dressing changes on skin grafts

[Bikechicky]

I'd like some feedback on this one please. I'm an ER nurse so my med surg experience is ancient history. A family member is in the hospital for trauma, crush injury to his lower leg. Has a external fix on his tib fib and has 2 skin grafts covering his open wounds due to fasciaotomy. I witnessed the nurse change his dressing, she put adaptic dressings over the skin grafts and since they were on both sides of his leg they kept dropping off, she simply picked them up off the bed linen and slapped them back on several times before finally getting the whole thing wrapped back up. Then she removed the dry dressing from the donor site, it was stuck so she just ripped it off causing the whole thing to bleed. When she put a new dry gauze dressing over the bleeding donor site I asked if she might use adaptic and she told me there was no order for that! He was discharged from the hospital that day and is getting much better care at home. Now several days later he has a infection in the whole thing. Also they never did any care of the pin sites either.

I have great empathy for over worked and under staffed nurses but this is beyond that this is just lousy care. I want to call the nurse manager of the floor and let her know that the nursing care on her unit is less than optimal, what do you think?

[BBFRN, BSN, PhD]

Having worked in Trauma Med/Surg, I can tell you that it's perfectly fine to use adaptic on donor sites as well as graft sites. We didn't need an order for this where I worked. We also used Bacitracin (with an order) to donor sites and graft sites to keep them from drying out. It is also a good practice to wet the dry drsg with NS when removing it to avoid causing the donor site to bleed, unless you're trying to debride it, of course. You were right to question what you saw. With the adaptic falling off, a simple sterile drape placed under the limb during the drsg change would've helped.

In addition, pin care with 1/2 NS & 1/2 H2O2 (preferably followed by Mercuroclear) should be done at least BID once that gauze from initial placement is removed. We actually did a study of the efficacy of pin care TID vs BID and found no increased infection rates, etc. for the BID. Pin care is very important, because the lack of it can cause osteomyelitis, etc. It was standard for us to teach pin care to pt's and family members prior to d/c home as well.

I would talk with the NM about this, because the nurses did deviate from the standards of care in these areas. You might want to suggest further education in these areas for the staff.