[micola75]

Dear burn nurses,

I like to know what is the most effective way to remove surgical staples and prevent having embedded staples in the patient's skin.

I believed that most of us who work in the burn unit experienced removing hundreds & hundreds of staples for patient that undergoing skin grafting. The procedure is frustrating and patient is normally in pain & sometimes yelling.

I think the worst is having staples embedded and overlooked. What is the best method to prevent having embedded staples? Do anyone have any suggestion or good idea to prevent it. Can share with me?

Thank you.

[RNsweetie]

I have limited experiance with staple removal as most of our CS are sutured, but i can imagine that one of the best ways to not have left over staples overlooked would be to insure proper documentation is done when pts come back from the OR... ie. 24 staples in situ and when removing them insure 24 removed...
I can imagine how painful that must be for them when you do have to remove them, do you cleanse with NS prior to removal to soften up the dried tissue over top of them? I remember that from my short stint on the surgical ward.....very short stint.

Erin

[micola75]

Thanks Erin for replying my posting.. Your suggestion is useful for small grafted area.. it'll be quite difficult to count surgical staples for huge, extensive burn patient. They have too many staples in them and it'll be very difficult for the surgeons to count the staples for a 60-90%. Sometimes it's really a "nursemare " to see the surgeons putting the hundreds staples on the grafted areas in the OT and imagine you are the nurse who is going to remove it at ward level

We did think about doing x-ray to prevent having embedded staples but it's not cost effective. It'll be a extra charge to the patient and so many part of the body need to do.. We are now practising "buddy checking" .. After i removed the staple, i'll get my colleague to check again. We are still hoping find a better way to prevent it.

Have anyone been encounter using dissolvable staples in their burns unit?? Can share with me? It sounds so miracle.. I tried to search google for information but so limited. Of course, there's fibrin glue but it's expensive ..

Well..to Erin's question- We'll have our graft inspection on the 5th POD, we did use NS to cleanse the wound and if the dressing is too dry, we'll soak the dressing with NS before removing it. Have to be very very gentle when doing it to prevent shifting or pulling the very precious graft. If the graft is well taken, we'll remove alternate staples or all staples and hv another graft inspection on the 8th POD.

Eva

[RNsweetie]

thanks for replying Eva, I had no idea that there would be that many staples, oh my i really feel for those patients and for you, can;t be an easy task.


Good luck on getting info on dissoving sutures..

[redwinggirlie]

Medicate, medicate, medicate.... that can solve the pain problem.
The many staples? I remove them as ordered and someone follows me to check.
Best bet? Vitamin M: Morphine and Vitamin A: Ativan help this process

[gwenith]

Some of the short term pain relievers are also very good. I have seen Entonox used successfully in situations like this although not recently.

[micola75]

Hey thanks for replying.. Been using either IV Morphine or IM Pethidine when removing staples.. Never though that Ativan works too...Do you give it orally or IV n how long does it take effect before the procedure???Thanks for the suggestion. Can try it out as long as to achieve painless procedure

We've been using entonox for a trial but i felt that it's very subjectively. After the trial, the researcher (an anesthetist) returned the gas n i nv see it again..Maybe can do a EBN on it and convinced my manager to use it if it really proven effective.

Gwenith, do you hv any protocol on administering of entonox?? Do a doctor need to be around when the gas is given??

Still looking forwards for help on dissolvable staples .. Anyone used or saw or read it before.. My surgeon told us tat he used it before n dont know is he bluffing us.. it'll be so good to know if there's really dissolvable staples.

Really thanks for replying n looking forward for all your wonderful replies.. I love burn nursing

[canuckeh!]

No burn unit experience but years of ER. We used to keep sterile magnets in the ER for removal of metallic foreign bodies. Maybe you could use a magnet to do a quick check and ensure you haven't missed any staples.

As for sedation, adding Midazolam might help as it gives a post procedure amnesia. The patient may still experience some discomfort but they won't remember it.

[gwenith]

Not sure any policies I have would help being an Aussie - our laws are quite different but remembering from a lecture I gave some years back the precautions are:-

1) ALWAYS "mix" the cylinder (just move it around) before using as the gas can separate (Entonox is 50/50 nitrous and O2)

2) Must have a "self-regulator" on the gas delivery system

3) The patient and ONLY the patient is to hold the mask on thier own face. The theory of Entonox is that they have to press hard to get a good enough seal to be able to trigger a gas flow. When they have enough they lose consciousness and thier hand falls away from thier face and bingo! no more gas flow until they wake again.

4) Be careful to explain that Entonox may not actually take the pain away - it just might "divorce" them from the feeling of pain. They know on a level that the procedure is painful but they don't care and it does not worry them. From personal experience (dentist) I felt I was 2 miles down the road saying "Ooooh! Looky! I have pain! Good thing it is over there and I am over here!" :

5) Don't use if there is a pneumothorax (can expand the pneumothorax)

6) keep locked away between use as it has been known to be abused by staff (like anything it can be addictive)

If you have further questions I do suggest asking in the CRNA forum - they would put my answer here to shame