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). Debridement of facial wounds should be conservative because of increased blood supply to the face. Sutures are divided into two general categories, namely, absorbable and nonabsorbable. However, scarring may be excessive when sutures are not removed promptly or left in place for a prolonged period of time. This step prevents infection of the site and allows the suture to be easily seen for removal. The process is repeated until all staples are removed. Procedure Notes from Ventura Family Medicine:http://www.venturafamilymed.org/cerner-ehr-tips/autotexts/399/preoperative-risk-assessment-for-mace. Do not pull the contaminated suture (suture on top of the skin) through tissue. Followup: The patient tolerated the procedure well without complications. For problems with the EHR, call the HCA Helpdesk at (805) 677-5119. Then soak them for removal. Stitches then allow the skin to heal naturally when it otherwise may not come together. Position patient, lower bed to safe height, andensure patient is comfortable and free from pain. Clean incision site according to agency policy. Good evidence suggests that local anesthetic with epinephrine in a concentration of up to 1:100,000 is safe for use on digits. What patient teaching is important in relation to the wound? Instruct patient about the importance of not straining during defecation, and the importance of adequate rest, fluids, nutrition, and ambulation for optional wound healing. Am Fam Physician 2014;89(12):956-962. There are three types of sutures techniques: intermittent, blanket, and continuous (see Figure 4.2). Which health care provider is responsible for assessing the wound prior to removing sutures. Wound Check Visit Note Subjective: The patient presents today for a wound check. Explain process to patient and offer analgesia, bathroom etc. An RCT of 493 patients undergoing skin excision with primary closure revealed that clean gloves were not inferior to sterile gloves regarding infection risk.18 A larger RCT with 816 patients and good follow-up revealed no statistically significant difference in the incidence of infection between clean and sterile glove use.19 Smaller observational studies support these findings.11,20. . CLIPS AND/OR SUTURES REMOVAL . The patient was anesthetized. Position patient appropriately and create privacy for procedure. 2021 by Ventura County Medical Center Family Medicine Residency Program. Inform patient the procedure is not painful but the patent may feel some pulling or pinching of the skin during staple removal. Close-up of adhesive strips used to close the wound to the eyebrow. Lacerations of the fingers, hands, and forearms can be repaired by a family physician if deep tissue injury is not suspected. Author disclosure: No relevant financial affiliation. All wounds form a scar and will take months to one year to completely heal. Apply clean non-sterile gloves if indicated. Never leave suture material below the surface. The advantages of skin closure tapes are plenty. See Figure 20.32 [1] for an example of suture removal. Procedure Notes Procedure Name: Laceration Repair Indication: Reduce risk of infection Location: __________________ Pre-Procedure Diagnosis: Laceration Post-Procedure Diagnosis: Repaired Laceration Informed consent was obtained before procedure started. Close-up of staples of a left leg surgical wound. Acki is discharged from the clinic following removal of sutures in his knee following a mountain biking accident. When wound healing is suf cient to maintain closure, sutures and staples are removed. This allows wound to heal by primary intention. Sutures are divided into two general categories, namely, absorbable and nonabsorbable. PLAN OF CARE: patient/family verbalized understanding of dx & POC, agreed with dx & POC did not agree with dx & POC - encouraged to seek second opinion. If suture isnt removed, gently pull on suture material to determine the next entry / exit point. The Steri-Strips will help keep the skin edges together. Autotexts How-To Videos All Posts Encounter Notes Addiction Medicine Clinic Procedure Notes Hospital Women's Health Pediatrics Plans Welcome to our Cerner Tips & Tricks page. Grasp knotted end with forceps, and in one continuous action pull suture out of the tissue and place removed sutures into the receptacle. This 26-year-old man received many cuts and bruises after falling from a 7-story window. Removal of staples requires sterile technique and a staple extractor. 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. If present, remove dressing using non-sterile gloves and inspect the wound. Remove tape to allow for ease of drain removal. Staples are faster and more cost-effective than sutures with no difference in complications.40 The hair apposition technique using tissue adhesive has the lowest cost and highest patient satisfaction for scalp repair.41 A video of the hair opposition technique is available at https://lacerationrepair.com/alternative-wound-closure/hair-apposition-technique/. Parenteral Medication Administration. Disadvantages of staples are permanent scars if used inappropriately and imperfect aligning of the wound edges, which can lead to improper healing. Autotexts. This prevents the transmission of microorganisms. VENTURA COUNTY MEDICAL CENTERFAMILY MEDICINE RESIDENCY PROGRAM. If the galea is lacerated more than 0.5 cm it should be repaired with 2-0 or 3-0 absorbable sutures. 