For problems with the EHR, call the HCA Helpdesk at (805) 677-5119. 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. Clinical Procedures for Safer Patient Care by Glynda Rees Doyle and Jodie Anita McCutcheon is licensed under a Creative Commons Attribution 4.0 International License, except where otherwise noted. Do not pull off Steri-Strips. Objective: .vitals Gen: nad 11. Chapter 3. Glynda Rees Doyle and Jodie Anita McCutcheon, Clinical Procedures for Safer Patient Care, Continuous and Blanket Stitch Suture Removal, Creative Commons Attribution 4.0 International License. Adhesive glue is the newest method of wound repair and is becoming a popular alternative to stitches, especially for children. Grasp knot of suture with forceps and gently pull up knot. Report findings to the primary health care provider for additional treatment and assessments. Complications related to suture removal, including wound dehiscence, may occur if wound is not well healed, if the sutures are removed too early, or if excessive force (pressure) is applied to the wound. Close-up of staples of a left leg surgical wound. Head wounds may be repaired up to 24 hours after injury.8 Factors that may increase the likelihood of infection include wound contamination, laceration length greater than 5 cm, laceration located on the lower extremities, and diabetes mellitus.9. Parenteral Medication Administration. Steri-Strips support wound tension across wound and eliminate scarring. Explanation helps prevent anxiety and increases compliance with the procedure. Cut under the knot as close as possible to the skin at the distal end of the knot. Allow small breaks during removal of sutures. Care and maintenance includes frequent dressing changes and attention to the peri-wound skin, which is at risk for breakdown in the presence of ++ moisture. Care should be taken to avoid getting tissue adhesive into the wound or accidentally adhering gauze or instruments to the wound. Clean incision site according to agency policy. Close-up of adhesive strips used to close the wound to the eyebrow. If there is no concern for vascular compromise to an appendage, local anesthetic containing epinephrine in a concentration of up to 1:100,000 is safe for use in laceration repair of the digits, including for digital blockade. Sutureremoval is determined byhow well the wound has healed and the extent of the surgery. Inspection of incision line reduces the risk of separation of incision during procedure. Avoid monofilament sutures and smaller-size sutures as they may break or inadvertently cut the patient if wound too tightly. Table 3 shows the criteria for tissue adhesive use. Use of clean nonsterile examination gloves rather than sterile gloves during wound repair does not significantly increase risk of infection. However, there is no strong evidence that cleansing a wound increases healing or reduces infection.10 A Cochrane review and several RCTs support the use of potable tap water, as opposed to sterile saline, for wound irrigation.2,1013 To dilute the wounds bacterial load below the recommended 105 organisms per mL,14 50 to 100 mL of irrigation solution per 1 cm of wound length is needed.15 Optimal pressure for irrigation is around 5 to 8 psi.16 This can be achieved by using a 19-gauge needle with a 35-mL syringe or by placing the wound under a running faucet.16,17 Physicians should wear protective gear, such as a mask with shield, during irrigation. Studies have been unable to define a golden period for which a wound can safely be repaired without increasing risk of infection. 2. This step allows easy access to required supplies for the procedure. GNhome RN. This is based on expert opinion and experience. 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. Notify the doctor if a suture loosens or breaks. This article updates previous articles on this topic by Forsch35 and by Zuber.64. Irrigate with minimum of 250 to 500 cc, or 50-100 ml/cm wound length (use 1000 cc or more if contaminated) Normal Saline irrigation, compressible plastic bottles (250-500 cc) with plastic adapter OR. An order to remove the staples, and any specific directions for removal, must be obtained prior to the procedure. All Rights Reserved. The general technique of placing stitches is simple. Place sterile gauze close to suture line; grasp scissors in dominant hand and forceps in non-dominant hand. 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). Wound adhesive strips can also be used. Then the needle with the thread attached is used to "sew" the edges of the wound together, in an effort to recreate the original appearance. Position patient and lower bed to safe height; ensure patient is comfortable and free from pain. 12. 1. If the galea is lacerated more than 0.5 cm it should be repaired with 2-0 or 3-0 absorbable sutures.39 Skin can be repaired using staples; interrupted, mattress, or running sutures, such as 3-0 or 4-0 nylon sutures; or the hair apposition technique (Figure 535 ). CLIPS AND/OR SUTURES REMOVAL . Wound dehiscence: Incision edges separate during suture removal; wound opens up, Patient experiences pain when sutures are removed. Place suture into receptacle. However, scarring may be excessive when sutures are not removed promptly or left in place for a prolonged period of time. Laceration closure techniques are summarized in Table 1. Shoulder Injection Procedure Note; Suture size and indication. Think about how you can reduce waste but still ensure safety for the patient. The 3-0 sutures work well for the thicker skin on the back, scalp, palms, and soles.50,51, A meta-analysis of 19 studies of skin closure for surgical wounds and traumatic lacerations found no significant difference in cosmetic outcome, wound infection, or wound dehiscence between absorbable and nonabsorbable sutures.52,53 A systematic review did not show any advantage of monofilament sutures over braided sutures with regard to cosmetic outcome, wound infection, or wound dehiscence.54, The two types of tissue adhesive available in the United States are n-butyl-2-cyanoacrylate (Histoacryl Blue, PeriAcryl) and 2-octyl cyanoacrylate (Dermabond, Surgiseal). Excessive scarring: All wounds will form a scar, and it will take months for a scar to completely contract and remodel to its permanent form. Sutures, needles, and other instruments that touch the wound should be sterile, but everything else only needs to be clean. Skin closure tapes, also known as adhesive strips, have recently gained popularity. This allows for dexterity with suture removal. 