VENTURA COUNTY MEDICAL CENTERFAMILY MEDICINE RESIDENCY PROGRAM. 8-10 Wind the distal portion of the suture tightly around the digit in a closed spiral (Figure 101-2B). Figure 4 is an algorithm for the management of lacerations. 1.2 Infection Prevention and Control Practices, 1.4 Additional Precautions and Personal Protective Equipment (PPE), 1.7 Surgical Hand Scrub, Applying Sterile Gloves and Preparing a Sterile Field, 2.5 Head-to-Toe / Systems Approach to Assessment, 2.6 Head-to-Toe Assessment: head and neck / Neurological Assessment, 2.7 Head-to-Toe Assessment: Chest / Respiratory Assessment, 2.8 Head-to-Toe Assessment: Cardiovascular Assessment, 2.9 Head-to-Toe Assessment: Abdominal / Gastrointestinal Assessment, 2.10 Head-to-Toe Assessment: Genitourinary Assessment, 2.11 Head-to-Toe Assessment: Musculoskeletal Assessment, 2.12 Head-to-Toe Assessment: Integument Assessment, 3.3 Risk Assessment for Safer Patient Handling, 3.7 Types of Patient Transfers: Transfers without Mechanical Assistive Devices, 3.8 Types of Patient Transfers: Transfers Using Mechanical Aids, 3.10 Assisting a Patient to Ambulate Using Assistive Devices, 4.3 Wound Infection and Risk of Wound Infection, 4.6 Advanced Wound Care: Wet to Moist 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 Preparing Medications from Ampules and Vials, 7.6 Intravenous Medications by Direct IV (Formerly IV Push), 7.7 Administering IV Medication via Mini-Bag (Secondary Line) or Continuous Infusion, 7.8 IV Medications Adverse Events and Management of Adverse Reactions, 8.2 Intravenous Therapy: Guidelines and Potential Complications, 8.6 Infusing IV Fluids by Gravity or an Electronic Infusion Device (Pump), 8.7 Priming IV Tubing / Changing IV Bags / Changing IV Tubing, 8.8 Flushing and Locking PVAD-Short, Midlines, CVADs (PICCs, Percutaneous Non Hemodialysis Lines), 8.9 Removal of a PVAD-Short, Midline Catheter, Percutaneous Non Hemodialysis CVC, and PICC, 8.11 Transfusion of Blood and Blood Products, 10.2 Caring for Patients with Tubes and Devices, Appendix 2: Checklists - Summary and Links. 1. Safe Patient Handling, Positioning, and Transfers, Chapter 6. Remove dressing and inspect the wound using non-sterile gloves. They are not generally used in hair-bearing areas (except in the hair apposition technique). The body determines the shape of the needle and is curved for cutaneous suturing. Compared with multilayer repair, single layer repair has similar cosmetic results for facial lacerations32 and is faster and more cost-effective for scalp lacerations.33 Running sutures reportedly have less dehiscence than interrupted sutures in surgical wounds.34 Mattress sutures (Figures 135 and 235 ) are effective for everting wound edges.36,37 Half-buried mattress sutures are useful for everting triangular edges in flap repair (Figure 3). Doctors use a special instrument called a staple remover. Apply dry, sterile dressing on incision site or leave exposed to air if wound is not irritated by clothing, or according to physician orders. 15. Figure 4.2 Suture techniques. Autotexts How-To Videos All Posts Encounter Notes Addiction Medicine Clinic Procedure Notes Hospital Women's Health Pediatrics Plans Cut under the knot as close as possible to the skin at the distal end of the knot. Alternating removal of staples provides strength to incision line while removing staples and prevents accidental separation of incision line. Apply Steri-Strips across open area and perpendicular to the wound. Disadvantages of using skin closure tapes include less precision in bringing wound edges together than suturing. After assessing the wound, decide if the wound is sufficiently healed to have the sutures removed. The wound appears improved to the patient. Wound dehiscence: Incision edges separate during suture removal; wound opens up, Patient experiences pain when sutures are removed. 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. 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. The adhesive simply falls off or wears away after about 5-7 days. You are about to remove your patients abdominal incisionstaples according to the physicians orders. They deny fevers or malaise. Closure: _ Monsels for hemostasis _ suture _ _ None 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). Gather sterile staple extractors, sterile dressing tray, non-sterile gloves, normal saline, Steri-Strips, and sterile outer dressing. Confirm prescribers order and explain procedure to patient. 11. When scheduled to have the stitches removed, be sure to make an appointment with a person qualified to remove the stitches. Also, surgeons use stitches during operations to tie ends of bleeding blood vessels and to close surgical incisions. Copyright 2023 American Academy of Family Physicians. Excision of Benign Skin Lesion Procedure Note. 19. Offer analgesic. 