Wound suturing (Advanced practice)

Revised: February 15, 2019

Introduction
Wound closure is a procedure commonly performed by advanced practice nurses in a variety of settings. It consists of
cleaning and debriding the wound, controlling bleeding, and repairing the wound. The goals of wound repair include
achieving hemostasis, optimizing wound strength, and restoring function while minimizing pain and avoiding infection and
scar formation. 1 2 Several options are available for closing wounds, including liquid tissue adhesives, staples, and sutures.
Each has advantages and disadvantages and is appropriate for different types of wounds. (See Wound closure devices. )

EQUIPMENT
WOUND CLOSURE DEVICES

Several options are available for closing wounds, including tissue adhesives, staples, and sutures. Each has advantages
and disadvantages and is appropriate for different types of wounds.

Wound closure device Advantages Disadvantages

Adhesives—suitable for closing small, low-tension, linear incisions Quick and easy Not as strong as
and lacerations that don't contain moisture or hair and for helping to use staples or sutures; of
repair skin tears and flaps in fragile skin that can't be closed with limited use
Painless wound
sutures
closure Limited resistance to
moisture
Microbial barrier
Possible inflammatory
Less scarring
reaction when in
than other wound
contact with
closure options
subcutaneous tissue
No removal
necessary after
the wound heals

Staples—suitable for closing long, linear incisions and lacerations Stronger than Possible pain during
present on the scalp, trunk, and limbs adhesives wound closure
Quick and easy Risk of scarring
to use
Removal necessary
Moisture- after the wound heals
resistant

Sutures—suitable for most incisions and lacerations Stronger than More complex wound
adhesives or closure technique
staples necessary than those
for adhesives or
Moisture-
staples
resistant
Possible pain during
No removal
wound closure
necessary after
the wound heals Risk of suture marks
(for absorbable
Removal necessary
sutures)
after the wound heals
(for nonabsorbable
sutures)
Suturing is the most commonly used technique for wound repair. Although there are multiple techniques for placing sutures
(such as simple interrupted, running [continuous], and mattress) and a wide variety of suturing materials available
(absorbable versus nonabsorbable, monofilament versus multifilament, and natural versus synthetic), the most typical type
is simple interrupted sutures using nonabsorbable monofilament synthetic suture material for closure of simple lacerations or
incisions. 3 4 The primary advantage of this technique is that if one stitch fails or needs to be removed (because of
infection or edema), the rest of the stitches can remain to hold the wound together while it heals. 2 4

In general, the practitioner should select the finest sutures that will provide enough tensile strength to maintain the closure
to maximize cosmetic results. Size 3-0 or 4-0 sutures are appropriate for the trunk; size 4-0 or 5-0, for the extremities and
scalp; and size 5-0 or 6-0, for the face. 1 2 3 4

Equipment
Gloves
Antiseptic solution (povidone-iodine or chlorhexidine)
Antiseptic pad
3-mL, 5-mL, or 10-mL syringe
25G, 27G, or 30G sterile needle
Local anesthetic solution (typically lidocaine 1% with or without EPINEPHrine or bupivacaine 0.25% with or without
EPINEPHrine)
Cleaning solution (normal saline solution, tap water, distilled water, or other solution)
Sterile gloves
Sterile drape
Sterile gauze
Nonabsorbable suture material (3-0, 4-0, 5-0, or 6-0 nylon or polypropylene)
Suture needle and holder
Adson forceps
Sterile scissors
Petrolatum ointment or antibiotic ointment
Emergency equipment (code cart with emergency medications, defibrillator, handheld resuscitation bag with mask,
intubation equipment)
Optional: gown, mask and goggles or mask with face shield, fluid-impermeable pad, prescribed pain medication,
forceps or hemostat, absorbable suture material, dry sterile dressing, tetanus toxoid vaccine and administration
supplies

Preparation of Equipment
Inspect all equipment and supplies; if a product is expired, its integrity is compromised, or it's defective, remove it from
patient use, label it as expired or defective, and report the expiration or defect as directed by your facility.

