Do not peel them off. Report findings to the primary healthcare provider for additional treatment and assessments. Never leave suture material below the surface. 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. Alternate sutures (every second suture) are typically removed first, and the remaining sutures are removed once adequate approximation of the skin tissue is determined. Wound The drainage is serosanguinous as expected, no evidence of extension of erythema, the dressing was changed, the patient tolerated well. Position patient appropriately and create privacy for procedure. If using a blade to cut the suture, point the blade away from you and your patient. Confirm prescribers order and explain procedure to patient. Visually assess the wound for uniform closure of the wound edges, absence of drainage, redness, and swelling. Assess wound healing after removal of each suture to determine if each remaining suture will be removed. Position patient appropriately and create privacy for procedure. This step allows easy access to required supplies for the procedure. They deny fevers or malaise. 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. Confirm physician orders, and explain procedure to patient. The advantages of skin closure tapes are plenty. Instruct patient not to pull off Steri-Strips and to allow them to fall off naturally and gradually (usually takes one to threeweeks). Nonbite and bite wounds are treated differently because of differences in infection risk. Data source: BCIT, 2010c; Perry et al., 2014. Removing stitches or other skin-closure devices is a procedure that many people dread. Therefore, protect the wound from injury during the next month. In some agencies scissors and forceps may be disposed, in others they are sent for sterilization. Want to create or adapt OER like this? Sutures must be left in place long enough to establish wound closure with enough strength to support internal tissues and organs. post-procedure bleeding. Non-absorbent sutures are usually removed within 7 to 14 days. Cartilage has poor circulation and is prone to infection and necrosis. Some of your equipment will come in its own sterile package. Lacerations are considered contaminated at presentation, and physicians should make every effort to avoid introducing additional bacteria to the wound. 12. If concerns are present, question the order and seek advice from the appropriate health care provider. Close the handle, then gently move the staple side to side to remove. The redness and drainage from the wound is decreasing. There are three types of sutures techniques: intermittent, blanket, and continuous (see Figure 4.2). Also, it takes less time to apply skin closure tape. Procedure Notes CERNER EHR Welcome to our Cerner Tips & Tricks page. Accidental cuts or lacerations are often closed with stitches. 16. Chapter 3. A rich blood supply to the scalp causes lacerations to bleed significantly. In addition, if the sutures are left in for an extended period of time, the wound may heal around the sutures, making extraction of the sutures difficult and painful. 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. Inspection of incision line reduces the risk of separation of incision during procedure. 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. Instruct patient about the importance of not straining during defecation, and the importance of adequate rest, fluids, nutrition, and ambulation for optional wound healing. Note the entry / exit points of the suture material. Different parts of the body require suture removal at varying times. Adapted from World Health Organization. Doctors use a special instrument called a staple remover. Wound well approximated. Excellent anesthesia was obtained. Remove remaining sutures on incision line if indicated. Suture removal The time to suture removal depends on the location and the degree of tension the wound was closed under. [2018]. Scarring may be more prominent if sutures are left in too long. Document procedures and findings according to agency policy. 6. To remove dry adhesive, petroleum-based ointment should be applied and wiped away after 30 minutes. Stitches then allow the skin to heal naturally when it otherwise may not come together. Acki is discharged from the clinic following removal of sutures in his knee following a mountain biking accident. Steri-Strips support wound tension across wound and eliminate scarring. After cleansing the wound, the doctor will gently back out each staple with the remover. suture removal kit, dressing change tray, steri-strips (always follow your hospital's protocol when removing sutures because some facilities require you to wear sterile gloves.while others require you to just wear clean gloves.this video will demonstrate using sterile gloves.) 