20.11 Checklist for Staple Removal

Staples are made of stainless-steel wire and provide strength for wound closure. Staples are strong, quick to insert, and simple to remove, but may cause more scarring than sutures.

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Removal of staples is similar to the removal of sutures but requires a sterile staple extractor instead of forceps and suture scissors. Typically, every second staple is initially removed, and then the remaining staples are removed at a later time. In general, staples are removed within 7 to 14 days. See Figure 20.34 for an example of staple removal.

Checklist for Staple Removal

Please follow the checklist below to review the steps for completion of “Staple Removal.”

Steps

Disclaimer: Always review and follow agency policy regarding this specific skill.

1. Gather supplies: sterile staple extractors, sterile dressing tray, nonsterile gloves, normal saline, Steri-Strips, and sterile outer dressing.
2. Perform safety steps:
   • Perform hand hygiene.
   • Check room for transmission-based precautions.
   • Introduce yourself, your role, the purpose of your visit, and an estimate of the time it will take.
   • Confirm patient ID using two patient identifiers (e.g., name and date of birth).
   • Be organized and systematic.
   • Use appropriate listening and questioning skills.
   • Listen and attend to patient cues.
   • Ensure the patient’s privacy and dignity.
   • Assess ABCs.
3. Confirm the provider order and explain the procedure to patient. Explanation helps prevent anxiety and increases compliance with the procedure. Inform the patient the procedure is not painful but they may feel some pulling or pinching of the skin during staple removal.
4. Prepare the environment, position the patient, adjust the height of the bed, and turn on the lights. Ensuring proper lighting allows for good visibility to assess the wound. Ensure proper body mechanics for yourself and create a comfortable position for the patient.
5. Place a clean, dry barrier on the bedside tables and add necessary supplies.
6. Perform hand hygiene and apply nonsterile gloves.
7. Remove the dressing and inspect the wound. Visually assess the wound for uniform closure of the wound edges, absence of drainage, redness, and swelling. After assessing the wound, decide if the wound is sufficiently healed to have the staples removed. If there are concerns, discuss the status of the wound before proceeding with the health care provider. For safety purposes, count the number of staples before beginning the procedure.
8. Irrigate the wound with sterile normal saline solution to remove surface debris or exudate to reduce risk of infection from microorganisms on the wound site or surrounding skin and to help loosen and remove any dried blood or crusted exudate from the sutures and wound bed.
9. Remove gloves, perform hand hygiene, and apply nonsterile gloves.
10. Place a sterile 2″ x 2″ next to the wound to collect the staples.
11. Remove the staples (start with every second staple).
12. Place the lower tip of the staple extractor beneath the staple. Do not pull up while depressing the handle on the staple remover or change the angle of your wrist or hand. Close the handle, and then gently move the staple side to side to remove. The closed handle depresses the middle of the staple causing the two ends to bend outward and out of the top layer of skin.
13. When both ends of the staple are visible, move the staple extractor away from the skin and place the staple on a sterile piece of gauze by releasing the handles on the staple extractor. This avoids pulling the staple out prematurely and avoids putting pressure on the wound. It also prevents scratching the skin with the sharp staple.
14. Using the principles of no-touch technique, place Steri-Strips on the location of every removed staple along the incision line. Steri-Strips are supplied in pre-cut lengths. Cut the Steri-Strips to allow them to extend 1.5 to 2 cm on each side of the incision. Steri-Strips support wound tension across wounds and eliminate scarring. This allows wounds to heal by primary intention.
15. Remove the remaining staples as indicated, followed by applying Steri-Strips along the incision line. Count the number of removed staples and compare to the pre-count to ensure safety.
16. Apply a dry, sterile dressing on the incision site or leave it exposed to the air according to provider orders.
17. Discard the supplies according to agency policies for sharps disposal and biohazard waste:
    • The staple extractor may be disposed of or sent for sterilization according to agency policy.
18. Perform hand hygiene.
19. Complete patient teaching regarding Steri-Strips, bathing, and inspecting wound for separation. Instruct the patient to:
    • Take showers rather than bathe in a tub.
    • Avoid pulling off Steri-Strips but allow them to fall off naturally and gradually (usually takes one to three weeks).
    • Receive adequate rest, fluids, nutrition, and ambulation for optional wound healing
20. Assist the patient to a comfortable position, ask if they have any questions, and thank them for their time.
21. Ensure safety measures when leaving the room:
    • CALL LIGHT: Within reach
    • BED: Low and locked (in lowest position and brakes on)
    • SIDE RAILS: Secured
    • TABLE: Within reach
    • ROOM: Risk-free for falls (scan room and clear any obstacles)
22. Document the procedure and assessment findings regarding the appearance of the incision. Report any concerns according to agency policy.

