TOPIC 2.2 : REMOVAL OF SUTURE & CLIP/STAPLES

TYPES OF SUTURE MATERIAL

1. Absorbable suture (no need to be remove) 2. Non-Absorbable suture (need to be remove)

APPLICATION OF STERI - STRIPS

1. Cut Steri-Strips to allow strips to extend 4 to 5 cm (1 ½ to 2 inches) on each side of the incision 2. Remove backing and apply across incision 3. Instruct patient to take showers rather than soak in bathtub according to doctor's order Apply Steri-Strips to support the incision after suture removal and cleaning the wound as ordered.

TYPES OF STAPLE/CLIPS MATERIAL

1. Michel's clips, kefa clips, staples (metal clips) o It is used for suturing edge of wound skin usually for obese, orthopaedic surgery and intravenous drug user (IVDU) patient o Available in various sizes

TECHNIQUES OF SUTURES REMOVAL

1. Place gauze nearby suture line 2. Grasp scissors in dominant hand and forceps in nondominant hand 3. Grasp knot of suture with forceps and gently pull up knot while slipping tip of scissors under suture near skin 4. Snip sutures as close to the skin as possible at end distal to the knot 5. Grasp knotted end with forceps and in one continuous smooth action pull the suture through the other side 6.Clip beneath the knot with the scissors to remove the suture. 7.Remove every other suture starting with the 2 nd suture.

TECHNIQUES OF STAPLES/CLIPS REMOVAL

1. Place sterile gauze nearby suture line 2. Place lower tips of staple remover under first staple 3. Close the handles, upper tip of staple remover depresses center of staple, causing both ends of staple to be bent upward and simultaneously exit their insertion sites in the dermal layer 4. Control staple remover carefully 5. Move the staple away from skin surface when both ends of staple is visible 6. Release handles of staple remover to allow staple to drop on the gauze

TYPES OF SUTURING

1. Plain interrupted 2. Plain continuous 3. Mattress interrupted 4. Mattress continuous 5. Blanket continuous 6. Retention suture (stay suture)

PRINCIPLES OF STO

1. Remove the sutures with a written order by doctor. 2. Count the suture before perform the STO. 3. Clean the wound before and after the procedure. 4. Snip the suture as close to the skin as possible at end distal to the knot using a sharp suture scissors . 5. Remove suture alternately to observe union of wound. 6. Snip the stitch at one part only to avoid the pieces of suture left in the tissue. 7. Pull out the suture according to the suturing. direction while applying pressure on the skin to reduce discomfort or pain. 8. Place the stitches on the gauze after removing each suture and do not forget to count them (document it too) ▪ This will help prevent the sutures from getting lost and allows nurse to count them. 9. Assess wound for: o discharge o gaping o bleeding o odor 11. Make sure all suture has been removed. If pieces of suture left infection may occur. 12. Stop the STO and report to doctor if the wound union is not complete. 13. Maintain aseptic technique during procedure. 14. Cover patient face while spray the opsite spray to the wound to prevent from contact to eye.

WOUND CLEANING FOR SUTURE SITE (TYPE 2)

1. Stroke 1. Swab (wipe) the area directly over the wound with a single stroke. Discard the applicator (sponge) into the container for contaminated wastes. 2. Stroke 2. On the patient's right side, swab (wipe) the area next to the wound with a single stroke. Discard the applicator (sponge). 3. Stroke 3. On the patient's left side, swab (wipe) the area next to the wound with a single stroke. Discard the applicator (sponge) 4. Stroke 4. On the patient's right side, swab (wipe) the area next to the second stroke with a single stroke. Discard the applicator (sponge). 5. Stroke 5. On the patient's left side, swab (wipe) the area next to the third stroke with a single stroke. Discard the applicator (sponge).

Staples are generally remove?

