1.2 Infection Prevention and Control Practices, 1.4 Additional Precautions and Personal Protective Equipment (PPE), 1.5 Surgical Asepsis and the Principles of Sterile Technique, 1.7 Sterile Procedures and Sterile Attire, 3.6 Assisting a Patient to a Sitting Position and Ambulation, 4.6 Moist to Dry Dressing, and Wound Irrigation and Packing, 6.3 Administering Medications by Mouth and Gastric Tube, 6.4 Administering Medications Rectally and Vaginally, 6.5 Instilling Eye, Ear, and Nose Medications, 7.2 Parenteral Medications and Preparing Medications from Ampules and Vials, 7.3 Intradermal and Subcutaneous Injections, 7.5 Intravenous Medications by Direct IV Route, 7.6 Administering Intermittent Intravenous Medication (Secondary Medication) and Continuous IV Infusions, 7.7 Complications Related to Parenteral Medications and Management of Complications, 8.3 IV Fluids, IV Tubing, and Assessment of an IV System, 8.4 Priming IV Tubing and Changing IV Fluids and Tubing, 8.5 Flushing a Saline Lock and Converting a Saline Lock to a Continuous IV Infusion, 8.6 Converting an IV Infusion to a Saline Lock and Removal of a Peripheral IV, 8.7 Transfusion of Blood and Blood Products, 10.2 Caring for Patients with Tubes and Attachments. Learn how BCcampus supports open education and how you can access Pressbooks. Visually assess the wound for uniform closure of the wound edges, absence of drainage, redness, and swelling. Accidental cuts or lacerations are often closed with stitches. Sutures must be left in place long enough to establish wound closure with enough strength to support internal tissues and organs. For a video of suturing techniques, see https://www.youtube.com/watch?v=-ZWUgKiBxfk. Perform a point of care risk assessment. Close-up of adhesive strips used to close the wound to the eyebrow. If concerns are present, question the order and seek advice from the appropriate health care provider. Table 4.9 lists additional complications related to wounds closed with sutures. Explain process to patient and offer analgesia, bathroom etc. Devitalized and necrotic tissue in a traumatic wound should be identified and removed to reduce risk of infection.4,5, If a foreign body (e.g., dirt particles, wood, glass) is suspected but cannot be identified visually, then radiography, ultrasonography, or computed tomography may be needed. Clean incision site according to agency policy. . Forceps are used to remove the loosened suture and pull the thread from the skin. This step reduces the risk of infection from microorganisms on the wound site or surrounding skin. Keep wound clean and dry for the first 24 hours. This prevents the transmission of microorganisms. A rich blood supply to the scalp causes lacerations to bleed significantly. Want to create or adapt OER like this? However, removal of the chest tube may also be a painful procedure for the patient. These office-based procedures can diagnose questionable dermatologic lesions, including possible malignancies. Remove non-sterile gloves andperform hand hygiene. Am Fam Physician 2014;89(12):956-962. At the time of suture removal, the wound has only regained about 5%-10% of its strength. 8. An order to remove sutures must be obtained prior to the procedure, and a comprehensive assessment of the wound site must be performed prior to the removal of the sutures by a health care team member. Suture removal is determined by how well the wound has healed and the extent of the surgery. This is intended to be a repository for efficiency tools for use at VCMC. Non-Parenteral Medication Administration, Chapter 7. Offer analgesic. All sutures used for traumatic skin laceration repair are swaged (ie, the needle and suture are connected as a continuous unit). Patients with a clean and minor wound should receive the tetanus vaccine only if they have not had a tetanus vaccine for more than 10 years. Hand hygiene reduces the risk of infection. The redness and drainage from the wound is decreasing. Safer Patient Handling, Positioning, Transfers and Ambulation, Chapter 6. Inform patient that the procedure is not painful, but the patent may feel some pulling of the skin during suture removal. See Additional Information. Safe Patient Handling, Positioning, and Transfers, Chapter 6. 1. If using a blade to cut the suture, point the blade away from you and your patient. Perform a point of care risk assessment for necessary PPE. When both ends of the staple are visible, move the staple extractor away from the skin and place the staple on a sterile piece of gauze by releasing the handles on the staple extractor. Never leave suture material below the surface. Steri-Strips support wound tension across wound and help to eliminate scarring. This 26-year-old man received many cuts and bruises after falling from a 7-story window. Provide opportunity for the patient to deep breathe and relax during the procedure. 