Assisting with Minor Surgery 44 PDF

Assisting with Minor Surgery 44 C A S E S T U D Y © Image Source/Getty Images RF Peter Smith is a 73-year-old male with a history of mild depression. He arrives at the clinic holding a bloody...

Assisting with Minor Surgery 44 C A S E S T U D Y © Image Source/Getty Images RF Peter Smith is a 73-year-old male with a history of mild depression. He arrives at the clinic holding a bloody towel over his left forearm. He is taken immediately back to the treatment area. He states that he cut himself with a large knife while cutting a pineapple. You take his vital signs while waiting for the physician. You notice the blood is leaking through the towel. You need to control the bleeding. You put on PPE, most importantly gloves, and apply a large dressing over the area, holding firm pressure. The physician arrives, examines the patient, and determines that the patient will need sutures. While you are preparing Mr. Smith for his wound repair procedure, he tells you that he recently started swimming for exercise and is going to the Bahamas for a snorkeling trip in 2 weeks. He wants to know if this will ruin his trip. Keep Mr. Smith in mind as you study this chapter. There will be questions at the end of the chapter based on the case study. The information in the chapter will help you answer these questions. L E A R N I N G O U T C O M E S After completing Chapter 44, you will be able to: 1. 44.1Define the medical assistant’s role in minor surgical procedures. 2. 44.2Describe surgical procedures performed in an office setting. 3. 44.3Identify the instruments used in minor surgery and describe their functions. 4. 44.4Describe the procedures for medical and sterile asepsis in minor surgery. 5. 44.5Summarize the medical assistant’s duties in preoperative procedures. 6. 44.6Describe the medical assistant’s duties during an operative procedure. 7. 44.7Implement the medical assistant’s duties in the postoperative period. K E Y T E R M S 1. abscess 2. anesthesia 3. anesthetic 4. approximate 5. cryosurgery 6. debridement 7. electrocauterization 8. formalin 9. incision 10. inflammatory phase 11. intraoperative 12. laceration 13. ligature 14. maturation phase 15. needle biopsy 16. postoperative 17. preoperative  18. proliferation phase 19. puncture wound 20. sterile field 21. suture 22. swaged needle Page 896 0. Introduction 1. Minor surgical procedures are frequently performed in ambulatory care settings and office practices. Assisting with minor surgery requires a variety of duties and skills. As a medical assistant, you must be knowledgeable of the types of procedures performed where you are employed. You need to know how to prepare the patient for surgery, assist the practitioner during surgery, and care for the patient after surgery. Because all types of surgery require surgical asepsis, a working knowledge of this technique is mandatory. 2. The Medical Assistant’s Role in Minor Surgery LO 44.1 3. Medical assistants play an important role in all aspects of minor surgical procedures. You will perform administrative tasks prior to the patient’s surgery, including completing forms for insurance and obtaining signed informed consent from the patient. You will explain basic aspects of the surgical procedure and answer the patient’s questions. Informing the doctor of all current prescription and over-the-counter (OTC) medications that the patient is currently taking is also an administrative task. Finally, you will make sure the patient knows how to follow the appropriate presurgical instructions. 4. In addition to presurgical administrative tasks, you also will perform many tasks directly related to the surgical procedure. You will make sure the surgical room is clean, neat, and properly lit. You will see that all the equipment, instruments, and supplies the doctor will use are clean, disinfected or sterilized, and properly arranged. You also may function as an unsterile assistant, ensuring the safety and comfort of the patient during the procedure and performing other duties. At other times, you may directly assist with the surgical procedure in a sterile capacity. 5. Following the surgical procedure, you will help dress the wound and perform other postoperative patient care, making sure the patient is not experiencing ill effects from the surgery or local anesthetic. You will educate the patient about wound care and proper procedures to follow after surgery and make sure the patient has safe transportation home. You also will clean the room and prepare it for the next patient. Surgery in the Physician’s Office LO 44.2 Minor surgical procedures are those that can be safely performed in the physician’s office or clinic without general anesthesia. Anesthesiais a loss of sensation, particularly the feeling of pain. An anesthetic is a medication that causes anesthesia. A general anesthetic affects the entire body, whereas a local anesthetic affects only a particular area. Minor surgical procedures typically involve the use of a local anesthetic in the form of an injection or a cream applied to the skin. Minor surgery is performed for many reasons, whether it be to diagnose an illness or repair an injury. Other procedures may be elective, or optional. Removal of a wart, skin tag (a small outgrowth of skin, occurring frequently on the neck as people get older), or other small growth for cosmetic reasons is an elective procedure. Some of the common minor surgical procedures you may assist the doctor with include the following: Repair of a laceration Irrigation and cleaning of a puncture wound Wound debridement Removal of foreign bodies Removal of small growths Removal of a nail or part of a nail Drainage of an abscess Collection of a biopsy specimen Cryosurgery Laser surgery Electrocauterization Common Surgical Procedures Many surgical procedures are routinely performed in a doctor’s office. You may perform some of these procedures on your own. For example, you may change dressings for surgical wounds, and under a doctor’s orders, you may remove sutures (commonly called stitches) or staples after wounds have healed. Any procedure that requires an incision (a surgical wound made by cutting into body tissue) must be performed by a doctor. Draining an Abscess An abscess is a collection of pus (white blood cells [WBCs], bacteria, and dead skin cells) that forms as a result of infection. A protective lining can form around an abscess and prevent it from healing. In such a case, the physician may make an incision in the lining of the abscess. This procedure is known as an incision and drainage (I&D). The physician may allow the abscess to drain on its own or insert a drainage tube. Obtaining a Biopsy Specimen A