ms
Content
Develop your skill by following a few simple steps. Four patient has a wound with nondissolvable surgical sutures or staples, and you have a physician's order to remove them. Do you have the knack? In this photo guide, I'll review how to remove these closure devices with nimal risk of contaminating the wound or harming the healing tissue (see Safety Tips for general safety measures). Getting started Before you begin, review the order for special instructions: How many sutures or staples are in place? Should you remove all of them at one session? Should you apply sterile adhesive strips or a dressing to wound after removing the sutures? Provide privacy for your patient and explain the procedure. Position him comfortably so you can easily work on the suture site, working from one end of the wound to the other. Then gather the following equipment: sterile towel or drape sterile suture removal kit with scissors and forceps or sterile staple extractor clean gloves sterile gloves sterile swabs containing antiseptic cleaning solution (follow your facility's policy) clean sponges sterile adhesive strips, dressings, or other ordered items. Wash your hands. Prepare a sterile field close to the wound and place the sterile supplies on it. Put on clean gloves; then expose the wound, remove the dressing, and place it in an appropriate receptacle. Remove the gloves and place them in the receptacle. Put on sterile gloves. Clean the wound with antiseptic solution; then clean around the wound with a fresh swab, making increasingly larger circles until you've cleaned the area that was covered by the dressing. Repeat if necessary. Examine the wound; if you find anything abnormal, notify the physician before removing the closure devices. Remove suture on the face in 4 days. Remove sutures from other parts of the body in 5-7 days. Sutures across a joint or sutures on the scalp may be left in place for 8-10 days. Unstow: AMP Surgical Instrument Assembly (Surgical Supply-2) (blue) Forceps (Surgical Supply-2) Scissors (Surgical Supply-2) Ziplock (AMP-3) 2. Carefully remove wound dressing. Using Forceps, gently lift suture knot away from skin and cut one side of suture. 4. Slowly pull to remove entire suture, discard in Ziplock Bag. 5. Continue until all sutures are removed. 6. Discard Ziplock Bag into biohazardous trash. 7. Contact Surgeon with description of laceration following suture removal and for advice on wound dressing. STAPLE REMOVAL 1. Unstow: AMP Staple Remover (Surgical Supply-3) (blue) Ziplock Bag (P4-B7)(AMP-3) 2. Remove Staple Remover from packaging. 3. Carefully remove dressing from stapled wound Insert teeth of Staple Remover between staple and skin. 5. Squeeze levers of Staple Remover together. Place removed staple in Ziplock Bag. 7. Continue until all staples removed. NOTE If Staple Remover required to remove abnormally placed staple during repair, wipe thoroughly with Alcohol Pad. 8. Discard Ziplock Bag into biohazardous trash. 9. Wipe Staple Remover thoroughly with Alcohol Pads before restowing in AMP (Surgical Supply-3). 10. Place new dressing using Polysporin Ointment, Gauze Pads, and Kling Bandages or Tape. Questions about postoperative pain relief How bad is your pain ? Regular assessment is made of your pain after surgery, but you should tell your treating doctors and nurses if your pain is not controlled. In many hospitals, a scoring system is used to assess the effectiveness of pain treatment. The scoring system usually asks you to score the severity of pain on a scale of zero to ten, with zero being no pain and ten being unbearable pain. Are you likely to become addicted to opiates or narcotics ? No, the administration of these potent drugs after surgery, to provide relief of surgical pain, does not lead to addiction even when large doses are required. Are there other methods of pain relief ? There are other methods of pain relief that do not involve the administration of drugs. These ‘non-pharmacological’ methods include:
who are staying in hospital after minor operations or who are to be discharged home the day of the operation. These drugs have few common side effects, apart from constipation with codeine and the risk of reduced breathing if an overdose of anileridine is taken. There have been a few rare cases of sudden onset of kidney failure in patients who have been given ketorolac, although the evidence proving such a link is not clear. intramuscular injections Most often this route is used for the administration of opiate or narcotic analgesics. These
are given on an intermittent basis, usually every few hours. A typical order would be ‘ morphine 10 mg im q4h prn’ (which translates to ‘give 10 mg of morphine intramuscularly every four hours - but no sooner - if the patient wishes it’). This technique provides adequate, but not very good, pain control. Shortly after receiving the injection, the patient gets the effect of a large amount of drug, which may reduce breathing and produce sedation and even confusion. Then the effect of the drug wears off, leaving the patient in pain until the next injection. The use of intramuscular injections is declining in popularity, not only because continuous administration methods provide better pain control, but also because of the discomfort of the injection. Continuous intravenous infusion