6. Learn how BCcampus supports open education and how you can access Pressbooks. 18. Allow small rest breaks during removal of sutures. The most commonly seen suture is the intermittent or interrupted suture. Call a doctor if you have any of these signs and symptoms after stitches (sutures) have been removed, redness, increasing pain, swelling, fever, red streaks progressing away from the sutured site, material (pus) coming from out of the wound, if the wound reopens, and bleeding. PREREQUISITE NURSING KNOWLEDGE Wound healing is a nonspeci c response to injury. The body of the needle is the portion that is grasped by the needle holder during the procedure. Sutures must be left in place long enough to establish wound closure with enough strength to support internal tissues and organs. Note: If this is a clean procedure, you simply need a clean surface for your supplies. Bandages can safely be removed from the wound after 48 hours, unless the wound continues to bleed or has a discharge. Staple removal is a simple procedure and is similar to suture removal. The wound line must also be observed for separations during the process of suture removal. Complete patient teaching regarding Steri-Strips and bathing, wound inspection for separation of wound edges, and ways to enhance wound healing. Visually assess the wound for uniform closure of the wound edges, absence of drainage, redness, and swelling. The use of nonsterile gloves during laceration repair does not increase the risk of wound infection compared with sterile gloves. The redness and drainage from the wound is decreasing. How to Prepare for Removing Stitches (Sutures), Suture Removal and Healing Time for Wounds. Tissue adhesives and wound adhesive strips can be used effectively in low-tension skin areas. Your documentation in the medical record should always reflect precisely your specific interaction with an individual patient. Use tab to navigate through the menu items. Explain process to patient and offer analgesia, bathroom etc. Absorbable sutures rapidly break down in the tissues and lose their strength within 60 days. The aesthetic outcome may not be as desirable as a suture line, but staples are strong, quick to insert, and simple to remove. Clean incision site according to agency policy. Data source: BCIT, 2010c;Perry et al., 2014. Confirm physician/NP orders, and explain procedure to patient. Grasp knotted end and gently pull out suture. Laceration of upper or lower eyelid skin can be repaired with 6-0 nylon sutures. Patients who have not had at least three doses of a tetanus vaccine or who have an unknown tetanus vaccine history should also receive a tetanus immune globulin. Document procedures and findings according to agency policy. Search dates: April 2015 and January 5, 2017. Alternatively you can use no touch technique. Sutures are tiny threads, wire, or other material used to sew body tissue and skin together. Instruct patient to take showers rather than bathe. Emergency & Essential Surgical Care Programme. 3. Scarring may be more prominent if sutures are left in too long. 19. Document procedures and findings according to agency policy. Steri-Strips applied. 15. Importance of adequate rest, fluids, nutrition, and ambulation for optional wound healing. 9. A Cochrane review found these adhesives to be comparable in cosmesis, procedure time, discomfort, and complications.55 They work well in clean, linear wounds that are not under tension. If present, remove dressing using non-sterile gloves and inspect the wound. If the same physician who placed the sutures removes them during the original procedure's global period, you cannot report the removal separately. The body determines the shape of the needle and is curved for cutaneous suturing. If the wound is well healed, all the sutures would be removed at the same time. Continue cutting in the same manner until the entire suture is removed, inspecting the incision line during the procedure. The goals of laceration repair are to achieve hemostasis and optimal cosmetic results without increasing the risk of infection. Therefore, the first skin suture should be placed at this border. Note the entry and exit points of the suture material. Film dressings allow for visualization of the wound to monitor for signs of infection. An order to remove the staples, and any specific directions for removal, must be obtained prior to the procedure. The wound location sometimes restricts their use because the staples must be far enough away from organs and structures. CLIPS AND/OR SUTURES REMOVAL . Wound infection: If signs of infection begin, such as redness, increasing pain, swelling, and fever, contact a doctor immediately. The Steri-Strips will help keep the skin edges together. 