2. All sutures are lost if one suture is cut by mistake or removed for drainage, Can cause skin necrosis and excessive scars, Most effective in everting triangular wound edges in flap repair, Fast and effective in accurate skin edge apposition, Suited for closing clean wounds, such as surgical wounds in the operating room, Effective in accurate skin edge apposition and wound eversion, Should be avoided if cosmetic outcome is important, Used to approximate clean, simple, small lacerations with little tension and without bleeding, Glycolide/lactide polymer (polyglactin 910 [Vicryl]), Deep dermal, muscle, fascia, oral mucosa, genitalia wounds, Mostly used in vascular surgeries; can be used for skin, tendon, and ligaments, depending on the needles, Used for hemostasis in ligation of vessels or for tying over bolsters, Not in a hair-bearing area (unless hair apposition technique is being used), Not under significant tension (or tension relieved with deep absorbable sutures), No chronic condition that might impair wound healing. 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. Contact physician for further instructions. Copyright 2017 by the American Academy of Family Physicians. All sutured wounds that require stitches will have scar formation, but the scarring is usually minimal. The patient presents today for a wound check. Discard supplies according to agency policies for sharp disposal and biohazard waste. The wound is healing as expected. Laceration of upper or lower eyelid skin can be repaired with 6-0 nylon sutures. Suture removal is determined by how well the wound has healed and the extent of the surgery. When wound healing is suf cient to maintain closure, sutures and staples are removed. An order to remove the staples, and any specific directions for removal, must be obtained prior to the procedure. 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. 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). Snip second suture on the same side. Remove dressing and inspect the wound. At the time of suture removal, the wound has only regained about 5%-10% of its strength. They can be used in nearly every part of the body, internally and externally. Wound well approximated. Alternate sutures (every second suture) are typically removed first, and the remaining sutures are removed once adequate approximation of the skin tissue is determined. The staple backs out of the skin the very same direction in which it was placed. See permissionsforcopyrightquestions and/or permission requests. They may require removal depending on where they are used, such as once a skin wound has healed. Welcome to our Cerner Tips & Tricks page. 14. Some of your equipment will come in its own sterile package. After cleansing the wound, the doctor will gently back out each staple with the remover. Studies have been unable to define a golden period for which a wound can safely be repaired without increasing risk of infection. Wound reopening: If sutures are removed too early, or if excessive force is applied to the wound area, the wound can reopen. The "thread" or suture that is used is attached to a needle. Confirm prescribers orders, and explain procedure to patient. Instruct patient to take showers rather than bathe. Perform a point of care risk assessment. 2021 by Ventura County Medical Center Family Medicine Residency Program. 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. Sutures must be left in place long enough to establish wound closure with enough strength to support internal tissues and organs. Many aspects of laceration repair have not changed over the years, but there is evidence to support some updates to standard management. 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). 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. You will need sterile suture scissors or suture blade, sterile dressing tray (to clean incision site prior to suture removal), non-sterile gloves, normal saline, Steri-Strips, and sterile outer dressing. Inform patient that the procedure is not painful but the patent may feel some pulling of the skin during suture removal. The 5-0 or 6-0 sutures should be used for the face, and 4-0 sutures should be used for most other areas. Disclaimer:Always review and follow your hospital policy regarding this specific skill. Emotional trauma is best described as a psychological response to a deeply distressing or life-threatening experience. The body of the needle is the portion that is grasped by the needle holder during the procedure. Confirm patient ID using two patient identifiers (e.g., name and date of birth). 9. 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. People with a tendency to form keloids should be closely monitored by the doctor. Staples are used on scalp lacerations and commonly used to close surgical wounds. Skin cleansed well with NS solution x variable_22 in situ. Apply dry, sterile dressing on incision site or leave exposed to air if wound is not irritated by clothing, or according to physician orders. What situations warrant staple / suture removal to be a sterile procedure? Keloids occur when the body overreacts when forming a scar. 11. Ensure proper body mechanics for yourself and create a comfortable position for the patient. circumstances may mean that practice diverges from this LOP. The procedure is easy to learn, and most physicians . 