7 to 10 days after surgery

DEFINITION OF STO

S = Suture T = To O = Off

can secure a wound faster than a sutures are

Skin staples and clips

WOUND CLEANING FOR SUTURE SITE (TYPE 1)

The suture line is the least contaminated area and will always cleanse it first 1. Use a sterile swab to clean the suture line and working toward one end 2. Use a new swab, start at the center of the incision and work toward the other end 3. Cleanse involves moving from one end to the other on each side of the incision 4. Swab in straight lines moving away from the suture line with each successive stroke

The location of the incision sometimes restrict their use because

because there must be adequate distance between the skin and structures that lie below the skin including bone and vascular structures -The cosmetic result is not always as desirable as that obtained with finer suture material -Commonly substitute for surface sutures where cosmetic results are not prime consideration such as abdominal closure

SIZES OF SUTURE THREAD

divided by the sequence of large diameter to small diameter • 5,4,3,2,1,0,2-0,3-0,4-10 until 11-0 • Size 5 is used to closed inner layer of abdomen • Size11-0 is the smallest diameter that used for plastic and ophthalmology surgery

Removal of sutures will be perform by nurses as ordered by doctor e.g.

o 3 - 5 days (face, head and neck) o 7-10 days (scalp) o 5 - 7 days (chest and abdomen) o 7 - 10 days (arms and legs) o 14 days (joints) o 14 - 21 days or more (retention suture) - doctor will remove the suture

Mattress continuous

o A series of connected mattress stitches that has a knot at its beginning and end

Mattress interrupted

o A series of independent stitches tunnelling completely under the incision line, except for a tiny portion visible on the skin surface at each side of the wound

Blanket continuous

o A series of looped stitches, tying a knot only at the beginning and end of the series

Plain continuous

o Also called a continuous running suture o Is a series of connected stitches that has a knot tied at the beginning and end of the suture

Retention suture (stay suture)

o Can be placed in skin, subcutaneous tissue and fascia, rectus muscle and peritoneum of an abdominal incision o Used often for patients in whom slow healing is expected due to malnutrition, obesity, carcinoma or infection o May be used as a preventive measure to prevent wound disruption

Non-Absorbable suture (need to be remove)

o Commonly used to close the skin surface, provide strength and immobility with minimal tissue irritation o This suture material is not absorbed during the healing process o Sutures used for skin closure are usually removed before healing is complete o e.g. Silk, nylon, cotton, linen and polypropylene

Absorbable suture (no need to be remove)

o Deeper sutures that disappear several days o Absorbable materials include: • chromic gut which is natural catgut treated with chromium trioxide for strength and prolonged absorption time • plain catgut which is absorbed faster than chromic catgut and tend to cause more tissue irritation o Synthetics such as polyglycolic acid which are replacing catgut, they are stronger, more durable and less irritating

Plain interrupted

o Is a series of individual sutures sew, each with a separate piece of thread tied independently o Half of the thread length crosses the suture line and the other half appears above the skin surface

Definition of suture

oA thread of wire or other material (silk, steel, cotton, linen, or nylon) used to sew body tissues together

DEFINITION OF STAPLE

oStaples are made of stainless steel wire are quick to use and provide strength for wound closure

STERI - STRIPS

oSteristrips are sterile pieces of medical tape used to maintain contact between wound edges if any separation greater than two stitches or two staples in width is apparent oSteristrips keep the wound clean and protected while it heals oSteristrips usually fall off on their own in about 7 to 10 days

COMMON PERIODS OF TIME FOR SUTURE REMOVAL

oThe suture should be removed at certain period of time. oThe time of removal is usually within 7-10 days.

PURPOSE

oTo prevent reaction of skin to the foreign body. oTo facilitate complete natural repair of wound. oTo avoid a pathway for microorganism to enter the deeper area of wound.

Staples are made of

stainless steel wire and provide strength for wound closure.

Removal of staple is done using?

staple remover

oBut it can be remove earlier or later. It depends on the:

• location • wound variation • cosmetic consideration • patient health condition