REMOVAL OF REMOVAL OF SUTURESSUTURES

CHRISTOPHER M. BENTRES BSN_RNCHRISTOPHER M. BENTRES BSN_RN

1650 BC – 2000’s 1650 BC – 2000’s ADAD

Through the ages,Through the ages,Practitioners have used a wide Practitioners have used a wide range of materials and range of materials and techniques for closing tissue…techniques for closing tissue…

The origins of surgery can The origins of surgery can be traced back many centuriesbe traced back many centuries

In the 10In the 10thth century BC, century BC, ANTSANTS was held over the wound until it was held over the wound until it seized the wound edges in its jaws. It was then decapitated. seized the wound edges in its jaws. It was then decapitated.

The The thornthorn, used by African , used by African

tribes to close tissue, tribes to close tissue, was passed through the skinwas passed through the skin

on either side of the wound.on either side of the wound. A strip of vegetable fibre A strip of vegetable fibre was then tied was then tied around the edge in a figure around the edge in a figure eighteight..

The tough membrane of The tough membrane of sheep intestinesheep intestine was provided was provided to the surgeon pre-sterilised and required threading to the surgeon pre-sterilised and required threading

through the eye of the needle before use.through the eye of the needle before use.

Sutures

Absorbable Non-absorbable

Natural Synthetic Natural Synthetic

Mono-filament

Multi-filament

Mono-filament

Multi-filament

Mono-filament

Multi-filament

Mono-filament

Multi-filament

Multifilament (braided)Multifilament (braided)MonofilamentMonofilament

Sterility

Low tissue reactivity

Easyhandling

knot security

Tensile strength

QUALITIES

ABSORBABLEABSORBABLE!!Usually lose their tensile strength within Usually lose their tensile strength within

60 days.60 days.ABSORBED byABSORBED by

Hydrolysis or enzymatic degradationHydrolysis or enzymatic degradation

Derived from the small intestine Derived from the small intestine of healthy sheep.of healthy sheep.

Loses 50% of tensile strength by Loses 50% of tensile strength by 5-7 days.5-7 days.

Used on mucosal surfaces.Used on mucosal surfaces.

PPLLAAIINN

GGUUTT

Treated with chromic acid to Treated with chromic acid to delay tissue absorption time.delay tissue absorption time.

50% tensile strength by 10-14 50% tensile strength by 10-14 days.days.

Used in episiotomy repairs.Used in episiotomy repairs.

CCHHRROOMMIICC

GGUUTT

MonofilamentMonofilament50% tensile strength = 30+ days50% tensile strength = 30+ days

Sites = need for prolonged Sites = need for prolonged strength, strength,

POLYDIOXANONE (P

DS ®)

POLYDIOXANONE (PDS ®)

Braided, synthetic polymerBraided, synthetic polymer50% tensile strength for 30 days50% tensile strength for 30 days

Used: subcutaneousUsed: subcutaneous

Polyglycane 910 (vicyle ®)

Polyglycane 910 (vicyle ®)

NON-ABSORBABLENON-ABSORBABLE!!

Permanent, used for long term strengthPermanent, used for long term strength

Appears to be stronger then Appears to be stronger then nylon and has better overall nylon and has better overall

wound security. wound security.

Polypropylene (Prolene®)

Polypropylene (Prolene®)

BraidedBraided Before the advent of synthetic fibers, Before the advent of synthetic fibers,

silk was the mainstay of wound closure.silk was the mainstay of wound closure.Easy handling, excellent knot security.Easy handling, excellent knot security.

High reactivity and infection dueHigh reactivity and infection dueto the absorption of body fluids to the absorption of body fluids

by the braided fibers. by the braided fibers.