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. Sutures may be absorbent (dissolvable) or non-absorbent (must be removed). Also, it takes less time to apply skin closure tape. Examine the knot. Confirm patient ID using two patient identifiers (e.g., name and date of birth). Apply Steri-Strips to suture line, then apply sterile dressing or leave open to air. Do not pull the contaminated suture (suture on top of the skin) through tissue. Skin cleansed well with chlorhexidine and NS solution cc of 2% Lidocaine injected at the laceration site. The wound is cleaned with an antiseptic to remove encrusted blood and loosened scar tissue. Confirm physician orders, and explain procedure to patient. 9. What factors increase risk of delayed wound healing? 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. Fernando Daniels III, MD. Cleaning also loosens and removes any dried blood or crusted exudate from the sutures and wound bed. Hand hygiene reduces the risk of infection. However, scarring may be excessive when sutures are not removed promptly or left in place for a prolonged period of time. The patient was prepped and draped in a sterile fashion. Search dates: April 2015 and January 5, 2017. Stitches (also called sutures) are used to close cuts and wounds in the skin. The wound line must also be observed for separations during the process of suture removal. %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 The wound line must also be observed for separations during the process of suture removal. Sutures must be left in place long enough to establish wound closure with enough strength to support internal tissues and organs. If bandages are kept in place and get wet, the wet bandage should be replaced with a clean dry bandage. Chapter 3. The goals of laceration repair are to achieve hemostasis and optimal cosmetic results without increasing the risk of infection. Checklist 38 provides the steps for intermittent suture removal. 13. The healthcare provider must assess the wound to determine whether or not to remove the sutures. Procedure Notes from Ventura Family Medicine:http://www.venturafamilymed.org/cerner-ehr-tips/autotexts/399/preoperative-risk-assessment-for-mace. At the time of suture removal, the wound has only regained about 5%-10% of its strength. 1996-2023 WebMD, Inc. All rights reserved. If necessary, clean and dry the incision site according to agency policy. Remove dressing and inspect the wound. Adhesive agents can be used to close a wound. This step reduces the risk of infection from microorganisms on the wound site or surrounding skin. 8. Explain process to patient and offer analgesia, bathroom etc. This step reduces risk of infection from microorganisms on the wound site or surrounding skin. At the time of suture removal, the wound has only regained about 5%-10% of its strength. Foam dressings are more absorptive but mostly used for chronically draining wounds. Safer Patient Handling, Positioning, Transfers and Ambulation, Chapter 6. Position patient and lower bed to safe height; ensure patient is comfortable and free from pain. What patient teaching is important in relation to the wound? Allow small breaks during removal of sutures. Followup: The patient tolerated the procedure well without complications. Document procedures and findings according to agency policy. Individual patient . Topical and injectable local anesthetics reduce pain during treatment of lacerations and may be used alone or in combination.2123 Topical anesthetics (eTable A) are particularly useful when treating children. Forceps are used to remove the loosened suture and pull the thread from the skin. VI. Confirm patient ID using two patient identifiers (e.g., name and date of birth). Keloids, on the other hand, rarely go away. to improve lung expansion after surgery (e.g., coughing, deep breathing). See Figure 20.32 [1] for an example of suture removal. Procedure Notes CERNER EHR Welcome to our Cerner Tips & Tricks page. All Rights Reserved. The wound is cleansed again. post-procedure bleeding. Confirm prescribers orders, and explain procedure to patient. POST-OP DIAGNOSIS: Same [2018]. Sutureremoval is determined byhow well the wound has healed and the extent of the surgery. Sutures may be absorbent (dissolvable) or non-absorbent (must be removed). PRE-OP DIAGNOSIS: _ This step prevents the transmission of microorganisms. Use tab to navigate through the menu items. Contact physician for further instructions. The body of the needle is the portion that is grasped by the needle holder during the procedure. Type of suture* Timing of suture removal (days) Arms: 4-0: 7 to 10: Face: 5-0 or . Confirm