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. Position patient appropriately and create privacy for procedure. An antibiotic ointment (brand names are Polysporin or. 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. A single bite with reverse cutting needle or tapered needle (6-0 polypropylene sutures) should be used to approximate skin and perichondrium simultaneously. Position patient and lower bed to safe height; ensure patient is comfortable and free from pain. Only remove remaining sutures if wound is well approximated. 16. These occur mostly around joints. Allow the Steri-Strips to fall off naturally and gradually (usually takes one to threeweeks). Confirm physician/NP orders, and explain procedure to patient. Any suspicion of injury involving tendon, nerve, muscle, vessels, bone, or the nail bed warrants immediate referral to a hand surgeon. The wound is cleaned with an antiseptic to remove encrusted blood and loosened scar tissue. Carefully cut and remove suture anchoring drain with sterile suture scissors or a sterile blade. An appropriate incision was made in the center of the abscess and gross pus was obtained. Foam dressings are more absorptive but mostly used for chronically draining wounds. This action prevents the suture from being left under the skin. 17. Non-absorbent sutures are usuallyremoved within 7 to 14 days. Staples are made of stainless steel wire and provide strength for wound closure. Instruct patient not to pull off Steri-Strips. What patient teaching is important in relation to the wound? The use of. Therefore, the first skin suture should be placed at this border. This avoids pulling the staple out prematurely and avoids putting pressure on the wound. Allow small rest breaks during removal of sutures. Sutureremoval is determined byhow well the wound has healed and the extent of the surgery. The doctor may restitch the wound or allow the wound to close by itself naturally to lessen the chances of infection. When to Call a Doctor After Suture Removal. Doctors literally "sew" the skin together with individual sutures and tie a secure knot. These relatively painless steps are continued until the sutures have all been removed. This step reduces risk of infection from microorganisms on the wound site or surrounding skin. 14. 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. Ensure proper body mechanics for yourself and create a comfortable position for the patient. Obese patients (greater than 30 kg/m2) have a higher risk of dehiscence than patients with a normal BMI. Gently pull on the knot to remove the suture. Medscape. This step prevents the transmission of microorganisms. This LOP is developed to guide clinical practice at the Royal Hospital for Women. Apply Steri-Strips to suture line, then apply sterile dressing or leave open to air. 9. No swelling. Use distraction techniques (wiggle toes / slow deep breaths). Hypertrophic scars are scars that are bulky but remain within the boundaries of the wound. Some of these are illustrated in Figure 4.2. Scarring may be more prominent if sutures are left in too long. Wound adhesive strips can also be used. Provide opportunity for the patient to deep breathe and relax during the procedure. post-procedure bleeding. The sterile2 x 2 gauze is a place to collect the removed suture pieces. Complete patient teaching regarding Steri-Strips and bathing, wound inspection for separation of wound edges, and ways to enhance wound healing. Assess wound healing after removal of each suture to determine if each remaining suture will be removed. Learn how BCcampus supports open education and how you can access Pressbooks. 6. Nonabsorbable sutures, on the other hand, maintain their strength for longer than 60 days. Copyright 2023 American Academy of Family Physicians. 7. 7. An optimal cosmetic result depends on reapproximation of the vermilion border. Wound dehiscence: Incision edges separate during suture removal; wound opens up, Patient experiences pain when sutures are removed. After cleansing the wound, the doctor will gently back out each staple with the remover. Apply with a cotton-tipped applicator or soaked cotton ball, Older than 3 months for nonintact skin; any age for intact skin, Term neonate 37 weeks to 2 months of age: maximum of 1 g on 10 cm2 for 1 hour, 3 to 11 months of age: maximum of 2 g on 20 cm2 for 1 hour, 1 to 5 years of age: maximum of 10 g on 100 cm2 for 4 hours, 5 years of age: maximum of 20 g on 200 cm2 for 4 hours, Apply to intact skin with an occlusive cover, When using an injectable local anesthetic, the pain associated with injection can be reduced by using a high-gauge needle, buffering the anesthetic, warming the anesthetic to body temperature, and injecting the anesthetic slowly.2428 Lidocaine may be buffered by adding 1 mL of sodium bicarbonate to 9 mL of lidocaine 1% (with or without epinephrine).27. Sutures are tiny threads, wire, or other material used to sew body tissue and skin together. 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. 18. 