and time-consuming, but doctors at Davis Hospital and Medical Centers
Hyperbaric and Wound Center have a new treatment they say is minimally invasive and takes
less time to heal.
Dr. Paul Barney, medical director of the Hyperbaric and Wound Center at Davis Hospital, Utah,
said the CelluTome system is a new technology. Right now, Davis Hospital is the first in the
western United States to provide the service.
The CelluTome system uses a template lined with small holes. The tool warms up the
skin and creates suction, adhering to a patients inner thigh. The heat and suction causes
small blisters to form at the junction of the epidermis and dermis, which is then lifted
from the donor site without injuring blood vessels and nerves. The harvested skin tissue
is placed on the wound, and as soon as the new skin roots to the damaged skin, the
healing process begins.

In traditional skin grafting, the wound is treated in an operating room and healing on the harvest
sites is often painful.

This new technology allows the procedure to be done in the office, avoiding the cost
and inconvenience of the operating room, including anesthesia,
The harvest site heals in one week, sometimes two weeks, without any evidence that a
procedure was done.
The transplant site closes 40 to 60 percent faster than untreated wounds.

The treatment is used for any patient with a wound that needs to be covered with new
skin. Many of those patients include burn victims, people with diabetes, pressure
wounds or bed sores and certain cancer patients.

REFERENCES
1. http://www.nursingtimes.net/focus-management-of-skin-graftsand-donor-sites/524913.fullarticle

2. http://nursingcareplanforpinoy.blogspot.my/2010/06/nursingcare-plan-ncp-skin-graft.html#.Vy-TTYR97IW
3. https://www.google.com/webhp?sourceid=chromeinstant&ion=1&espv=2&ie=UTF-8#q=skin%20graft%20ssg
4. https://www.google.com/search?
q=anatomy+of+skin&espv=2&biw=1366&bih=623&source=lnms
&tbm=isch&sa=X&ved=0ahUKEwizrrX1ksvMAhWDBY4KHT82DH
YQ_AUIBigB#imgrc=g1cLKbtWagtYIM%3A
5. https://www.nlm.nih.gov/medlineplus/ency/patientinstructions/00
0743.htm
6. http://nursingcareplanforpinoy.blogspot.my/2010/06/nursingcare-plan-ncp-skin-graft.html#.Vy-TTYR97IW