biopsy specimen is a small amount of tissue removed from the body for examination under a microscope. Most biopsies involve cutting the tissue. For a needle biopsy, the doctor uses a needle and syringe to aspirate (withdraw by suction) fluid or tissue cells. (The procedure in the Assisting in Other Medical Specialties chapter describes how to assist with a needle biopsy.) All specimens must be placed in a preservative, most commonly a 10% formalin solution (a dilute solution of formaldehyde), to prevent changes in the tissue. Mole Removal A mole, also called a nevus, is a small, discolored area of the skin. It may be raised or flat. Any mole that changes shape, size, or color should be evaluated for possible removal. Moles are typically removed by excision or by slicing flush with the skin. If the mole is excised, sutures are usually necessary. Moles that are removed by slicing flush with the skin do not require sutures but may need to be cauterized. Caring for Wounds A wound is any break in the skin. The break may be accidental or intentional, as from a surgical procedure. There are several types of accidental wounds. A laceration is a jagged, open wound in the skin that can extend down into the underlying tissue. The jagged edges may have to be cut away before the wound is closed. A puncture wound is a deep wound caused by a sharp object. (See the Emergency Preparedness chapter for further information on types and care of accidental wounds.) Both surgical and accidental wounds require special care to prevent infection. Proper wound care that promotes healing without infection is discussed in the Caution: Handle with Care feature. CAUTION: HANDLE WITH CARE Conditions That Interfere with Fast, Effective Wound Healing The goals for treating both surgical and nonsurgical wounds are similar: to heal the wound without infection and to preserve normal skin function and appearance. Nonsurgical wounds often involve conditions that do not promote fast, effective healing. In these cases, the wounds require special attention to ensure good results. Many types of nonsurgical wounds contain foreign material that can lead to infection. For example, a child may have a deep laceration from landing on a dirty, broken bottle when falling off a bicycle. These types of wounds always need vigorous cleaning. Some may need debridement. Wounds heal better when the edges are brought closely together, or approximated. Jagged edges in a laceration make approximation harder. It is also difficult to approximate crushed tissue, as you would see with fingers closed in a car door. Crushing disrupts a tissue’s blood supply by rupturing blood vessels throughout the affected area. A physician might debride this type of wound with a scalpel to remove severely damaged tissue and achieve a clean wound edge before suturing. After a surgical or nonsurgical wound is closed and sutured, it is essential to keep the wound clean and dry to help prevent infection. Infection delays the healing process and can have other serious consequences. A sutured wound heals more quickly and smoothly when no scab forms because the migrating skin cells encounter no barrier to their movement. Proper postoperative care, including daily cleaning with soap and water or a mild antiseptic, keeps a wound scab-free. Although skin cells migrate across the space of a wound more easily in a somewhat moist environment, a wet wound offers the ideal conditions for bacteria to grow and cause infection. Covering a wound with a clean, dry dressing helps prevent infection. Wound healing may be delayed in a number of instances not directly related to the surgery or injury. The presence of any of the following conditions can put a patient at risk for wound healing problems. Wounds in such patients may require extra attention and care. Poor circulation. This condition results in inadequate supplies of nutrients, blood cells, and oxygen to the wound, all of which delay the healing process. Aging. Physiologic changes that occur with age can decrease a person’s resistance to infection. Diabetes. Patients with diabetes experience changes in their artery walls that result in poor circulation to peripheral tissues. These patients also may have a decreased resistance to infection. Poor nutrition. Patients who are undernourished, particularly those who are deficient in protein or vitamin C, do not have the physiologic resources for vigorous healing. High levels of stress. An increase in stress-related hormones can decrease resistance to infection. Weakened immune system. Patients who are on certain medications or who have certain chronic diseases may have weakened immune systems, putting them at increased risk of infection. Obesity. When someone is obese, the circulation directly under the skin is often poor, leading to slow healing. Smoking. Nicotine constricts the blood vessels in the skin, reducing circulation to the wound area and slowing healing. Cleaning a Wound The first step in preventing a non-surgical wound from becoming infected is careful cleansing. First, clean around the wound with soap and water. Then, it must be irrigated with sterile saline solution or sterile water, applied with a syringe and needle. Debridement is the removal of debris or dead tissue from a wound. This special type of cleaning may be required for a wound that has dead or sloughing tissue. This procedure helps to expose healthy tissue and promote healing. The doctor may use one of a number of wound debridement methods: Surgical—cutting away tissue with scalpel and scissors Chemical—using special compounds to dissolve tissue Mechanical—applying a dressing that sticks to the wound, removing dead tissue when the dressing is removed, or irrigating the wound with sterile saline Autolytic—applying a dressing that helps the body’s natural fluids dissolve dead tissue Wound Healing It is important to know how a wound heals so that you can care for it properly. A wound heals in three phases: inflammatory phase, proliferation phase, and maturation phase. The time it takes for a wound to heal depends on several factors, including the patient’s age, nutritional status, and overall health. During the initial phase, or inflammatory phase, bleeding is reduced as blood vessels in the affected area constrict. Platelets, clotting factors, and WBCs play an important role in this phase. They seal the wound, clot the blood that has seeped into the area, and remove bacteria and debris from the wound. The wound contracts under the clot or scab that forms. Page 898 During the second phase, or proliferation phase, new tissue forms. Skin cells at the edges of the wound begin to move together to close off the wound. The scab that often forms