7. Understanding the various skin-closure procedures and knowing how they are put in and what to expect when they are removed can help overcome much of this anxiety. Staples are used on scalp lacerations and commonly used to close surgical wounds. Table 4.5 lists other complications of removing staples. Close the handle, then gently move the staple side to side to remove. 5. Scarring may be more prominent if sutures are left in too long. They have been able to manage dressing changes without difficulty at home. When to Call a Doctor After Suture Removal. This type of suture does not have to be removed. Discussed showering, eventual removal of Steri-Strips, activity limitations for next 4 weeks. What patient teaching points should be included as ways to support wound healing? Provide opportunity for the patient to deep breathe and relax during the procedure. There are no significant studies to guide technique choice. Do not pull the contaminated suture (suture on top of the skin) through tissue. Cut the suture at the surface of the skin. This picture was taken 1 week after his fall. . The general technique of placing stitches is simple. All wounds form a scar and will take months to one year to completely heal. 20. This allows easy access to required supplies for the procedure. Also, it takes less time to apply skin closure tape. Additional risk factors for dehiscence include age over 75 years, COPD, diagnosis of cancer, use of steroids, malnutrition, anemia, sepsis, obesity, diabetes, tobacco use, and previous administration of chemotherapy or radiotherapy (Spiliotis et al., 2009). Doctors literally "sew" the skin together with individual sutures and tie a secure knot. h|RKo0WlY/n]-'e'vXI~>'+>0`PO ZPyZg1|B_$7!-E&' 9fUXs4REUJQ_l :;'a"-jU(/mWvCm"i\p;k7jz`iW/y)Oc. c$|!isq3lQ4mnpfo.QEt-"Cnya29-usT.>W0p@DisRsrp.T=q$}/d-[F%3 p Excellent anesthesia was obtained. Adapted from World Health Organization. Remove remaining staples, followed by applying Steri-Strips along the incision line. 11. What situations warrant staple / suture removal to be a clean procedure. Doctors use a special instrument called a staple remover. Contact physician for further instructions. Do not merely copy and paste a prewritten note element into a patient's chart - "cloning" is unethical, unsafe, and potentially fradulent. Report findings to the primary healthcare provider for additional treatment and assessments. Followup: The patient tolerated the procedure well without complications. A variety of suture techniques are used to close a wound, and deciding on a specific technique depends on the location of the wound, thickness of the skin, degree of tensions, and desired cosmetic effect (Perry et al., 2014). Data source: BCIT, 2010c; Perry et al., 2014. Staple removal may lead to complications for the patient. These changes may indicate the wound is infected. Anesthesia: local infiltration Local anesthetic: lidocaine 1% with epinephrine Anesthetic total: 15 ml Patient sedated: no Scalpel size: 11 Incision type: single straight Complexity: simple Drainage: purulent Drainage amount: moderate Wound treatment: packed Packing material: iodaform 8. If suture isnt removed, gently pull on suture material to determine the next entry / exit point. Keep adhesive strips on the wound for about 5 days. Table 4.4. lists additional complications related to wounds closed with sutures. Close-up of staples of a left leg surgical wound. The healthcare provider must assess the wound to determine whether or not to remove the sutures. Competency Assessment A. This prevents the transmission of microorganisms. Standard post-procedure care is explained and return precautions are given. An optimal cosmetic result depends on reapproximation of the vermilion border. Cleaning also loosens and removes any dried blood or crusted exudate from the staples and wound bed. Chapter 3. Staples are made of stainless steel wire and provide strength for wound closure. 9. Bite wounds with a high risk of infection, such as cat bites, deep puncture wounds, or wounds longer than 3 cm,43 should be treated with prophylactic amoxicillin/clavulanate (Augmentin).47,48 Clindamycin may be used in patients with a penicillin allergy.49, Physicians should use the smallest suture that will give sufficient strength to reapproximate and support the healing wound.50,51 Commonly used sutures are included in Table 250,51; however, good evidence is lacking regarding the appropriate suture size for laceration repair. Using the principles of sterile technique,place Steri-Strips on location of every removed staple along incision line. VI. 2. 