Make sure that emergency equipment is functioning properly and readily available in case of an adverse reaction to the local
anesthetic, such as anaphylaxis.
Implementation
Review the patient's history for hypersensitivity to the local anesthetic or antibiotic ointment.
Gather and prepare the necessary supplies and equipment.

Perform hand hygiene. 5 6 7 8 9 10

Confirm the patient's identity using at least two patient identifiers. 11
Provide privacy. 12 13 14 15
Obtain a thorough history from the patient to determine how and when the injury occurred and the appropriateness of
using staples for wound closure. Wound closure is most effective for wounds that occurred within the past 12 hours. 3
Also assess the patient's tetanus immunization history. 3 4
 Screen and assess the patient's pain using facility-defined criteria that are consistent with the patient's age, condition,
and ability to understand. 16 (See the "Pain assessment" procedure.)
Treat the patient's pain, as needed, using nonpharmacologic, pharmacologic, or a combination of approaches. Base
the treatment plan on evidence-based practices and the patient's clinical condition, past medical history, and pain
management goals. 16 (See the "Pain management" procedure.) Administer pain medication, as indicated, following
safe medication administration practices. 4 17 18 19 20
Explain the procedure to the patient and family (if appropriate) according to their individual communication and
learning needs to increase their understanding, allay their fears, and enhance cooperation. 21

Confirm that informed consent has been obtained and that the signed consent form is in the patient's medical
record. 22 23 24 25
Raise the bed to waist level when providing care to prevent caregiver back strain. 26
Ensure adequate lighting with which to visualize the wound. 4

Perform hand hygiene. 5 6 7 8 9 10

Put on gloves and, if needed, other personal protective equipment to comply with standard precautions. 27 28 29
Assist the patient to a supine position while ensuring access to the wound. 4

Assess the wound and surrounding tissue to determine your approach. 1 2 4

Place a fluid-impermeable pad under the wound to absorb drainage and prevent soiling.
Clean the skin surrounding the wound with an antiseptic solution. Avoid getting the antiseptic solution in the
wound. 1 2
Attach the 25G, 27G, or 30G sterile needle to the syringe. Select the smallest needle that will be effective in reaching
the tissue to be anesthetized to minimize pain.
1 2

Thoroughly disinfect the injection port of the vial of anesthetic with an antiseptic pad. Allow it to dry completely. Use a
single-dose vial when available.

Clinical alert: Dedicate multidose medication vials to one patient whenever possible to reduce the risk of bloodborne
pathogen transmission and infection. Infection transmission risk is reduced when multidose vials are dedicated to one
patient. If you must use multidose vials for more than one patient, you should keep and access them in a dedicated
medication preparation area, away from immediate patient treatment areas to prevent inadvertent contamination of the vial
through direct or indirect contact with potentially contaminated surfaces or equipment that could lead to infections in
subsequent patients. 30 31 32
Draw the anesthetic solution into a 3-mL, 5-mL, or 10-mL syringe, depending on the anticipated total volume
necessary.
Anesthetize the skin surrounding the wound. (See the "Local infiltration of anesthetic [Advanced practice]" procedure.)
Test the skin or wound margins for adequate anesthesia by lightly touching the skin with a needle or other sharp
object several minutes after infiltration. 33
Clean the wound and surrounding tissue using a technique that's appropriate for the individual wound type and
location. Possible techniques include irrigating the wound (see the "Wound irrigation" procedure) with or without
pressurized irrigation or gently cleaning the wound under running water. 2 3
Assess the wound for foreign bodies and, if present, remove them with sterile forceps or a hemostat. 2 3
Perform hand hygiene. 5 6 7 8 9 10
Put on sterile gloves.
Place a sterile drape around the affected area.
Control bleeding with direct pressure using sterile gauze. 1 2 3 For deep wounds, wounds that continue to bleed, or
wounds that don't approximate well, place one or more absorbable subcutaneous or dermal sutures. 1 3