over a wound actually slows down this movement of skin cells. The edges of the wound eventually come together and form a continuous layer, closing off the wound. The proliferation phase speeds up if the edges of an incision or a nonsurgical wound are approximated, or brought together so that the tissue surfaces are close. This intervention protects the area from further contamination and minimizes scab and scar formation. Small wounds can be held together with butterfly closures, sterile strips, or adhesive. Skin adhesive is a special type of glue used for closing small wounds. Larger wounds or those subject to strain may require suturing or stapling. The maturation phase (the third phase) involves the formation of scar tissue. Scar tissue is important for closing large, gaping, or jagged wounds. The continuous layer of skin cells formed during the second phase becomes thicker and pushes off the scab, leaving a scar. Scar tissue contains no nerves or blood vessels and lacks the resilience of skin. Wound Healing Closing a Wound Sutures are surgical stitches a physician uses to close a wound. Suture materials, or ligature, can be either absorbable or nonabsorbable. The type and location of the wound will determine the type of suture material the healthcare practitioner chooses. The body breaks down absorbable sutures, so they do not require removal after the wound has healed. If a wound is particularly deep, the health-care practitioner may need to suture in layers, from inside to outside. In this case, absorbable sutures are used for the inner suturing. Removable (nonabsorbable) sutures are generally Page 899 used for the outside layer. Nonabsorbable ligature must be removed after wound healing is well under way. Sutures are discussed in greater detail later in the chapter. Staples may be used to bring the edges of a wound together if there is considerable stress on the incision. For example, a long and deep surgical wound or a wound across the leg would have a strong tendency to gape open if not firmly secured. Surgical staples look somewhat like ordinary staples. They are inserted into the skin with a disposable staple unit. Special Minor Surgical Procedures Some types of minor surgical procedures require special surgical instruments. These procedures include laser surgery, cryosurgery, and electrocauterization. They all remove excess or abnormal tissue, as in the case of warts or skin lesions, and usually require surgical aseptic technique because they break the integrity of the skin. Laser Surgery A laser emits an intense beam of light that is used to cut away tissue. Laser surgery is sometimes preferred over conventional surgery because it causes less damage to surrounding healthy tissue than does conventional surgery. Laser surgery also promotes quick healing and helps prevent infection. When a laser is used in an office setting, close blinds and shades to keep out stray light. Remove any items—like the paper from wrapped sterile instruments or syringes—that could catch fire if they came in contact with the laser beam. Cover any shiny or reflective surfaces or use nonshiny instruments. Make sure that everyone in the room, including the patient, wears special safety goggles to protect the eyes. You should have a fire extinguisher in the room where it is out of the way but easily accessible. Post a standard laser warning placard in the room’s entryway, per Occupational Safety and Health Administration (OSHA) regulations. Position, drape, and prepare the patient as you would for conventional surgery. Place gauze around the surgical site and assist the physician with administration of a local anesthetic if requested. The physician uses the laser to vaporize the unwanted tissue; vaporized tissue is cleared away by the vacuum hose portion of the unit (see Figure 44- 1). You may be asked to apply pressure to control any bleeding. Clean the wound with an antiseptic and apply a sterile dressing. Give the patient the normal instructions on wound care, including the recommendation to protect the site from sun exposure. FIGURE 44-1 Suction eliminates vaporized tissue as a physician uses a laser to remove a wart from a patient’s hand.© Barry Slaven Photography Cryosurgery The use of extreme cold to destroy unwanted tissue is called cryosurgery. Cryosurgery is often used to remove skin lesions and lesions on the cervix. Before cryosurgery, inform the patient that an initial sensation of cold will be followed by a burning sensation.Instruct the patient to remain as still as possible to prevent damage to nearby tissue. The doctor may freeze the tissue by touching it with a cotton-tipped applicator dipped in liquid nitrogen or by spraying it with liquid nitrogen from a pressurized can. Sometimes, a special cryosurgical instrument is used, most often during surgery on the cervix. Make the patient aware that more than one freezing cycle may be necessary. A local anesthetic is usually not required because the cold itself reduces sensation in the area. After the procedure, the area is cleaned with an antiseptic and a sterile dressing may be applied. An ice pack may be applied to reduce swelling and pain relievers given for pain. Reassure the patient that some pain, swelling, or redness is normal after a cryosurgical procedure. Encourage the patient to use ice and pain relievers as necessary. Let the patient know that a large, painful, bloody blister may form. Left undisturbed, the blister usually ruptures in about 2 weeks. It should be left intact to promote healing and prevent infection. The patient should call the doctor if a blister becomes too painful. Be sure to provide the patient with complete wound care instructions. Electrocauterization This is a technique whereby a needle, probe, or loop heated by electric current destroys the target tissue. A physician may use electrocauterization to remove growths such as warts, to stop bleeding, and to control nosebleeds that either will not subside or continually recur. Several types of electrocautery units are in use. Some are small, handheld units powered by battery or by ordinary household electric current. Other, larger units are designed for countertop placement or wall mounting. Some units use disposable probes and others employ reusable ones. With certain units, a grounding pad or plate is placed on or under the patient’s body during the procedure. This grounding completes the circuit and prevents electric shock to the patient, the physician, and staff members. Reassure the patient that grounding causes no discomfort. A local anesthetic may be administered before the procedure. After electrocauterization, a scab or crust generally forms over the area. Healing may take 2 to 3 