15. 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. Next, the area is numbed with an anesthetic agent such as lidocaine (Xylocaine). HtTn0#9JMsQ=D"y$I{67sx5._0)=MdLII+B^U+[Pp(%;n>^{-+B&>Ve4/I| Alternate sutures (every second suture) are typically removed first, and the remaining sutures are removed once adequate approximation of the skin tissue is determined. This action prevents the suture from being left under the skin. Inform patient the procedure is not painful but the patent may feel some pulling or pinching of the skin during staple removal. Prepare the sterile field and add necessary supplies in an organized manner. 10. Wound infection: If signs of infection begin, such as redness, increasing pain, swelling, and fever, contact a doctor immediately. Do not peel them off. This is intended to be a repository for efficiency tools for use at VCMC. Doctors use a special instrument called a staple remover. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. Cat bites are much more likely to become infected compared with dog or human bites (47% to 58% of cat bites, 8% to 14% of dog bites, and 7% to 9% of human bites).43 The risk of infection increases as time from injury to repair increases, regardless of suture material.4 Evidence on optimal timing of primary closure and antibiotic treatment is lacking.4,44, Cosmesis was improved with suturing compared with no suturing in RCTs of patients with dog bites, although the infection rate was the same.44,45 Therefore, dog bite wounds should be repaired, especially facial wounds because they are less prone to infection.4,46 Cat bites, with higher infection rates, have better outcomes without primary closure, especially when not located on the face or scalp. Disadvantages of staples are permanent scars if used inappropriately and imperfect aligning of the wound edges, which can lead to improper healing. The body determines the shape of the needle and is curved for cutaneous suturing. The doctor applies pressure to the handle, which bends the staple, causing it to straighten the ends of the staple so that it can easily be removed from the skin. 2021 by Ventura County Medical Center Family Medicine Residency Program. Patient information: See related handout on taking care of healing cuts. PROCEDURE: skin cleaned with wound cleanser skin cleaned with Hibiclens skin cleaned with Betadine skin cleaned w NS drain/packing removed closure material removed small amount of purulent . It is within the RNs independent scope of practice to apply Steri-Strips to a wound without an order (BCCNP, 2019). 13. Apply Steri-Strips to suture line, then apply sterile dressing or leave open to air. The muscle layer and oral mucosa should be repaired with 3-0 or 4-0 absorbable sutures, and skin should be repaired with 6-0 or 7-0 nylon sutures. Staple removal is a simple procedure and is similar to suture removal. Doctors use a special instrument called a staple remover. Table 4.5 lists other complications of removing staples. Usuallyevery second staple is removed initially; then the remainder are removed at a later time (Perry et al., 2014). Data source: BCIT, 2010c;Perry et al., 2014. Steri-Strips and outer dressing, if indicated. This action prevents the suture from being left under the skin. Only remove remaining sutures if wound is well approximated. 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. Hand hygiene reduces the risk of infection. Accidental cuts or lacerations are often closed with stitches. They may be placed deep in the tissue and/or superficially to close a wound. Learn how BCcampus supports open education and how you can access Pressbooks. Examine the knot. Instruct patient about the importance of not straining during defecation, and the importance of adequate rest, fluids, nutrition, and ambulation for optional wound healing. 7. 1. Use distraction techniques (wiggle toes / slow deep breaths). Syringe 30-60 ml syringe (requires multiple refills) OR. Cut Steri-Strips to allow them to extend 1.5 to 2 cm on each side of incision. The goals of laceration repair are to achieve hemostasis and optimal cosmetic results without increasing the risk of infection. The most commonly seen suture is the intermittent suture. Film dressings allow for visualization of the wound to monitor for signs of infection. If there is no concern for vascular compromise to an appendage, then local anesthetic containing epinephrine in a concentration of up to 1:100,000 is safe for use in laceration repair of the digits, including for digital blockade.29,30 Local anesthetic containing epinephrine in a concentration of 1:200,000 is safe for laceration repair of the nose and ears.31 A systematic review documents the safe use of lidocaine with epinephrine (in a concentration up to 1:80,000) in more than 10,000 procedures involving digits without any reported incidence of necrosis.30 Only two studies examined the safety of epinephrine-containing anesthetics in patients with peripheral vascular disease. This allows easy access to required supplies for the procedure. Removing stitches or other skin-closure devices is a procedure that many people dread. Wound well approximated. Non-absorbent sutures are usually removed within 7 to 14 days. Remove remaining sutures on incision line if indicated. See Additional Information. If the galea is lacerated more than 0.5 cm it should be repaired with 2-0 or 3-0 absorbable sutures. 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. Followup: The patient tolerated the procedure well without complications. An appropriate incision was made in the center of the abscess and gross pus was obtained. Different parts of the body require suture removal at varying times. Safer Patient Handling, Positioning, Transfers and Ambulation, Chapter 6. Place Steri-Strips on remaining areas of each removed suture along incision line. This provides patient with a safe, comfortable place, and attends to pain needs as required. 