Surgical Wounds Care and Suture and Staple Removal
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Bow Valley College, Calgary *
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NURS1203
Subject
Medicine
Date
Feb 20, 2024
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docx
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Uploaded by BarristerDugong382
Surgical Wounds Care and Suture and Staple Removal
The phases of healing of surgical incisions:
-
Hemostasis: reduced bleeding and forms clot
-
Inflammatory: killing phase, infiltration of leukocytes
-
Proliferative: granulation tissue, immature collagen
-
Maturation: scar tissue becomes flexible, tissue strength increases
Patient assessments to be done prior to completing a surgical dressing
change:
-
Check Doctor’s orders
-
Pain assessment (check if pain relief is required)
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Assess outside of dressing for shadowing
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Explain procedure to patient
Wound assessments necessary during a surgical dressing change:
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Check Doctor’s orders
-
TACO (type, amount, colour/consistency, odour)
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REEDA (redness/erythema, ecchymosis/bruising, edema/swelling, discharge/drainage, approximation
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How the patient is tolerating the pain
The steps of dressing removal, cleansing the wound, removing sutures or staples, and application of a new dressing to a surgical wound:
Dressing Removal
1)
Hand hygiene
2)
Remove binders and/ or tape
3)
Don clean gloves
4)
Remove dressing away from patients’ line of sight
5)
Asses wound drainage
6)
Discard old dressing and gloves in biohazard container
Cleansing the wound
1) Set up sterile field
2) Cleanse wound with normal saline unless otherwise ordered. Use surgical asepsis to not contaminate wound bed (cleanest to dirtiest)
3) If drain present cleanse and avoid reaching across cleansed wound
4) Dry peri wound tissue as necessary
Removing sutures or staples
Staples
1) Insert the tips of the staple remover under each wire staple.
2) Close staple remover and squeeze the centre of the staple with the tips
Sutures
1) Cut the suture as close to the skin as possible away from the knot
2) Remove the suture and never pull the contaminated stitch through the
tissues
New dressing
1) Apply sterile gauze to wound maintaining surgical asepsis
2) Apply sterile pad over sterile gauze
as required
3) Secure dressing with tape
4) Date and initial dressing
Purpose of skin closures:
-
Speed up healing
-
Protect underlying tissues
-
Reduce scar formation
Common types of sutures:
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intermittent: individuals stitches are not connected
-
continuous: stiches are connected along the wound
-
blanket: sub-category of continuous, self-locking
Absorbable vs non-absorbable sutures and deep versus superficial sutures:
Absorbable:
made from materials that the body can naturally absorb over time
Non-absorbable:
Must be removed
Assessments needed before the removal of sutures or staples:
-
Practitioner’s orders
-
Approximation of incision
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What type of closure device was used
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If sutures were used, are they absorbable or not
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Count how many staples/sutures are present
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Any signs of infection such as redness, swelling, or drainage
Supplies needed for removal of sutures or staples:
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Cavi wipes
-
Hand sanitizer
-
Dressing tray
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Normal saline
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Clean gloves
-
Staple remover and suture removal kit
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Steri-strips
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Extra sterile supplies such as gauze, forceps, etc.
Contraindications to suture or staple removal:
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Wound is not well approximated
-
Wound appears to be infected
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Process of applying steri-strips to the incision following removal of sutures or staples:
-
Remove all the staples/sutures you are going to prior to application
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Ensure wound is dry
-
Remove steri-strips from sheet touching edges only to maintain sterility of
middle strip
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Apply to wound
Complications to suture or staple removal:
-
Dehiscence (partial or total separation of wound layers
-
Evisceration (protrusion of internal organs through wound opening)
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Fistulas (abnormal passage between two organs or between and organ and the outside of the body)
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Hemorrhage (bleeding or hematoma)
-
Infection
Nursing actions if complications arise during or following suture or staple removal:
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Complications: Stop removal, cover wound, and inform physician (SBAR)
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Infection: Cleanse the wound (saline), Wound culture
Patient teachings for the care of surgical wound:
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Nutrition
-
Signs of infection
-
Wound care
-
activities they can/cannot do
Report and document pertinent information following the changing of a
surgical dressing and suture or staple removal:
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DARP (data, action, response, plan)
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How many stitches/how many removed
-
What was done after
Surgical dressing change:
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Contact layer/primary layer
-
Absorbent layer
-
Outer protective layer/secondary layer
-
Secure, packing, and comfortable
Intermittent suture removal: hold scissors in dominant hand and forceps in non-dominant hand. Grasp knot of suture with forceps and gently pull up knot while slipping the tip of
the scissors under suture near the skin. Cut under the knot as close as possible to the skin at the distal end of the knot (Never snip both ends of the knot as there will be no way to remove the suture from below the surface). Grasp knotted end with forceps, and in one continuous action pull suture out of the tissue. Remove every second suture until the end of the incision line. place Steri-Strips on location of every removed suture along incision line. Remove remaining sutures on incision line if indicated.
Continuous suture removal:
Snip first suture close to the skin surface, distal to the knot. Snip second suture on the same side. Grasp knotted end and gently pull-out suture. Continue cutting in the same manner until the entire suture is removed, inspecting the incision line during the procedure. Apply Steri-Strips to suture line, then apply sterile dressing or leave open to air.
Staple removal:
1)
Place remover, insert tips under each staple.
2)
While slowly closing the ends of the remover, squeeze the center of the staple with the tips, freeing the staple from the skin (may require a gentle
back and forth motion).
-
Remove every second one and place Steri-Strips on location of every removed staple.
-
If Staple gets stuck in remover use a forceps to remove to maintain sterility of staple remover tip
Staples are normally taken out between 7-10 day of wound healing
Sutures are taken out 4-14 days after being placed
Dehiscence is partial or total separation of previous approximated wound edges
Sutures and staples fall under primary intention
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