The nurse prepares to remove the client's continuous sutures today. Choose suitable nursing interventions for suture removal and rank the nursing interventions beginning with the first nurs-ing action

Question

1. Perform thorough hand hygiene and open supplies.
2. Obtain suture extractor and incisional cleansing agents.
3. Gather sterile supplies and explain procedure to the client.
4. Remove every other suture today and then assess incision.
5. Ask client to cleanse incision in shower with chlorhexidine.
6. Instruct nursing assistant to remove and dispose of dressing

Answer 1

3, 1
3. After inspecting the incisional area, the nurse gathers clean and sterile supplies for suture re-moval and brings them to the client's bedside to decrease exposure of the client and the incision and to perform suture removal efficiently.
1. The nurse performs hand hygiene to decrease the microorganism count on the hands and then uses clean hands to open the sterile supplies and cleansing swabs to avoid unnecessary contami-nation of the supplies.
2. A staple extractor exists but a suture extractor does not; the nurse uses a suture scissors or a surgical scissors and a pair of tweezers or a hemostat to remove suture material.
4. Because the client has continuous sutures, the nurse must remove all the sutures at one time because removing every other suture leaves unsecured suture material in the incision. The suture material is likely to disappear because of suture migration from spontaneous client movements and actions such as breathing. This increases the risk of infection and potentially for subsequent procedures to remove hidden suture fragments.
5. The nurse avoids delegating incisional cleansing to the client and cleanses the incision before suture removal.
6. The nurse avoids delegating dressing removal to the nursing assistant because the assistant does not receive the training to perform the tasks; besides, the duty the nurse owes to the client is to remove and assess the incision.