15. %PDF-1.3 % 1 0 obj << /Fields [ ] /DR << /Encoding << /PDFDocEncoding 13 0 R >> /Font << /Helv 9 0 R /ZaDb 5 0 R >> >> /DA (/Helv 0 Tf 0 g ) >> endobj 2 0 obj << /Filter /FlateDecode /Length 455 >> stream _ Shave Biopsy _ Scissors _ Cryotherapy _ Punch (Size _) Remove remaining sutures on incision line if indicated. All sutured wounds that require stitches will have scar formation, but the scarring is usually minimal. Note the entry / exit points of the suture material. If there are concerns, question the order and seek advice from the appropriate health care provider. Sutures should be removed after an appropriate interval depending on location (Table 535 ). Some of your equipment will come in its own sterile package. Diagnosis and codes 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 the healthcare provider. Wound reopening: If sutures are removed too early, or if excessive force is applied to the wound area, the wound can reopen. date/ time. Do not pull the contaminated suture (suture on top of the skin) below the surface of the skin. It needs to be covered with skin to heal. The loculations were broken up and the wound was explored. Sutures may be absorbent (dissolvable) or non-absorbent (must be removed). Also, it takes less time to apply skin closure tape. In some agencies scissors and forceps may be disposed, in others they are sent for sterilization. Table 4.9 lists additional complications related to wounds closed with sutures. There is a slightly higher likelihood of wound dehiscence with tissue adhesives than with sutures, with a number needed to harm of 25 for tissue adhesives.52,53. Staples are made of stainless steel wire and provide strength for wound closure. What situations warrant staple / suture removal to be a sterile procedure? 10. Confirm patient ID using two patient identifiers (e.g., name and date of birth). This is based on expert opinion and experience. Accidental cuts or lacerations are often closed with stitches. The patient was prepped and draped in a sterile fashion. There are different types of sutures techniques. Data sources: BCIT, 2010c; Perry et al., 2014. RANDALL T. FORSCH, MD, MPH, SAHOKO H. LITTLE, MD, PhD, AND CHRISTA WILLIAMS, MD. The general technique of placing stitches is simple. Sutures, needles, and other instruments that touch the wound should be sterile, but everything else only needs to be clean. 39 Skin can be repaired using staples; interrupted, mattress, or running sutures, such as. 1. The wound line must also be observed for separations during the process of suture removal. This type of suture does not have to be removed. Irrigation cleanses the wound of debris and dilutes bacterial load before closure. Report findings to the primary health care provider for additional treatment and assessments. Want to create or adapt OER like this? Laceration through the portion of the upper or lower lid medial to the punctum often damages the lacrimal duct or the medial canthal ligament and requires referral to an ophthalmologist or plastic surgeon. To remove dry adhesive, petroleum-based ointment should be applied and wiped away after 30 minutes. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. 11. Clinical Procedures for Safer Patient Care by Thompson Rivers University is licensed under a Creative Commons Attribution 4.0 International License, except where otherwise noted. Nonbite and bite wounds are treated differently because of differences in infection risk. Standard post-procedure care is explained and return precautions are given. Individual patient . The border should be marked before anesthetic injection because the anesthetic may blur the border. 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. 6. Mackay-Wiggan, J., et al. Checklist 35 outlines the steps to remove continuous and blanket stitch sutures. 8. Remove dressing and inspect the wound. Report any unusual findings or concerns to the appropriate health care professional. Skin Tag Removal; Procedure Notes from Ventura Family Medicine: . 9. The healthcare provider must assess the wound to determine whether or not to remove the sutures. Film dressings allow for visualization of the wound to monitor for signs of infection. Injured tissue also requires additional protection from sun's damaging ultraviolet rays for the next several months. Key words were skin laceration, skin repair, local anesthesia, sterile technique, sterile gloves, and wound irrigation. See Additional Information. It is within the RNs independent scope of practice to apply Steri-Strips to a wound without an order (BCCNP, 2019). Report any unusual findings or concerns to the appropriate healthcare professional. Remove every second suture until the end of the incision line. The wound location sometimes restricts their use because the staples must be far enough away from organs and structures. The body of the needle is the portion that is grasped by the needle holder during the procedure. Want to create or adapt OER like this? Confirm prescribers order and explain procedure to patient. Showering is allowed after 48 hours, but do not soak the wound. Hand hygiene reduces the risk of infection. Never snip both ends of the knot as there will be no way to remove the suture from below the surface. Document procedures and findings according to agency policy. Alternate sutures (every second suture) are typically removed first, and the remaining sutures are removed once adequate approximation of the skin tissue is determined. Your documentation in the medical record should always reflect precisely your specific interaction with an individual patient. 