4.8 Staple Removal

Staples are made of stainless steel wire and provide strength for wound closure. Staples are strong, quick to insert, and simple to remove.

Removal of staples requires aseptic considerations and a staple extractor. An order to remove the staples, and any specific directions for removal (i.e., remove alternate staples only), must be obtained prior to the procedure. The healthcare professional performing the removal must also inspect the wound prior to the procedure to ensure the wound is adequately healed to have the staples removed. Usually every second staple is removed initially; then the remainder are removed at a later time (Perry et al., 2014). In general, staples are removed within 7 to 14 days.

Checklist 39 outlines the steps for removing staples from a wound.

Checklist 39: Staple Removal

Disclaimer: Always review and follow your agency policy regarding this specific skill.

Safety considerations: 

• Perform hand hygiene.

• Check room for additional precautions.

• Introduce yourself to patient.

• Confirm patient ID using two patient identifiers (e.g., name and date of birth).

• Explain process to patient and offer analgesia, bathroom, etc.

• Listen and attend to patient cues.

• Ensure patient’s privacy and dignity.

• Complete QPA including safety.
• Assess patient risk for delayed wound healing and potential dehiscence.
• perform a point of care risk assessment for PPE

Steps

 Additional Information

1. Confirm prescriber’s orders, and explain procedure to patient. Explanation helps prevent anxiety and increases compliance with the procedure. Inform patient the procedure is not painful, but the patent may feel some pulling or pinching of the skin during staple removal. 2. Gather appropriate supplies after deciding if this is a clean or sterile procedure. Clean techniques suffice if wounds have been exposed to the air and the wound is approximated and healing. You will need staple remover, receptacle for suture material (gauze, tissue, garbage bag), antiseptic swabs can be used for clean procedure, sterile dressing tray if this is a sterile procedure. Steri-Strips and outer dressing, if indicated. 3. Position patient appropriately and create privacy for procedure. Ensure proper body mechanics for yourself, and create a comfortable position for the patient. 4. Perform hand hygiene. This reduces the risk of infection. 5. If necessary prepare the sterile field and add necessary supplies (staple extractor).

Note: If this is a clean procedure you simply need a clean surface for your supplies. Some of your equipment will come in its own sterile package. Think about how you can reduce waste but still consider safety for the patient.

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Additional reading:
Essential Elements of The Retinal Exam This step allows easy access to required supplies for the procedure. 6 Apply non-sterile gloves.
Single-Use Medical Devices &Disposable Medical Supplies

If present, remove dressing and inspect the wound.

Visually assess the wound for uniform closure of the edges, absence of drainage, redness, and inflammation.

After assessing the wound, determine if the wound is sufficiently healed to have the staples removed. If concerns are present, question the order and seek advice from the appropriate healthcare provider.

7. If necessary, clean incision site according to agency policy. This reduces the risk of infection from microorganisms on the wound site or surrounding skin.

Cleaning also loosens and removes any dried blood or crusted exudate from the staples and wound bed.

 When removing staples, remove every other one first. 8. With the staple remover at an angle of less than 30º to the skin, place lower tip of staple extractor beneath the staple.

Do not pull up while depressing handle on staple remover or change the angle of your wrist or hand. Close the handle, observe the staple ends lifting out of the skin. If necessary, gently move the staple side to side to remove.