Placing the suture

Grasp the needle holder in the palm of your dominant hand. 4

Gently evert the edges of the wound with Adson forceps held in your nondominant hand. Take care to avoid squeezing
the tissue too tightly because this can damage the tissue.
4
 Pick up the needle with the needle holder at the point on the needle approximately one-third the length of the needle
from the needle tip. 4
Position the needle perpendicular to the skin at the midpoint of the long axis of the wound. 3
Pierce the skin with the needle at a 90-degree angle to the skin to promote wound edge eversion and subsequent
proper wound healing (as shown below). Insert the needle through the skin and subcutaneous tissue to a bite depth
at least equal to the bite width. 2 4

Using a smooth rotating movement of your wrist, bring the needle and suturing material perpendicularly through the
skin on the opposite side of the wound, incorporating the same amount of skin and subcutaneous tissue on this side
as on the first side. The resulting loop of suturing material should be at least as wide at the base as it is at the surface
of the skin, and the width and depth of the suture loop on one side of the wound should equal those on the other side
of the wound. 1 2 4
Pull the suturing material through the skin on the second side of the wound until a 2- to 3-cm tail of suturing material
remains on the first side of the wound. 1 4
Hold the needle end of the suturing material in your nondominant hand, taking care to avoid letting the suturing
material out of the sterile field.

Clinical alert: To avoid contaminating the suturing material while tying the knot, grasp the needle between the thumb
and index finger of your nondominant hand and gently wrap the excess suturing material loosely around your fingers. 1

Tying the knot

For the first throw of the knot, hold the needle holder in your dominant hand directly above and parallel to the long
axis of the wound. 1 4
With your nondominant hand, wrap the needle end of the suturing material over the needle holder twice to create a
double loop (as shown below). 1 2 4
 With your dominant hand, rotate the needle holder toward the short tail of the suture, open the jaws of the needle
holder slightly, and grasp the tail of the suturing material in the jaws of the needle holder. 1 4
Pull the short tail end of the suture through the two loops and across the wound by crossing your hands to create a
knot. 1 4
Tighten the knot just enough to approximate the wound edges without constricting the tissue (as shown below). 4

With your hands still crossed, for the second throw of the knot, hold the needle holder above and parallel to the long
axis of the wound, wrap the suturing material over the needle holder just once this time, pull the tail of the suturing
material through the single loop, and tighten the knot. Your hands should now be uncrossed. Repeat this step for two
more throws, as appropriate. 1 2 4
Trim the ends of the knot with sterile scissors so that the two tails are approximately 0.5 cm long. 1 4

Completing the procedure

Using the same suturing and knotting technique as above, place the second (as shown below) and third sutures in the
middle of the remaining wound lengths. Continue placing sutures in the middle of the remaining wound lengths until
 the wound is completely closed and there are no gaps at the wound edges. The distance between sutures should be
equal to the length of the sutures. The suture knots should all be on the same side. 1

Pat the wound dry with a sterile gauze.

Apply a thin layer of petrolatum ointment or antibiotic ointment to the wound to promote healing. 1
Apply a dry sterile dressing, as needed, to protect the wound. 1
Administer the tetanus toxoid vaccine, as needed, following safe medication administration practices. 3 4 17 18 19 20
Discard used supplies in the appropriate receptacles.