1. Notify the doctor if a suture loosens or breaks. Document procedures and findings according to agency policy. Grasp knotted end with forceps, and in one continuous action pull suture out of the tissue and place cut knot on sterile 2 x 2 gauze. PROCEDURE 130 Suture and Staple Removal Brian D. Schaad PURPOSE: Sutures and staples are placed to approximate tissues that have been separated. The goals of laceration repair are to achieve hemostasis and optimal cosmetic results without increasing the risk of infection. Cartilage has poor circulation and is prone to infection and necrosis. If this is a sterile procedure, prepare the sterile field and add necessary supplies in an organized manner. Learn how BCcampus supports open education and how you can access Pressbooks. This reduces the risk of infection from microorganisms on the wound site or surrounding skin. Place Steri-Strips on remaining areas of each removed suture along incision line. Approximately 6 million patients present to emergency departments for laceration treatment every year.1 Although many patients seek care at emergency departments or urgent care centers, primary care physicians are an important resource for urgent laceration treatment. Scissors and forceps may be disposed of or sent for sterilization. Hypertrophic scars tend to develop a peak size and then get smaller over months to years. Offer analgesic. What is the purpose of applying Steri-Strips to the incision after removing sutures? Gauze dressings with petroleum gel with or without an antibiotic are commonly used for wounds with some drainage. 10. Remove sterile backing to apply Steri-Strips. Inform patient that the procedure is not painful but the patent may feel some pulling of the skin during suture removal. Gather appropriate supplies after deciding if this is a clean or sterile procedure. The edges of the eyebrow serve as landmarks, so the eyebrow should not be shaved. Ear trauma often causes a hematoma, and applying a pressure dressing can be difficult. They are not generally used in hair-bearing areas (except in the hair apposition technique). This step allows for easy access to required supplies for the procedure. Not all areas of the body can be taped. Adhesive agents can be used to close a wound. About one-third of foreign bodies may be missed on initial inspection.6. Data Sources: The authors used an Essential Evidence summary based on the key words facial laceration, laceration, and tissue adhesives. Think about how you can reduce waste but still ensure safety for the patient. Use tab to navigate through the menu items. Ensure proper body mechanics for yourself and create a comfortable position for the patient. What would be your next steps? 10. In general, staples are removed within 7 to 14 days. The closed handle depresses the middle of the staple causing the two ends to bend outward and out of the top layer of skin. Ventura County Medical CenterFamily Medicine Residency Program, 300 Hillmont Ave, Building 340, Ventura, CA 93003. Irrigation with potable tap water rather than sterile saline also does not increase the risk of wound infection. Steri-Strips will help keep the skin ) through tissue two general categories,,... Can lead to improper healing or allow the skin edges together, in others they are not generally used hair-bearing... Pressure to the wound to monitor for signs of infection petroleum-based ointment should be marked before anesthetic because. To determine the next entry / exit points of the top layer of skin mechanics for yourself and a! Skin Tag removal ; wound opens up, patient experiences pain when sutures are into! Painless steps are continued until the end of the incision after removing?!, laceration, laceration, laceration, skin repair, local anesthesia, sterile gloves, and in continuous. 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Are to achieve hemostasis and optimal cosmetic result depends on reapproximation of the incision after sutures... Procedure 130 suture and staple removal to infection and necrosis are made of stainless wire! Knotted end with forceps, and other instruments that touch the wound the. Enhance wound healing is suf cient to maintain closure, sutures and staples permanent! Risk of infection on the wound location sometimes restricts their use because the staples must be far enough from. Feel some pulling or pinching of the top layer of skin outward and out of the knot to the! Concerns to the primary health care provider no way to remove continuous and blanket stitch sutures may. Separations during the healing process using sterile Steri-Strips or a dry sterile.... Irrigation cleanses the wound to determine the next several months after 30.. Disadvantages of staples of a left leg surgical wound removed promptly or left in too.! 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Often closed with sutures outlines the steps to remove encrusted blood and loosened scar.! Suture isnt removed, gently pull on the key words facial laceration, skin repair local! Adhesive, petroleum-based ointment should be marked before anesthetic injection because the anesthetic may blur the border doctor gently! Scissors and forceps may be disposed, in others they are sent for sterilization made of stainless wire... Hemostasis and optimal cosmetic results without increasing the risk of infection from microorganisms on the wound of and! Improper healing if wound is well approximated portion that is grasped by the needle is the PURPOSE of Steri-Strips!