The closed handle depresses the middle of the staple causing the two ends to bend outward and out of the top layer of skin. 9. When both ends of the staple are visible, move the staple extractor away from the skin and place the staple on a receptacle by releasing the handles on the staple extractor. This avoids pulling the staple out prematurely and avoids putting pressure on the wound. It also prevents scratching the skin with the sharp staple. 10. Continue to remove every second staple to the end of the incision line. Alternating removal of staples provides strength to incision line while removing staples and prevents accidental separation of incision line. 11. If necessary, apply Steri-Strips.

Apply appropriate sized Steri-Strips to provide support on either side of the incision, generally 1 to 2 in long.

Using the principles of asepsis, place Steri-Strips perpendicular along the incision line with gaps of approximately 2 to 3 mm between each.

 

Steri-Strips support wound tension across wound and eliminate scarring.

This allows wound to heal by primary intention.

12. Remove remaining staples, followed by applying Steri-Strips along the incision line. Steri-Strips support wound tension across wound 13. If necessary, apply dry, sterile dressing on incision site or leave exposed to air if wound is not irritated by clothing, or according to physician orders. This reduces risk of infection. 14. Position patient, lower bed to safe height, and ensure patient is comfortable and free from pain. This provides patient with a safe, comfortable place, and attends to pain needs as required. 15. Complete patient teaching. Instruct patient regarding:

• Take showers rather than bathe.
• Pat dry, not scrub or rub the incision.
• Do not pull off Steri-Strips. Allow the Steri-Strips to fall off naturally and gradually (usually takes one to three weeks).
• Importance of avoiding strain on the wound (i.e., if this is an abdominal wound, no straining during defecation; if this is a knee wound, avoid kneeling; etc.).
• Importance of adequate rest, fluids, nutrition, and ambulation for optional wound healing.
• Observe the wound for signs and symptoms of infection and notify a healthcare professional if any concerns.

16. Discard supplies according to agency policies for sharps disposal and biohazard waste. Staple extractor may be disposed of or sent for sterilization. 17. Perform hand hygiene and document procedure and findings according to agency policy. Report any unusual findings or concerns to the appropriate healthcare professional. Hand hygiene reduces the risk of infection. Data source: BCIT, 2010c; Perry et al., 2014

Watch the video Staple Removal developed by Renée Anderson and Wendy McKenzie (2018) of TRU School of Nursing.

Staple removal may lead to complications for the patient. When removing staples, consider the length of time the staples have been in situ. Wound dehiscence, a mechanical failure of wound healing, remains a problem and can be affected by multiple factors (Spiliotis et al., 2009). Obese patients (greater than 30 kg/m2) have a higher risk of dehiscence than patients with a normal BMI. Additional risk factors for dehiscence include age over 75 years, COPD, diagnosis of cancer, use of steroids, malnutrition, anemia, sepsis, obesity, diabetes, tobacco use, and previous administration of chemotherapy or radiotherapy (Spiliotis et al., 2009).

Table 4.10 lists other complications of removing staples.

Table 4.10 Potential Complications of Staple Removal

Complication

Solution

Unable to remove staple from tissue Contact physician for further instructions. Dehiscence: Incision edges separate during staple removal Stop removing staples.

Apply Steri-Strips across open area.

Notify physician.

Patient experiences pain when staples are removed Allow small breaks during removal of staples.

Use distraction techniques.

Provide opportunity for the patient to deep breathe and relax during the procedure.

Data source: BCIT, 2010c; Perry et al., 2018

Critical Thinking Exercises

1. You are about to remove your patient’s abdominal incision staples according to the prescriber’s orders. As you start to remove the staples, you notice that the skin edges of the incision line are separating. What would be your next steps?
2. Your patient informs you that he is feeling significant pain as you begin to remove his staples. What would you do next?

Attributions

Figure 4.4 Surgical staples after total hip replacement by Karl-Heinz Wellmann, Wikipedia is used under the CC BY 3.0 license.

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