The nurse removes the skin staples of the client's incision. Which does the nurse expect during staple removal?
1. Skin edges separate slightly.
2. Staple end sticks in the skin.
3. Client complains of stinging.
4. Incision drains 30 ml of blood.
3
3. The nurse expects the client to complain about stinging during staple removal, usually caused by the small skin adhesions to the staple; the nurse prepares the client before beginning the pro-cedure.
1. The nurse avoids beginning staple removal unless the wound edges are well approximated. If the wound edges separate during staple removal, the nurse applies Steri-Strips to secure the inci-sion's integrity.
2. Because of potential adhesions and the shape of the staple, the small terminal hook on the staple does not slip out of the puncture and sticks in the skin. When this occurs, the nurse gently eases the staple out of the skin.
4. Thirty milliliters of bloody drainage from the incision during staple removal is excessive; if the procedure is incomplete, the nurse should apply Steri-Strips as necessary, dress the wound, and collaborate with the surgeon. The nurse should also obtain a culture of the wound and drainage.
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