weeks. General wound care instructions are appropriate for this procedure, except that a dressing may be omitted to keep the area drier. Instruments Used in Minor Surgery LO 44.3 The type of minor surgical procedure determines which surgical instruments are used. Surgical instruments have specific purposes and may be classified by function. Cutting and Dissecting Instruments Cutting and dissecting instruments have sharp edges and are used to cut (incise) skin and tissue. Figure 44-2 illustrates some of the basic cutting and dissecting instruments you will encounter. You must be careful when cleaning, sterilizing, and storing these instruments to avoid injuring yourself and to protect the instruments’ sharp edges. FIGURE 44-2 These are typical cutting and dissecting instruments used in minor surgical procedures. Scalpels A scalpel consists of a handle that holds a disposable blade. Scalpel handles are either reusable or disposable and vary in width and length. A scalpel’s specific use determines the shape and size of its blade. General-purpose scalpels have wide blades and a straight cutting surface (Figure 44-3). A no. 15 blade is the most common one for performing minor procedures.  FIGURE 44-3 Scalpel blades come in various sizes and shapes, some of which are represented here. Take special care when handling a scalpel. If the physician requests a reusable scalpel handle, it is essential that you load and unload the blade correctly on the handle. Carefully follow these steps when loading and unloading a scalpel blade: Steps for Loading a Scalpel Handle 1. Carefully grasp the blade with a needle holder, staying away from the sharp edge. 2. Ensure that the blade edge is pointed away from you and you are gripping the blade just above the blade slot. 3. Firmly hold the scalpel handle in your nondominant hand. Hold the handle in the center, not close to the blade lock. 4. Carefully slide the blade over the grooves of the blade lock until it snaps into place. 5. The blade should slide smoothly down the groove. If it jams, carefully slide it back up the blade lock while grasping the blade with the needle holder, realign the blade slot, and slide the blade back down the blade lock. 6. Never use your fingers to load a blade on a scalpel handle. The blade is very sharp and may slip, causing serious injury. Steps for Unloading a Scalpel Handle 1. Using your nondominant hand, hold the scalpel handle in the center. 2. With the blade lock facing up, point the blade and handle downward over a sharps container (make sure the sharps container is well below the blade and the blade is not pointed toward anyone in the room). 3. Using the needle holder, grasp the angled edge of the blade near the blade lock. 4. Page 901 Lift the blade slightly over the blade lock and slide it up to disengage the blade from the blade lock. 5. Immediately drop the blade into the sharps container. 6. Do not touch the blade with your fingers. 7. The blade handle is now ready for sanitization and sterilization. A number of special blade removal devices are also available. These devices contain the blade in a case or box before removal. Follow the manufacturer’s instructions for safe scalpel blade removal. Scissors Surgical scissors come in various sizes. They may be straight or curved and have either blunt or pointed tips. Tissue scissors must be sharp enough to cut without damaging or ripping surrounding tissue. Suture scissors have blunt points and a curved lower blade. The lower blade is inserted under the suture material to cut it. Bandage scissors are used to remove dressings. They have a blunt lower blade to prevent injuring the skin next to the dressing. Clippers are scissor-like instruments used for cutting nails or thick materials. Curettes The doctor uses a curette for scraping tissue. Curettes come in a variety of shapes and sizes and consist of a circular blade—actually a loop—attached to a rod- shaped handle. The blade is blunt on the outside and sharp on the inside. The inner part of the blade may also be serrated. Serrated blades may be used to take Pap (Papanicolaou) smears. Blunt curettes, known as Buck ear curettes, are used to remove wax from the ear canal when a large amount of cerumen has accumulated. Grasping and Clamping Instruments Special instruments are used for grasping and clamping tissue. Grasping instruments are used to hold surgical materials or to remove foreign objects, such as splinters, from the body. Clamping instruments are used to apply pressure and close off blood vessels. They also are used to hold tissue and other materials in position. Figure 44-4 shows some common grasping and clamping instruments. FIGURE 44-4 These are typical grasping and clamping instruments used in minor surgical procedures. Forceps Forceps are instruments that are commonly used to grasp or hold objects. Grasping types are usually shaped like tweezers and include thumb forceps and tissue forceps. Thumb forceps, also called smooth forceps, vary in shape and size. The blades of thumb forceps are tapered to a point and have small grooves at the tip. Tissue forceps (serrated forceps) have one or more fine teeth at the tips of the blades. When closed, these forceps hold tissue firmly. Holding forceps have handles with ratchets that lock the teeth in a closed position. Dressing, or sponge, forceps have ridges to hold a sponge or gauze when it is used to absorb body fluids. Hemostats The most commonly used surgical instruments are hemostats. These surgical clamps vary in size and shape and are typically used to close off blood vessels. The serrated jaws of hemostats taper to a point. Like holding forceps, hemostats have handles that lock on ratchets, holding the jaws securely closed. Towel Clamps Towel clamps are used to keep towels used for draping the surgical site in place during a surgical procedure. This stability is important in maintaining a sterile field. Retracting, Dilating, and Probing Instruments Retracting instruments are used to hold back the sides of a wound or an incision. Dilating and probing instruments may be used to enlarge, examine, or clear body openings, body cavities, or wounds. The shapes of these instruments vary with their functions. Some typical retracting, dilating, and probing instruments are shown in Figure 44-5. FIGURE 44-5 These are typical retracting, dilating, and probing instruments used in minor surgical procedures. Retractors The use of retractors allows greater access to and a better view of a surgical site. Some retractors must be held open by hand, while others have ratchets or locks to keep them open. Dilators Dilators are slender, pointed instruments used to enlarge a body opening, such as a tear duct. Probes