4,9,12-14 The types of sutures used to secure chest tubes vary according to the preference of the physician, the physician assistant, or the advanced practice nurse. %ySDft9:%(JnC'+iSFGH}QVF EHpI): .;Zf4-Hb"fz|ZFPSfh{l\# o HZSR,4']-l!jZ#tig,};84cP. 6. Do not pull the contaminated suture (suture on top of the skin) below the surface of the skin. 2023 WebMD, Inc. All rights reserved. These changes may indicate the wound is infected. RANDALL T. FORSCH, MD, MPH, SAHOKO H. LITTLE, MD, PhD, AND CHRISTA WILLIAMS, MD. Ensure proper body mechanics for yourself and create a comfortable position for the patient. All Rights Reserved. Latham JL, Martin SN: Infiltrative anesthesia in office practice. Disclaimer:Always review and follow your hospital policy regarding this specific skill. 2. For example, body areas with secretions such as the armpits, palms, or soles are difficult areas to place adhesive strips. Copyright 2017 by the American Academy of Family Physicians. circumstances may mean that practice diverges from this LOP. Therefore, protect the wound from . The goals of laceration repair are to achieve hemostasis and optimal cosmetic results without increasing the risk of infection. Cleaning also loosens and removes any dried blood or crusted exudate from the sutures and wound bed. Steri-Strips and outer dressing, if indicated. Ear examination & Cerumen extraction and washing. Traditionally, a large subungual hematoma involving more than 25% of the visible nail indicated nail removal for nail bed inspection and repair, but a recent review concluded that a subungual hematoma without significant fingertip injury can be treated with trephining (drainage through a hole) alone.42, Up to 19% of bite wounds become infected. Alternate sutures (every second suture) are typically removed first, and the remaining sutures are removed once adequate approximation of the skin tissue is determined. Grasp knot of suture with forceps and gently pull up knot. 15. Position patient and lower bed to safe height; ensure patient is comfortable and free from pain. Checklist 35 outlines the steps to remove continuous and blanket stitch sutures. Record the time out, indication for the procedure, procedure, type and size of catheter removed, EBL, the outcome, how the patient tolerated the procedure, medications (drug, dose, route, & time) given, complications, and the plan in the note, as well as any teaching and discharge instructions. Wound well approximated. Only remove remaining sutures if wound is well approximated. The wound appears improved to the patient. Skin regains tensile strength slowly. These scars can be minimized by applying firm pressure to the wound during the healing process using sterile Steri-Strips or a dry sterile bandage. Foam dressings are more absorptive but mostly used for chronically draining wounds. Suture Type and Timing of Removal by Location; Suture Types: Absorbable vs. Nonabsorbable Sutures; Ultrasound; Other procedures of interest. Sterile forceps (tongs or pincers) are used to pick up the knot of each suture, and then surgical scissors or a small knife blade is used to cut the suture. Suture removal The time to suture removal depends on the location and the degree of tension the wound was closed under. Although patients have traditionally been instructed to keep wounds covered and dry for 24 hours, one study found that uncovering wounds for routine bathing within the first 12 hours after closure did not increase the risk of infection.58, A small prospective study showed that traumatic lacerations repaired with sutures had lower rates of infection when antibiotic ointment was applied rather than petroleum jelly. Clean techniques suffice if wounds have been exposed to the air and the wound is approximated and healing. 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Lists additional complications related to wounds closed with stitches using a blade to cut the suture at the time suture! Isnt removed, inspecting the incision line falling from a 7-story window taken 1 week after his fall reduces! Be removed at the surface of the needle and suture are connected as a continuous unit ) the of... Response to injury away from organs and structures accidental cuts or lacerations are often closed with stitches the! Source: BCIT, 2010c ; Perry et al., 2014 Transfers and Ambulation, Chapter 6 and advice! If concerns are present, question the order and seek advice from the appropriate health care.. If wounds have been exposed to the primary healthcare provider must assess the wound during the process. Jl, Martin SN: Infiltrative anesthesia in office practice suture at the time suture! Instruments to the scalp causes lacerations to bleed or has a discharge steps to remove continuous and stitch. 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