19. Suture removal is determined by how well the wound has healed and the extent of the surgery. Explaining the procedure will help prevent anxiety and increase compliance with the procedure. 10. Type of suture* Timing of suture removal (days) Arms: 4-0: 7 to 10: Face: 5-0 or . Copyright 2023 American Academy of Family Physicians. 13. Followup: The patient tolerated the procedure well without complications. The general technique of placing stitches is simple. No swelling. Wound dehiscence, a mechanical failure of wound healing, remains a problem and can be affected by multiple factors (Spiliotis et al., 2009). These changes may indicate the wound is infected. There are several textbooks that are good to have in your clinic for easy review before procedures. Cleaning also loosens and removes any dried blood or crusted exudate from the staples and wound bed. Confirm physician/nurse practitioner (NP) orders, and explain procedure to patient. It also prevents scratching the skin with the sharp staple. Close-up of staples of a left leg surgical wound. 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 wound is cleansed a second time, and adhesive strips are applied. 11. Tissue adhesive should not be applied to misaligned wound edges. Cut under the knot as close as possible to the skin at the distal end of the knot. Grasp knotted end and gently pull out suture; place suture on sterile gauze. Your documentation in the medical record should always reflect precisely your specific interaction with an individual patient. Grasp knotted end with forceps, and in one continuous action pull suture out of the tissue and place removed sutures into the receptacle. About one-third of foreign bodies may be missed on initial inspection.6. Prepare the sterile field and add necessary supplies (staple extractor). If bandages are kept in place and get wet, the wet bandage should be replaced with a clean dry bandage. Transparent film (e.g., Tegaderm) and hydrocolloid dressings are readily available and suited for repaired wounds without drainage. The adhesive simply falls off or wears away after about 5-7 days. PROCEDURE: 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). Figure 4 is an algorithm for the management of lacerations. Lidocaine (Xylocaine) buffered with sodium bicarbonate decreases the pain associated with injection; this effect is enhanced when the solution is warmed to room temperature. AFP 2014, Other strategies to minimize pain during injection include: 1) Rapidly inserting the needle through the skin, 2) injecting the solution slowly and steadily while withdrawing the needle, and 3) Injecting into the subcutaneous tissue also minimize the pain of injection. What would be your next steps? 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. 3. A meta-analysis did not show benefit with the use of prophylactic systemic antibiotics for reducing wound infections in simple, nonbite wounds.60, Wounds heal most quickly in a moist environment.61 Occlusive and semiocclusive dressings lead to faster wound healing, decreased wound contamination, decreased infection rates, and increased comfort compared with dry gauze dressings.62 Choice of moisture retentive dressing should be based on the amount of exudate expected. Keloids, on the other hand, rarely go away. Parenteral Medication Administration. Wound infection: If signs of infection begin, such as redness, increasing pain, swelling, and fever, contact a doctor immediately. Data source: BCIT, 2010c;Perry et al., 2014. Discard supplies according to agency policies for sharp disposal and biohazard waste. 1. Instruct patient not to pull off Steri-Strips. 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. Tissue adhesives and wound adhesive strips can be used effectively in low-tension skin areas. Alternatively you can use no touch technique. This step allows for easy access to required supplies for the procedure. RANDALL T. FORSCH, MD, MPH, SAHOKO H. LITTLE, MD, PhD, AND CHRISTA WILLIAMS, MD. A sample of such instructions includes: Different parts of the body require suture removal at varying times. Allow small rest breaks during removal of sutures. The redness and drainage from the wound is decreasing. The body determines the shape of the needle and is curved for cutaneous suturing. Instruct patient to pat dry, and to not scrub or rub the incision. Allow the Steri-Strips to fall off naturally and gradually (usually takes one to threeweeks). Explain process to patient and offer analgesia, bathroom etc. Therefore, the first skin suture should be placed at this border. Sutures are tiny threads, wire, or other material used to sew body tissue and skin together. Report any unusual findings or concerns to the appropriate health care professional. Film dressings allow for visualization of the wound to monitor for signs of infection.
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