SS

II

LL

KK

5..4..3..2..1..0..2/0..3/0..4/0..5/0..6/0..7/0..8/0..9/0..10/0..11/05..4..3..2..1..0..2/0..3/0..4/0..5/0..6/0..7/0..8/0..9/0..10/0..11/0

ThickThick ThinThin

Suture sizeSuture size

USP (United States Pharmacopoeia)USP (United States Pharmacopoeia)

GeneralGeneral

Bowel: 2/0 - 3/0Bowel: 2/0 - 3/0Fascia: 1 - 0Fascia: 1 - 0Ligatures: 0 - 3/0Ligatures: 0 - 3/0Pedicles: 2 - 0Pedicles: 2 - 0Skin: 2/0 - 5/0Skin: 2/0 - 5/0Arteries: 2/0 - 8/0Arteries: 2/0 - 8/0Micro surgery 9/0 - 10/0Micro surgery 9/0 - 10/0Corneal closure: 9/0 - 10/0Corneal closure: 9/0 - 10/0

SUTURE SELECTIONSUTURE SELECTION

The Suture PackagingThe Suture Packaging

STRAND STRAND SIZESIZE

MATERIALMATERIAL

STRAND STRAND LENGTHLENGTH

PRODPRODUCT UCT

CODECODENEEDLE NEEDLE CODE CODE

WITH LIFE WITH LIFE SIZE SIZE

PICTURE PICTURE OF OF

NEEDLENEEDLE

NEEDLE NEEDLE LENGTHLENGTHCOLOURCOLOUR

POINT POINT TYPETYPE

NEEDLE NEEDLE CIRCLECIRCLE

BASIC SURGICAL KNOTS BASIC SURGICAL KNOTS & SUTURING& SUTURING

Suture techniques

Common suture stitching techniques include:• Simple Interrupted Stitch • Running Stitch • Mattress • Horizontal mattress • Vertical mattress • Continuous locking• Subcuticular

Surgical techniques

• Continuous

• Running stitch

Surgical techniques

• Simple interrupted

• Subcuticular

Surgical techniques

• Mattress

Surgical needles

• Traumatic needles are needles with holes or eyes which are separate from their suture thread.

• Atraumatic needles with sutures comprise an eyeless needle attached to a specific length of suture thread.

Surgical needles

There are several shapes of surgical needles, including:

• straight • half curved or ski • 1/4 circle • 3/8 circle • 1/2 circle • 5/8 circle • compound curve

Needles

Other methods• Tissue adhesivesTopical cyanoacrylate adhesives ("liquid stitches")

have been used in combination with, or as an alternative to, sutures in wound closure.

• Surgical staples Specialized surgery staples, which prove to be

faster, consistent & accurate. Staple lines are less likely to leak blood, air or bowel contents.

Staples

REMOVING OF SUTURES SKIN SUTURES• Are used to hold tissue and skin together.

Sutures may be black silk, synthetic material, or fine wire. Sutures are removed when enough tensile strength has developed to hold the wound edges together during healing.

• The time frame varies depending on the patient’s age, nutritional status and wound location. Frequently, after the skin sutures are removed, Steri- strips (small wound- closure strips of adhesive) are applied across the wound to give additional support as it continous to heal.

• The removal of sutures may be done by the physician or by the nurse with a physician’s order

EQUIPMENT

Sterile suture removal kit or sterile forceps and scissors

Gauze Wound cleansing agent, according to facility

policy Clean disposable gloves Sterile gloves Steri- strips Tincture of Benzoin, if indicated

ASSESSMENT Inspect the surgical incision and the surrounding

tissue. Assess the appearance of the wound for the

approximation of wound edges, the color of the wound and surrounding area, presence of wound drainage, noting color, volume and odor, and for signs of dehiscene.

Note the stage of the healing process and characteristic of any drainage.

Assess the surrounding skin for color, temperature, and the presence of edema, maceration or ecchymosis.

NURSING DIAGNOSIS Determine the related factors for the nursing diagnosis

based on the patient’s current status. An appropriate nursing diagnosis is Risk for Infection.