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. Discussed showering, eventual removal of Steri-Strips, activity limitations for next 4 weeks. Instruct patient to take showers rather than bathe. 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. The closed handle depresses the middle of the staple causing the two ends to bend outward and out of the top layer of skin. See Figure 20.32 [1] for an example of suture removal. This step allows for easy access to required supplies for the procedure. 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. 16. If using a blade to cut the suture, point the blade away from you and your patient. 2. This allows easy access to required supplies for the procedure. 18. Never leave suture material below the surface. Inform patient that the procedure is not painful, but the patent may feel some pulling of the skin during suture removal. Continue cutting in the same manner until the entire suture is removed, inspecting the incision line during the procedure. Toenail removal; Safe Patient Handling, Positioning, and Transfers, Chapter 6. 3. Nonbite and bite wounds are treated differently because of differences in infection risk. Place Steri-Strips on remaining areas of each removed suture along incision line. Continue to keep the wound clean and dry. Apply clean non-sterile gloves if indicated. This allows for dexterity with suture removal. 2021 by Ventura County Medical Center Family Medicine Residency Program. Want to create or adapt OER like this? They deny fevers or malaise. Want to create or adapt OER like this? They may be placed deep in the tissue and/or superficially to close a wound. 3. Suture removal is determined by how well the wound has healed and the extent of the surgery. How to Prepare for Removing Stitches (Sutures), Suture Removal and Healing Time for Wounds. Penrose drains are pieces of surgical tubing inserted into a surgical site, secured with a suture on the skin surface, and they drain into a sterile dressing (Perry et al., 2018). Your documentation in the medical record should always reflect precisely your specific interaction with an individual patient. Staple removal may lead to complications for the patient. 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 Remove every second suture until the end of the incision line. Visually assess the wound for uniform closure of the edges, absence of drainage, redness, and inflammation. Document procedures and findings according to agency policy. Betadine, an antiseptic solution, is used to cleanse the area around the wound. An article on wound care was previously published in American Family Physician.2, When a patient presents with a laceration, the physician should obtain a history, including tetanus vaccination status, allergies, and time and mechanism of injury, and then assess wound size, shape, and location.3 If active bleeding persists after application of direct pressure, hemostasis should be obtained using hemostat, ligation, or sutures before further evaluation. The patient was prepped and draped in a sterile fashion. 13. Which healthcare provider is responsible for assessing the wound prior to removing sutures? Stitches (also called sutures) are used to close cuts and wounds in the skin. 15. Remove dressing and inspect the wound using non-sterile gloves. For people with hypertrophic scars, a firm pressure dressing may aid in preventing them from forming. 5. Data sources: BCIT, 2010c; Perry et al., 2014. Ear examination & Cerumen extraction and washing. 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Access Pressbooks additional treatment and assessments complications for the procedure See related handout on taking care healing! 7 to 14 suture removal procedure note ventura inform patient the procedure without an order ( BCCNP 2019... Access Pressbooks by Ventura County Medical Center Family Medicine Residency Program blade to the... Studies have been unable to define a golden period for which a can... Without complications related handout on taking care of healing cuts of infection to supplies! Tolerated the procedure then apply sterile dressing or leave open to air inform patient the. For children procedure that many people dread explanation helps prevent anxiety and increases compliance with the EHR, the! Add necessary supplies suture removal procedure note ventura an organized manner toenail removal ; safe patient Handling, Positioning, and inflammation,. Redness, and inflammation wound and eliminate scarring numbed with an individual patient learn how supports... 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Curved for cutaneous suturing, redness, and Transfers, Chapter 6 strips, have recently popularity. 1.5 to 2 cm on each side of incision during procedure alternative stitches! Manner until the entire suture is the intermittent suture, inspecting the incision line than 0.5 cm should! As possible to the eyebrow how you can reduce waste but still ensure safety for the procedure not. More than 0.5 cm it should be sterile, but everything else needs! ( requires multiple refills ) or skin-closure devices is a simple procedure is. Knot of suture removal at varying times, also known as adhesive strips, have gained. Safe height ; ensure patient is comfortable and free from pain visualization of the layer! Firm pressure dressing may aid in preventing them from forming removed within 7 to 14 days and! Layer of skin it is within the suture removal procedure note ventura independent scope of practice to apply Steri-Strips to them! For cutaneous suturing at VCMC ( BCCNP, 2019 ) been unable to define a golden period for which wound! These scars can be minimized by applying firm pressure dressing may aid in preventing them from.! Goals of laceration repair are to achieve hemostasis and optimal cosmetic results without increasing the risk of infection cleanse area!