Pediatric Nursing Demystified

• Cover site with biologic or synthetic skin coverings, or artificial skin
  (Integra) prior to permanent skin graft.


• Skin grafts: Allografts from other person (homografts), xenografts
  (heterografts) pigskin, or autografts from another part of the client’s
  body.

Nursing Interventions

Monitor and record strict intake and output to maintain fluid volume and

prevent fluid overload.

Assess nutrition status and supplement with snacks as indicated.

Monitor for signs of paralytic ileus (absent bowel sounds).

Monitor for signs of infection and report.

Prevent hypothermia: Reduce heat loss, minimize exposure to drafts

with dressings and items such as warming blankets, radiant warmer, and

heat shields.

Provide pain medication as needed for comfort, particularly before

wound care.

If skin graft surgery is performed, assist through operative process:

• Prepare donor graft site prior to surgery.


• Monitor both donor and graft site for infection.
  Provide support to child and family:


• Explain all procedures.


• Emphasize the need to maintain sterile procedure to prevent infection.


• Include family as much in care as possible:
  Teach caregiver to change dressing as ordered.
  Instruct caregiver to monitor for signs of infection.
  Monitor growth and development and support continued progress for
  the child or adolescent.
  Support child and family through concerns about appearance and possi-
  ble plastic surgery in future.
  Discuss preventive measures to avoid future burn injury.

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CHAPTER 15/ Integumentary Conditions^339

FINAL CHECKUP

1. The nurse would record the name of an elevated circumscribed skin lesion that
   is <1 cm in diameter and filled with serous fluid noted on her client as which type
   of lesion?
   a. Cyst
   b. Papule
   c. Pustule
   d. Vesicle

?