patient ID using two patient identifiers (e.g., name and date of birth). The wound is healing as expected. The Steri-Strips will help keep the skin edges together. https://www.youtube.com/watch?v=-ZWUgKiBxfk, https://lacerationrepair.com/alternative-wound-closure/hair-apposition-technique/. Learn how BCcampus supports open education and how you can access Pressbooks. This action prevents the suture from being left under the skin. Some of your equipment will come in its own sterile package. Am Fam Physician 2014;89(12):956-962. Data source: BCIT, 2010c;Perry et al., 2014. Prepare the sterile field and add necessary supplies (staple extractor). Glynda Rees Doyle and Jodie Anita McCutcheon, Clinical Procedures for Safer Patient Care, Next: 4.6 Moist to Dry Dressing, and Wound Irrigation and Packing, Creative Commons Attribution 4.0 International License. Laceration closure techniques are summarized in Table 1. PROCEDURE: Emergency and Trauma Care Module 2: Basic surgical skills:Practical suture techniques. Toenail removal; The wound is cleansed a second time, and adhesive strips are applied. Allow the Steri-Strips to fall off naturally and gradually (usually takes one to threeweeks). 17. Removing subcutaneous fat may lead to depression of the scar.38 Single layer 5-0 or 6-0 nylon sutures are sufficient.32. Keloids occur when the body overreacts when forming a scar. Hand hygiene reduces the risk of infection. Showering is allowed after 48 hours, but do not soak the wound. Wound dehiscence, a mechanical failure of wound healing, remains a problem and can be affected by multiple factors (Spiliotis et al., 2009). Adhesive strips are often placed over the wound to allow the wound to continue strengthening. How to Prepare for Removing Stitches (Sutures), Suture Removal and Healing Time for Wounds. Nonabsorbable sutures, on the other hand, maintain their strength for longer than 60 days. Report any unusual findings or concerns to the appropriate healthcare professional. Instruct on the importance of not straining during defecation, and of adequate rest, fluids, nutrition, and ambulation for optional wound healing. Key words were skin laceration, skin repair, local anesthesia, sterile technique, sterile gloves, and wound irrigation. There are no significant studies to guide technique choice. If tissue adhesive is misapplied, it should be wiped off quickly with dry gauze. After assessing the wound, decide if the wound is sufficiently healed to have the sutures removed. Injection of anti-inflammatory agents may decrease keloid formation. This step reduces the risk of infection from microorganisms on the wound site or surrounding skin. Depending on the type of wound, it may be reasonable to close even 18 or more hours after injury. 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. Using potable tap water instead of sterile saline for wound irrigation does not increase the risk of infection. 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. Perform a point of care risk assessment for necessary PPE. 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. Disclaimer:Always review and follow your hospital policy regarding this specific skill. They deny fevers or malaise. No redness. Gently pull on the knot to remove the suture. Steri-Strips and outer dressing, if indicated. The body determines the shape of the needle and is curved for cutaneous suturing. The most commonly seen suture is the intermittent or interrupted suture. 16. All sutures used for traumatic skin laceration repair are swaged (ie, the needle and suture are connected as a continuous unit). Welcome to our Cerner Tips & Tricks page. Cut under the knot as close as possible to the skin at the distal end of the knot. The wound location sometimes restricts their use because the staples must be far enough away from organs and structures. Parenteral Medication Administration. Common periods of time for removal are as follows, but times vary according to the health care professionals that perform the procedure: Sutures may be taken out all at one visit, or sometimes, they may be taken out over a period of days if the wound requires it. 6. Data source: BCIT, 2010c; BCCNP 2019; Healthwise Staff, 2017; Perry et al., 2018. Suture removal is determined by how well the wound has healed and the extent of the surgery. Do not pull off Steri-Strips. Use distraction techniques (wiggle toes / slow deep breaths). 16. 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. An alternative is to remove all sutures on day 3 and support the closure by then applying wound tape. Non-Parenteral Medication Administration, Chapter 7. Clinical Procedures for Safer Patient Care, Continuous / Blanket Stitch Suture Removal, Creative Commons Attribution 4.0 International License. Figure 4.3Intermittent plain suturesby Jones, S. isused under the CC BY-SA 2.0license. After cleansing the wound, the doctor will gently back out each staple with the remover. Areas with hair also would not be suitable for taping. 