Other nursing diagnoses that maybe appropriate include: Anxiety Pain Acute pain Impaired skin integrity Delayed surgical recovery Risk for Situational Low Self- Esteem

OUTCOME IDENTIFICATION AND PLANNING

The expected outcome to achieve when removing surgical sutures is that the sutures are removed without contaminating the incisional by maintaining sterile technique, without causing trauma to the wound, and without causing the patient to experience pain or discomfort. In addition, other outcomes that are appropriate include: the patient remains free form exposure to infectious microorganisms; the patient remains free of complications that would delay recovery; and the patient verbalizes positive aspects about self.

IMPLEMENTATIONACTION1.Review the physician’s

order for suture removal.RATIONALE- Reviewing the order

validates the correct patient and correct procedure

IMPLEMENTATION ACTION2. Gather the necessary

supplies.RATIONALE

- Adequate preparation ensures efficient time management.

IMPLEMENTATIONACTION3. Identify the patient.RATIONALE- This ensures the right

patient receives the right intervention

IMPLEMENTATIONACTION4. Explain the procedure to the

patient. Describe the sensation as a pulling or slightly uncomfortable experience.

RATIONALE- Discussion and explanation help

allay the anxiety and prepare the patient for what to expect

IMPLEMENTATIONACTION5. Perform hand

hygiene.

RATIONALE- Hand hygiene

prevents the spread of microorganisms

IMPLEMENTATIONACTION6. Close the room door or curtain.

Place the bed at an appropriate and comfortable working height.

RATIONALE- Closing the door or curtains

provide privacy. Placing the bed at an appropriate height helps reduce back strain when performing the procedure

IMPLEMENTATIONACTION7. Assist the patient to a comfortable

position that provides easy access to the wound area. Use the bath blanket to cover any exposed area other than the wound.

RATIONALE- A comfortable patient position helps

reduce anxiety. Bath blanket provides for comfort and warmth.

IMPLEMENTATIONACTION8. Put on clean gloves. Remove and

dispose of any dressings on the surgical incision. Remove gloves and put on sterile gloves. Inspect the incision area.

RATIONALE- Use of gloves and proper removal of

dressings help prevent spread of microorganisms. Removal of dressings allows access to the incision

IMPLEMENTATIONACTION9. Clean the incision using the

wound cleanser and gauze, according to facility policies and procedures.

RATIONALE- Incision cleaning prevents the

spread of microorganisms and contamination of the wound

IMPLEMENTATION ACTION11. Using the sterile scissors, cut one

side of the suture below the knot, close to the skin. Grasp the knot with the forceps and pull the cut suture through the skin. Avoid pulling the visible portion of the suture through the underlying tissue.

RATIONALE- Pulling the cut suture through the skin helps reduce the risk for contamination of the incision area and resulting infection.

IMPLEMENTATIONACTION12. Remove every other suture to be sure the

wound edges are healed. If they are, remove the remaining sutures as ordered . Dispose of sutures in a biohazard bag.

RATIONALE- Removing every other suture allows for

inspection of the wound, while leaving adequate suture in palce to promote continued healing if the edges are not totally approximated. Follow standard precautions in disposing of sutures.

IMPLEMENTATIONACTION13. Apply steri- strips if

ordered. If necessary, prepare the skin with tincture of bezoin before applying steri- strips

RATIONALE- Steri- strips provide

additional support to the wound as it conitnues to heal. Applying benzoin aids in adherene of steri- strpis.

IMPLEMENTATIONACTION14. Reapply the dressing,

depending on the physician’s orders and facility policy.

RATIONALE- A new dressing protects the

wound. Some policiess advise leaving the area uncovered.

IMPLEMENTATIONACTION15. Remove gloves and

perform hand hygieneRATIONALE- Removing gloves and

performing hand hygiene prevent the spread of microorganism.

EVALUATIONThe expected outcome is

met when the patient exhibits an incision area that is clean, dry, and intact without sutures.

The incision area is free of trauma and infection, and the patient verbalizes minimal to no complaints of pain or discomfort and positive aspects about self