With this technique, opiates or narcotics are delivered directly via an intravenous cannula at a predetermined rate. This provides a steady concentration of drug in the bloodstream (in contrast to the intramuscular technique which gives a variable blood concentration). Nursing or medical staff may adjust the rate of infusion, according to the pain relief obtained. Continuous subcutaneous infusion of analgesics This is similar to the intravenous method, except that the fluid is pumped through a fine needle into the tissues just under the skin, usually on the abdomen. Because the volume of fluid is small, there is little swelling or discomfort and the drug is well absorbed. patient controlled analgesia (PCA) This is another method of intravenous injection of opiates or narcotics, except that the patient controls the analgesia by pushing a button to determine when the injection is given. The administration of the drug is determined by a pump that has been programmed to deliver a fixed, safe dose of drug every time the patient requests it. There is a maximum hourly dose and a 'lock-out' interval that can be adjusted to prevent overdose. (This is similar to bank machines, which have limits on withdrawals.) This technique is based on the principle that if the patient who has become sleepy will not push the button until the effect of the drug wears off. Of course, this principle requires that only the patient, and not a friend or family member, pushes the PCA button. Often anaesthetists are in charge of programming these pumps, although surgeons or specially trained nurses may also do so. If necessary, the dose and timing of the drug may be adjusted by reprogramming. Drugs commonly administered by this method include morphine, pethidine ( meperidine), and fentanyl. Some doctors also prescribe a constant infusion (or a ‘background infusion’) of a small amount of drug, so that there is always some pain relief present. However, this technique carries a greater risk of reduction of breathing, than does the ‘demand’ technique alone, although it is useful in certain patients with extreme pain. spinal narcotic injection Some anaesthetists like to add a small amount of an opiate or narcotic when they inject local anaesthetic into the spinal at the time of the operation. This can provide very good pain relief. For example, a woman having a caesarean section might not need any other pain medication after the operation if she has received some spinal (‘intrathecal’) opiate or narcotic. Spinal or epidural infusions
Continuous infusions of local anaesthetics and/or narcotic analgesics into the spinal fluid or epidural space may be given for several days after surgery. The advantage with this technique is that there is little sedation, compared with other methods. These methods are particularly useful for patients undergoing chest operations (thoracotomies) or upper abdominal operations, or major orthopaedic surgery to the hips and legs. These operations are painful and most patients require large amounts of intramuscular opiates or narcotics to provide adequate pain relief, with the possible risk of reduced breathing. The use of an epidural or spinal means that the patient can actually be pain-free. Nerve blocks In addition to general anaesthesia, some anaesthetists like to perform a nerve block – to provide analgesia (pain relief) of the area in which the operation or procedure is to take place. This is commonly done for children undergoing circumcision (with a penile nerve block) or hernia repair (with a caudal anaesthetic). Some anaesthetists believe that blocking pain nerves before the patient has any pain actually decreases the amount of pain relief required. This is termed ‘pre-emptive analgesia’. Two other important points must be made about pain management. The first is the role of the acute pain Service (APS). In the 1970s, researchers began to investigate different methods for the relief of postoperative pain. Then in the 1980s, anaesthetists started to apply this knowledge to improve pain relief. These methods included all those described above. Use of these different techniques has varied widely between institutions; however, most large anaesthetic departments provide a postoperative analgesia service (or Acute Pain Service). Successful programmes rely on the assistance of dedicated, specially trained nursing support. The other important point about pain management is that all patients who receive opiates or narcotics are at risk of reduced breathing. Some patients need to be looked after in special care units, not only because of the narcotics but for other medical or surgical reasons. Other patients require frequent monitoring, but can be cared for with regular nursing.
•
Application of warmth: Heated gel or beanbag pads may be used, as may infrared lamps. Great care must be taken to avoid burning the skin, especially in the elderly and those with fragile skin or poor circulation. Lamps, in particular, should only be used for a short time. Distraction: This is a method of pain relief which is useful in patients of all ages, but particularly in children. The idea is to concentrate the mind on something other than the pain. This can be done by reading, doing puzzles, story-telling, looking out a window at a busy street, and even watching television. Relaxation: Three ways of relaxing and reducing the psychological awareness of pain are listening to music, meditating, and having a massage.