A surgical probe is a slender rod with a blunt, bulb-shaped tip. Probes are used to explore wounds or body cavities and to locate or clear blockages. Suture Material and Suturing Instruments Suturing instruments are used to introduce suture materials into and retrieve them from a wound. Some carry the suture material, whereas others manipulate the suture carriers. Examples of suturing instruments are shown in Figure 44-6. FIGURE 44-6 These are typical suturing instruments. Page 902 Page 903 Suture Materials As a medical assistant, you need to be familiar with the various types of sutures. The healthcare practitioner will ask for a specific suture type based on several considerations, including the type and location of the wound. Sutures may be natural or synthetic, absorbable or nonabsorbable. The healthcare practitioner will choose a needle that causes the least possible trauma to the tissues. The needle may be curved or straight, cutting, blunt, or tapered. A swaged needle has the suture material permanently attached to the needle. The needle may also have an eye where the suture material is manually threaded. It is important that you be able to quickly find information about the type of suture material in a package. Figure 44-7 illustrates the most common information found on a suture package. FIGURE 44-7 Information about the suture material can be found on the package. General Features of Suture Materials Regardless of the type, suture materials have some general qualities in common: Page 904 Sterility Uniform diameter Tensile strength (resistance to breaking under tension or pull) Flexibility Ability to retain or hold a knot Low incidence of tissue reactivity Suture Size Suture size is determined by the diameter or thickness of the strand. Sizes range from 11-0 (smallest) to 7 (largest). The number in front of the “0” determines the number of zeros. Remember, the more zeros in the size, the smaller the suture. For example, a 6-0 suture is smaller in diameter than a 3-0 suture. The sizes you will most often see used for minor surgical procedures are 6-0 to 3-0. Sutures sized 6-0 and 5-0 are used most often to close wounds of the face, lips, and eyebrow. Wounds of the sole of the foot generally require a suture that is thicker in diameter. These wounds are usually repaired with a 3-0 or 4-0 suture. Suture Needles Surgical suture needles carry suture material, or ligature, through the tissue being sutured. They are either pointed or blunt at one end and may have an eye at the other end to hold suture material. Ligature often comes prepackaged with the needle already connected. Prepackaged suture needles with attached ligature (swaged) have no eye and produce less trauma to the tissue being sutured than do suture needles with eyes. Suture needles may be straight, or they may be curved to allow deeper suture placement. Taper point needles (needles that taper into a sharp point) are used to suture tissues that are easily penetrated. They create only very small holes, thus minimizing tissue fluid leakage. Cutting needles (needles that have at least two sharpened edges) are used on tough tissues that are not easily penetrated, such as skin. Several measurements are used to determine the size of a surgical needle. Needle length is the distance from the tip to the end, measuring along the body of the needle. Chord length is the straight-line distance from the tip to the end of the needle. (Chord length is not the same as needle length in curved needles.) The radius of a curved needle is determined by mentally continuing the curve of the needle into a full circle and finding the distance from the center of the circle to the needle body. The diameter is the thickness of the needle. Needle size generally corresponds to the size of suture material used. Smaller needles are used for delicate procedures, such as eye surgery or repair of a facial laceration. Larger needles are used for suturing wounds of less delicate parts of the body, such as the hands or legs. Needle Holders Curved suture needles require special instruments to hold, insert, and retrieve them during suturing. Most needle holders look like hemostats with short, sturdy jaws. Syringes and Needles Sterile syringes and needles are used to inject anesthetic solutions, withdraw fluids, and obtain biopsy specimens. The size of the syringe and needle varies with the intended use. For example, a needle used to perform a biopsy is generally larger than needles used for most injections. (Syringes and needles used for injections are discussed and illustrated in the Medication Administration chapter.) Both syringes and needles are provided in individual sterile envelopes. Instrument Trays and Packs All the surgical instruments needed for a specific procedure are usually assembled beforehand. They are then sterilized together in a pack. Certain surgical supplies necessary for the procedure (such as gauze) are included in the pack because they, too, must be sterile. Surgical trays can be quickly set up with these instrument packs. Individually wrapped items also may be added as needed. These are the common types of instrument trays: Laceration repair tray (see Figure 44-8)  Laceration repair with debridement tray Incision and drainage tray Foreign body or growth removal tray Onychectomy (nail removal) tray Vasectomy (male sterilization procedure) tray Suture removal tray Staple removal tray FIGURE 44-8 This laceration repair tray contains scissors, several pairs of forceps, a needle holder, and sterile gauze. Suture material must be added for the procedure.© David Kelly Crow Asepsis LO 44.4 Maintaining asepsis during surgical procedures is always a priority. It is critical to the health and safety of both the patient and the healthcare professional. The two levels of aseptic technique are medical asepsis (clean technique) and surgical asepsis (sterile technique). Medical asepsis is discussed in detail in the Infection Control Fundamentals chapter. You will use both levels of asepsis when assisting with minor surgery. Page 905 Personal Protective Equipment Personal protective equipment, or PPE, includes all items used as a barrier between the wearer and potentially infectious or hazardous medical materials. PPE includes gloves, gowns, and masks and protective eyewear or face shields. OSHA regulations regarding PPE are discussed in detail in the Infection Control Fundaments and Infection Control Practices chapters. Gloves are of particular importance during surgical procedures. You should wear properly sized latex, nitrile, or vinyl gloves during any procedure that might expose you to potentially infectious or hazardous materials. (Gloves that are too big can catch on