13. Continue to remove every second staple to the end of the incision line. The patient was anesthetized. What is the purpose of applying Steri-Strips to the incision after removing sutures? They have been able to manage dressing changes without difficulty at home. 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. They may be placed deep in the tissue and/or superficially to close a wound. Grasp the knot of the suture with forceps and gently pull up. Disclaimer:Always review and follow your hospital policy regarding this specific skill. An appropriate incision was made in the center of the abscess and gross pus was obtained. Allow small breaks during removal of staples. 14. Visually assess the wound for uniform closure of the wound edges, absence of drainage, redness, and swelling. 13. 1. (A): Suture of laceration (P): Closure performed under sterile conditions. July 10, 2018. 12. Ventura County Medical CenterFamily Medicine Residency Program, 300 Hillmont Ave, Building 340, Ventura, CA 93003. Cosmetic outcomes of facial wounds repaired without deep dermal sutures are similar to layered closure.37 The approach to repair varies by wound location. Adapted from World Health Organization. 3. Avoid monofilament sutures and smaller-size sutures as they may break or inadvertently cut the patient if wound too tightly. 10. 14. Absorbable sutures rapidly break down in the tissues and lose their strength within 60 days. All wounds form a scar and will take months to one year to completely heal. 2. Wound Check Visit Note Subjective: The patient presents today for a wound check. , 2014 Care Module 2: Basic surgical skills: Practical suture techniques its sterile! Sterile gloves, normal saline, Steri-Strips, and adhesive strips are often over... Swaged ( ie, the wet bandage should be wiped off quickly with dry.! Necessary, clean and dry the incision line while removing staples and prevents accidental separation of incision.. 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Surgical incisions a continuous unit ) using potable tap water instead of sterile saline for wound irrigation in to... Continue strengthening their use because the staples must be left in place for a.! 10: Face: 5-0 or 6-0 nylon sutures are sufficient.32 staples provides to! Place and get wet, the needle and suture are connected as continuous! And Transfers, Chapter 6 when forming a scar and will take months to one year to completely.... Grasp the knot of the needle is the intermittent or interrupted suture Commons Attribution 4.0 International License are... Ave, Building 340, Ventura, CA 93003 and Transfers, Chapter 6 12 ).. Each staple with the remover the hair apposition technique ) safe patient Handling, Positioning and., clean and dry the incision site according to agency policy made the... Review and follow your hospital policy regarding this specific skill is cleaned an. Checklist 38 provides the steps for intermittent suture removal and Healing time for wounds the intermittent or suture... 7 to 10: Face: 5-0 or and removes any dried blood or crusted exudate from sutures! Well without complications be observed for separations during the process of suture removal days! Removal ( days ) Arms: 4-0: 7 to 10::! Of using skin closure tapes include less precision in bringing wound edges together than suturing appropriate was. Sterile technique, sterile gloves, and Transfers, Chapter 6 physician 2014 ; 89 12! Sterile gloves, and explain procedure to patient and offer analgesia, etc. Bleeding blood vessels and to close a wound Check year to completely heal: //www.youtube.com/watch?,... Location sometimes restricts their use because the staples must be removed ) closure with enough strength to line... From pain prepare for removing stitches ( also called sutures ) are used to close wound. Also be observed for separations during the process of suture removal ( days ):... Presents today for a wound Commons Attribution 4.0 International License report any unusual or... Will help keep the skin the thread from the sutures and wound bed and! For cutaneous suturing not soak the wound to continue strengthening can be used to remove every second to! The shape of the needle and is curved for cutaneous suturing and wound irrigation ) or non-absorbent ( must removed... And the extent of the needle and is curved for cutaneous suturing and prevents accidental of. And organs position patient and offer analgesia, bathroom etc potable tap water instead of sterile saline for irrigation!