•
•
The management of postoperative pain is a continuation of the pain control provided during your anaesthetic. Both your anaesthetist and your surgeon may be involved in prescribing the drugs used for relieving your pain. There are several options for postoperative pain control, which can be distinguished by the route or manner by which these drugs are given. These options include the following. oral or rectal analgesics and anti-inflammatory drugs
These drugs include paracetamol or acetaminophen (alone and with codeine), codeine phosphate, anileridine, tramadol, buprenorphine, indomethacin, and ketorolac. Most of them are taken as tablets, although a syrup may be used for children. Many of these drugs may also be given as suppositories. They are used for mild to moderate pain and are suitable for patients
who are staying in hospital after minor operations or who are to be discharged home the day of the operation. These drugs have few common side effects, apart from constipation with codeine and the risk of reduced breathing if an overdose of anileridine is taken. There have been a few rare cases of sudden onset of kidney failure in patients who have been given ketorolac, although the evidence proving such a link is not clear. intramuscular injections Most often this route is used for the administration of opiate or narcotic analgesics. These
are given on an intermittent basis, usually every few hours. A typical order would be ‘ morphine 10 mg im q4h prn’ (which translates to ‘give 10 mg of morphine intramuscularly every four hours - but no sooner - if the patient wishes it’). This technique provides adequate, but not very good, pain control. Shortly after receiving the injection, the patient gets the effect of a large amount of drug, which may reduce breathing and produce sedation and even confusion. Then the effect of the drug wears off, leaving the patient in pain until the next injection. The use of intramuscular injections is declining in popularity, not only because continuous administration methods provide better pain control, but also because of the discomfort of the injection. Continuous intravenous infusion
With this technique, opiates or narcotics are delivered directly via an intravenous cannula at a predetermined rate. This provides a steady concentration of drug in the bloodstream (in contrast to the intramuscular technique which gives a variable blood concentration). Nursing or medical staff may adjust the rate of infusion, according to the pain relief obtained. Continuous subcutaneous infusion of analgesics This is similar to the intravenous method, except that the fluid is pumped through a fine needle into the tissues just under the skin, usually on the abdomen. Because the volume of fluid is small, there is little swelling or discomfort and the drug is well absorbed. patient controlled analgesia (PCA) This is another method of intravenous injection of opiates or narcotics, except that the patient controls the analgesia by pushing a button to determine when the injection is given. The administration of the drug is determined by a pump that has been programmed to deliver a fixed, safe dose of drug every time the patient requests it. There is a maximum hourly dose and a 'lock-out' interval that can be adjusted to prevent overdose. (This is similar to bank machines, which have limits on withdrawals.) This technique is based on the principle that if the patient who has become sleepy will not push the button until the effect of the drug wears off. Of course, this principle requires that only the patient, and not a friend or family member, pushes the PCA button. Often anaesthetists are in charge of programming these pumps, although surgeons or specially trained nurses may also do so. If necessary, the dose and timing of the drug may be adjusted by reprogramming. Drugs commonly administered by this method include morphine, pethidine ( meperidine), and fentanyl. Some doctors also prescribe a constant infusion (or a ‘background infusion’) of a small amount of drug, so that there is always some pain relief present. However, this technique carries a greater risk of reduction of breathing, than does the ‘demand’ technique alone, although it is useful in certain patients with extreme pain. spinal narcotic injection Some anaesthetists like to add a small amount of an opiate or narcotic when they inject local anaesthetic into the spinal at the time of the operation. This can provide very good pain relief. For example, a woman having a caesarean section might not need any other pain medication after the operation if she has received some spinal (‘intrathecal’) opiate or narcotic. Spinal or epidural infusions
Continuous infusions of local anaesthetics and/or narcotic analgesics into the spinal fluid or epidural space may be given for several days after surgery. The advantage with this technique is that there is little sedation, compared with other methods. These methods are particularly useful for patients undergoing chest operations (thoracotomies) or upper abdominal operations, or major orthopaedic surgery to the hips and legs. These operations are painful and most patients require large amounts of intramuscular opiates or narcotics to provide adequate pain relief, with the possible risk of reduced breathing. The use of an epidural or spinal means that the patient can actually be pain-free. Nerve blocks In addition to general anaesthesia, some anaesthetists like to perform a nerve block – to provide analgesia (pain relief) of the area in which the operation or procedure is to take place. This is commonly done for children undergoing circumcision (with a penile nerve block) or hernia repair (with a caudal anaesthetic). Some anaesthetists believe that blocking pain nerves before the patient has any pain actually decreases the amount of pain relief required. This is termed ‘pre-emptive analgesia’. Two other important points must be made about pain management. The first is the role of the acute pain Service (APS). In the 1970s, researchers began to investigate different methods for the relief of postoperative pain. Then in the 1980s, anaesthetists started to apply this knowledge to improve pain relief. These methods included all those described above. Use of these different techniques has varied widely between institutions; however, most large anaesthetic departments provide a postoperative analgesia service (or Acute Pain Service). Successful programmes rely on the assistance of dedicated, specially trained nursing support. The other important point about pain management is that all patients who receive opiates or narcotics are at risk of reduced breathing. Some patients need to be looked after in special care units, not only because of the narcotics but for other medical or surgical reasons. Other patients require frequent monitoring, but can be cared for with regular nursing.
•
Application of warmth: Heated gel or beanbag pads may be used, as may infrared lamps. Great care must be taken to avoid burning the skin, especially in the elderly and those with fragile skin or poor circulation. Lamps, in particular, should only be used for a short time. Distraction: This is a method of pain relief which is useful in patients of all ages, but particularly in children. The idea is to concentrate the mind on something other than the pain. This can be done by reading, doing puzzles, story-telling, looking out a window at a busy street, and even watching television. Relaxation: Three ways of relaxing and reducing the psychological awareness of pain are listening to music, meditating, and having a massage.
•
•
The management of postoperative pain is a continuation of the pain control provided during your anaesthetic. Both your anaesthetist and your surgeon may be involved in prescribing the drugs used for relieving your pain. There are several options for postoperative pain control, which can be distinguished by the route or manner by which these drugs are given. These options include the following. oral or rectal analgesics and anti-inflammatory drugs
These drugs include paracetamol or acetaminophen (alone and with codeine), codeine phosphate, anileridine, tramadol, buprenorphine, indomethacin, and ketorolac. Most of them are taken as tablets, although a syrup may be used for children. Many of these drugs may also be given as suppositories. They are used for mild to moderate pain and are suitable for patients