instruments or equipment and cause accidents.) When you wear gloves, you also protect the patient from any infectious organisms on your hands. Vinyl, nitrile, and latex gloves can all prevent contamination of the hands with bacteria. Although latex gloves were the preference of healthcare professionals for many years, the incidence of latex allergy among healthcare professionals has grown. Allergic reactions to latex can range from a skin rash to shock and even death. Many healthcare institutions are switching to less allergenic low-powder or powderless non-latex gloves. The powder in latex gloves, which makes them easier to put on, is one of the primary sources of latex allergy. The latex protein that causes the allergy mixes with the powder. When the gloves are removed, the powder containing the latex protein becomes airborne and is inhaled. If you work in a facility that uses latex gloves, take these steps to prevent latex allergy: If possible, use powder-free gloves only. Thoroughly dry hands after washing. Frequently apply non-oil-based lotion to the hands. Clean areas and equipment contaminated with latex-containing dust frequently. If you notice latex allergy symptoms, consider consulting an allergist. You also should discuss your symptoms with your supervisor, who will recommend that you switch to hypoallergenic or vinyl gloves. If you have an allergy, the healthcare facility is required to provide nonlatex gloves for your use. Sharps and Biohazardous Waste Handling and Disposal Sharp medical and surgical instruments have great potential for transmitting infection through cuts and puncture wounds. Used scalpels, needles, syringes, and other sharp objects should be disposed of in a puncture-resistant sharps container. All items other than sharps that have come in contact with tissue, blood, or body fluids must be disposed of in a leakproof plastic bag or container. The container must be either red or labeled with the orange-red biohazard symbol. The proper procedure for handling and disposing of sharps and biohazardous waste is discussed in detail in the Infection Control Practices chapter. Surgical Asepsis Surgical asepsis completely eliminates microorganisms. The goal of surgical asepsis is to control microorganisms before they enter the body. To accomplish this goal, the items used in healthcare must be sterile (completely free of microorganisms). Surgical instruments are sterilized before use, and sterile technique procedures must be followed. You will be expected to perform the following common procedures involving sterile technique: Creating a sterile field Adding sterile items to the sterile field Performing a surgical scrub Putting on sterile gloves Sanitizing, disinfecting, and sterilizing equipment Creating a Sterile Field A sterile field is an area free of microorganisms that is used as a work area during a surgical procedure. Always be aware that the sterile field is understood to become contaminated and must be redone in the following circumstances: An unsterile item touches the field. Someone reaches across the field. The field becomes wet. The field is left unattended and uncovered. You turn your back on the field. For more rules of sterile technique, see the Caution: Handle with Care feature. CAUTION: HANDLE WITH CARE Rules for Sterile Technique A sterile field is a microorganism-free area used during a surgical procedure. To maintain sterility throughout the procedure, follow surgical technique and adhere to these rules: 1. Do not touch a nonsterile article to a sterile article or area. This will cause the sterile area or article to be considered nonsterile.  2. If you are unsure about the sterility of an article or area, consider it nonsterile. 3. Unused, opened sterile supplies must be discarded or resterilized. 4. Packages must be wrapped or sealed in such a way that they can be opened without contamination. 5. The edges of wrappers (1-inch margin) covering sterile supplies and the outer lips of bottles and flasks containing sterile solutions are not considered sterile. 6. If a sterile surface or package becomes wet, it is considered contaminated and should not be used. 7. Do not reach over a sterile field when you are not wearing sterile clothing. This action contaminates the sterile field. 8. Keep your hands between your shoulders and your waist when wearing sterile gloves to maintain sterility. 9. Do not turn your back on a sterile field even if you are in a sterile gown. Your back is always considered contaminated. The sterile field is often set up on a Mayo stand—a movable, stainless steel instrument tray on a stand. Adjust the stand so that the tray is slightly above waist level. Remember, items placed below waist level are considered contaminated. Before beginning, disinfect the Mayo stand with 70% isopropyl alcohol and allow it to dry. To create the sterile field, cover the stand with two layers of sterile material. This material can be sterile disposable drapes, separately sterilized muslin towels, or the muslin towels that the surgical instruments are wrapped in before autoclaving to produce office-sterilized sterile instrument packs. Commercially prepared sterile instrument packs, usually with disposable paper wrappings, are also used to create a sterile field. Procedure 44-1, at the end of this chapter, describes how to prepare a sterile field and how to open sterile packages. When assembling the necessary supplies, place all unsterile items that may be used during the procedure outside the sterile field. Unsterile items include items that are sterile on the inside but not on the outside, such as a sterile gauze pack or a sterile liquid such as alcohol, saline, or peroxide inside an unsterile bottle. Unsterile supplies should be arranged on a counter away from the sterile field. A typical arrangement of unsterile items used in surgery is shown in Figure 44-9. If you place an unsterile item within the sterile field, the field is no longer sterile and you must repeat the entire process.  FIGURE 44- 9 For each surgical procedure, unsterile surgical supplies must be gathered and arranged in an area separate from the sterile field.