Clean nondisposable items and return them for sterilization. 29

Remove and discard your gloves and, if worn, other personal protective equipment. 29

Perform hand hygiene. 5 6 7 8 9 10

Reassess and respond to the patient's pain by evaluating the response to treatment and progress toward pain
management goals to ensure adequate control of the patient's pain.
Assess for adverse reactions and risk factors for
adverse events that may result from treatment. 16

Return the bed to the lowest position to prevent falls and maintain patient safety. 34
Perform hand hygiene. 5 6 7 8 9 10

Document the procedure. 35 36 37 38

Special Considerations
The Joint Commission has issued a sentinel event alert concerning the transmission of pathogens related to the misuse
of vials that have caused viral and bacterial infections including hepatitis B, hepatitis C, meningitis, and epidural
abscesses. These infections have been attributed to the reuse of single-dose vials that typically don’t contain
preservatives, re-entering multidose vials with used syringes and needles, and using multidose vials for multiple
patients. To prevent these infections, follow evidence-based best practices, such as disinfecting the vial’s rubber
stopper before piercing, using single-dose vials only once and then discarding the vial, dedicating multidose vials to a
single patient, and using a new syringe and needle when re-entering a multidose vial. Assign the appropriate “beyond-
use” date when first entering a multidose vial and store multidose vials as directed by your facility and according to
the manufacturer’s instructions.
39

Consider referral to a surgeon for deep, complex, or severely contaminated wounds as well as those on or near
delicate anatomic structures, such as nerves, tendons, and arteries. 3 4 40

Patient Teaching
Teach the patient how to perform daily wound care. Tell the patient to keep the site dry for 24 hours, after which the
patient should gently clean and pat dry the wound and then apply a thin layer of petrolatum or antibiotic ointment and a
nonadherent dressing if desired. Tell the patient that showering is permitted with nonabsorbable sutures but to avoid
bathing or swimming. Instruct the patient not to pick or otherwise disrupt the sutures. Inform the patient when to return for
suture removal (if the patient has nonabsorbable sutures), which should occur in 1 to 2 weeks, depending on the wound
location. Advise the patient to notify the practitioner if the wound opens or if signs and symptoms of infection (redness,
swelling, purulent drainage, and increased pain) occur.

Complications
Complications associated with wound closure with sutures include dehiscence, infection, and scarring. Sutures can also
cause tissue reactivity and leave suture marks on either side of the wound. Hypersensitivity reactions to the local anesthetic,
antiseptic agent, antibiotic ointment, and adhesives in the dressing materials can occur.

Documentation
Record the date and time of the procedure. Document your assessment of the wound before and after the procedure.
Record the method of wound cleaning and whether you removed any foreign bodies. Document all medications you
administered. Record the details of wound closure, including the type and number of sutures you used and the type of
dressing you applied. Document the patient's tolerance of the procedure, any unexpected outcomes, your interventions, and
the patient's response to those interventions. Document teaching you provided to the patient and family (if applicable), their
understanding of that teaching, and any need for follow-up teaching.

Related Procedures
Bite management, animal (Advanced practice)
Bite management, human (Advanced practice)
Bite management, insect (Advanced practice)
Hydrocolloid dressing application
Hydrogel dressing application
Hydrotherapy for wound care
Moist saline gauze dressing application
Negative pressure wound therapy
Negative pressure wound therapy, pediatric
Puerperal infection care
Traumatic abrasion wound care
Traumatic abrasion wound care, ambulatory care
Traumatic amputation wound care
Traumatic bite wound care, ambulatory care
Traumatic laceration wound care
Traumatic puncture wound care
Traumatic puncture wound care, ambulatory care
Traumatic simple laceration wound care, ambulatory care
Wound assessment
Wound care using maggots
Wound care, gunshot
Wound care, pediatric
Wound pouching
Wound stapling (Advanced practice)

References
(Rating System for the Hierarchy of Evidence for Intervention/Treatment Questions)
1. Mayeaux, E. J. (2015). The essential guide to primary care procedures (2nd ed.). Philadelphia, PA: Wolters Kluwer.
2. Shah, K. H., & Mason, C. (2015). Essential emergency procedures (2nd ed.). Philadelphia, PA: Wolters Kluwer.
3. Forsch, R. T., et al. (2017). Laceration repair: A practical approach. American Family Physician, 95, 628-636. (Level
VII)
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