© McGraw-Hill Education. David Moyer, photographer Creating a Sterile Field Page 906 Adding Sterile Items to the Sterile Field The outer 1 inch of the sterile field is considered contaminated. So before you add sterile items to the sterile field, carefully plan where you will place the instruments so that they are within the sterile field. Instruments and Supplies If you have used sterile disposable drapes or separately sterilized muslin towels to create the sterile field, you will need to add the necessary instruments. Stand away from the sterile field and open the sterile instrument pack in the manner described inProcedure 44-1. Place the pack on a counter or hold it open in your hand. Transfer and arrange the instruments on the sterile field with sterile transfer forceps. Never reach across the sterile field. Some instruments are sterilized individually in autoclave bags, and many sterile supplies are prepackaged. Stand away from the sterile field as you open an individual bag or package. You can pull the flaps of the packaging partway apart, then snap (remove from position by a sudden movement) the item onto the sterile field from a distance of 8 to 12 inches. Alternatively, you can use sterile forceps to grasp and place the items in the sterile field. Pouring Sterile Solutions Sterile solutions are often required during the surgical procedure to rinse or wash the wound. These can be added to the sterile field after the sterile instruments. Several sterile solutions are commonly used during minor surgical procedures, including sterile water and normal saline (0.9% sodium chloride). Bottles of these sterile solutions come in a variety of sizes. Choose the smallest size that will supply the amount of solution needed during the procedure to help minimize cost, because unused solutions are typically discarded. When pouring a solution, cover the label on the bottle with the palm of your hand to keep the label dry. Pour a small amount of the liquid into a liquid waste receptacle to clean the lip of the bottle. As you pour the solution into a sterile bowl on the field, hold the bottle at an angle to avoid reaching over the sterile area. Hold the bottle fairly close to the bowl without touching it. Pour the contents slowly to avoid splashing the drape, which would contaminate the field (see Figure 44-10). FIGURE 44-10 When pouring a sterile solution for use on a sterile field, be careful not to splash the solution. When a sterile solution bottle is opened and may be used again during the procedure, do not let any unsterile object touch the inside of its cap. To accomplish this, place the cap on a clean location with the sterile inside of the cap facing up. Performing a Surgical Scrub and Donning Sterile Gloves If you assist in a surgical procedure, you must perform a surgical scrub and wear sterile surgical gloves. Surgical scrub procedures are similar to those for aseptic handwashing, but there are several distinctions: A sterile scrub brush is used instead of a disposable nailbrush. Both the hands and the forearms are washed. Page 907The hands are kept above the elbows to prevent water from running from the arms onto washed areas. Sterile towels are used instead of paper towels. Sterile gloves are put on immediately after the hands are dried. You may wonder why a surgical scrub is necessary if you are planning to wear sterile gloves. The answer is that there is always the possibility that a glove may be punctured. If the skin is as clean as possible, the risk of contamination from a punctured glove is minimized. Nevertheless, if a glove is damaged during a sterile procedure, you must consider anything touched by that glove after it is damaged to be contaminated. Contaminated items must be resterilized or replaced before you continue. A surgical scrub removes microorganisms more effectively than does routine handwashing. Routine handwashing removes bacteria present on the skin’s surface, whereas the surgical scrub removes bacteria in deeper layers of the skin—where the hair follicles and oil-producing glands exist. Procedure 44-2, at the end of this chapter, describes the process for performing a sterile scrub. Sterile gloves are required for many procedures. You don sterile gloves after you perform the surgical scrub. The process for donning sterile gloves is described in Procedure 44-3 at the end of this chapter. Remember, once you are wearing sterile gloves, you may touch only the items in the sterile field. So you must remove any drape covering the sterile instrument tray before you glove. Sterile gloves provide a small margin of safety in preventing contamination; your movements must be controlled and precise to work within this margin to protect the sterile area. Preoperative Procedures LO 44.5 You must complete a number of steps before a surgical procedure, including performing various preliminary duties, preparing the surgical room, and physically preparing the patient for surgery. Preliminary Duties The first tasks you will perform before the surgery include providing preoperative (prior to surgery, or “pre-op”) instructions to the patient, completing various administrative tasks, and easing the patient’s fears. Preoperative Instructions When a patient is scheduled for a minor surgical procedure in the doctor’s office, you must explain the preoperative instructions. Be prepared to answer the patient’s questions about the procedure and possible risks. The patient may ask you, rather than the doctor, such questions or may need clarification of information provided by the doctor. A patient may need to follow certain dietary and fluid restrictions before a minor surgical procedure. Not eating or drinking for a specific period of time is a common restriction. The patient’s medications may also be restricted because of anesthetic administration during the procedure. Non-English-speaking patients may need an interpreter who can help them understand the forms they must sign and their instructions. Instruct the patient to wear either comfortable, loose-fitting clothes that will not interfere with the procedure or clothing that can be removed easily. In most cases, patients also need to arrange for someone to drive them home and stay with them for 24 hours after the procedure. Administrative and Legal Tasks You must ensure that all the necessary paperwork is completed before surgery. Routine administrative tasks include completing the required insurance forms and obtaining prior authorization from the patient’s insurance company. Make absolutely certain the patient reads, understands, and signs the surgical consent form. The patient needs a clear understanding of what to expect during and after the surgery to give informed consent as required by law. Sometimes surgery is performed on a child or a patient with limited understanding of legal documents. In such cases, the consent form must be signed by the patient’s parent or legal guardian. Failure to obtain the necessary paperwork prior to a surgical procedure can cause serious legal problems. The doctor and other staff members could be held legally liable if problems were to develop during or after the procedure. It is common practice to call the patient the day before the surgery to confirm the appointment. This call also provides a chance to ensure that the patient follows the preoperative instructions. You may be responsible for making this call. Page 908 Easing the Patient’s Fears Knowing what to expect during and after a surgical procedure will ease the patient’s fears. This information allows him or her to plan daily activities and, if necessary, to arrange for help at home during the recovery period. Some offices have educational materials such as brochures, fact sheets, or videos about the procedure the patient will undergo. You may assist in preparing or acquiring these materials if your office’s policy includes such participation for medical assistants. This type of information may increase patient compliance with pre- and postoperative instructions. Much of a patient’s fear about a surgical procedure can be overcome if you spend sufficient time before the procedure explaining what to expect. Be prepared to answer the patient’s questions honestly, calmly, and confidently. Your calm and knowledgeable manner will reassure the patient. If the answer to a question requires experience or knowledge beyond your own, pass the question on to the healthcare practitioner. Preparing the Surgical Room Prior to surgery, the doctor should inform you of specific instructions concerning patient preparation. He also will tell you what special equipment or supplies are necessary for the procedure. Because patients are likely to feel anxious before a procedure, it is best to have everything ready in the surgical room before you escort the patient into the room. Make sure the room is clean, neat, and free of waste from previous procedures. The examining table should have been cleaned and disinfected, and surface barriers (table paper and pillow covers) should have been changed. Check to see that there is adequate lighting. Make sure that all equipment and supplies necessary for the procedure are available. Check the date and sterilization indicator on sterilized packs and supplies. You will then wash your hands and prepare the sterile field as outlined in Procedure 44- 1 at the end of this chapter. The sterile field and the instruments should be draped with a sterile towel. Preparing the Patient Just before the surgery, various concerns must be addressed and procedures completed in sequence. The initial tasks are followed by gowning and positioning the patient and preparing the patient’s skin for surgery. Initial Tasks Before leading the patient into the surgical room, give the patient an opportunity to use the bathroom. You must also find out whether she has followed the presurgical instructions. Restrictions on food and fluid intake are of particular concern. Also, ask what medications the patient is taking and whether she has taken that day’s dosage. Measure the patient’s vital signs. Ask if there are any symptoms or problems the doctor should know about before the surgery. If any unusual signs or symptoms are present, notify the doctor. The doctor will want to examine the patient before proceeding. Check the chart for medication orders, such as pain medication or a tranquilizer to calm the patient. Medications should be administered at this time so that they can take effect before surgery. Gowning and Positioning the Patient Some procedures require the patient to disrobe and put on a gown to expose the surgical site. If this is the case, you should offer to assist, if appropriate, or leave the room while the patient changes. You should then help the patient onto the table and into the position required for the procedure. You may use one or more small pillows to make the patient as comfortable as possible. Then adequately drape the patient to retain body heat and preserve personal dignity. Sterile drapes are also used to create a sterile field on a patient’s body around the surgical site. Drapes come in a variety of sizes and styles. A fenestrated drape has a round or slit-like opening cut out in the center to provide access to the surgical site. Surgical Skin Preparation Prior to surgery, the patient’s skin must be prepared to reduce the number of microorganisms and the risk of surgical site infection. Preparation includes cleaning the area, removing the hair, and applying antiseptic. The area prepared should be 2 inches larger than the intended surgical field. The surgical field is the area exposed in the center of the fenestrated drape. The extra prepared skin area allows for draping without contaminating the surgical field. Cleaning the Area Before proceeding with the surgical skin preparation, wash your hands and don exam gloves. Place a plastic-backed drape under the surgical site to absorb any liquids. Clean the site first with an iodine-based solution, using forceps and gauze sponges dipped in the solution. Begin at the center of the surgical site and work outward in a firm, circular motion (Figure 44-11). Discard the gauze sponge after each complete pass. Clean in concentric circles until you cover the full preparation area. Continue the process, repeating as Page 909necessary, for at least 2 minutes or the amount of time specified in the office’s procedure manual. Cleaning takes more time if a wound is dirty or contains foreign materials. When procedures are performed on a hand or foot, clean the entire hand or foot. The skin and body openings, particularly the nose, mouth, and perineum, cannot be considered sterile. Nevertheless, the principles of aseptic technique require that you try to keep the area as contamination-free as possible. FIGURE 44-11 Clean the surgical site with an iodine-based solution. Begin at the center of the surgical site and work outward in a firm, circular motion. Clean in a circular, outward pattern 2 inches larger than the surgical field. Removing Hair from the Area Depending on office policy, you may be required to remove hair from the surgical site. Shaving often causes many small wounds on the skin, which increases the risk of infection, and is not recommended. Some experts feel that hair should not be removed unless it is thick enough to interfere with surgery. If this is the case, hair may be trimmed with scissors or electric trimmers or smoothed out of the way. This should be done with care—to avoid damaging the skin—immediately before surgery. Applying the Antiseptic Antiseptics are agents applied to the skin to limit the growth of microorganisms and to help prevent infection. Povidone iodine (Betadine®) is most commonly used, but chlorhexidine gluconate (Hibiclens®) or benzalkonium chloride (Zephiran®) may also be used, particularly if the patient is allergic to iodine. After cleaning or removing the hair when needed, swab an area 2 inches larger than the surgical field with the antiseptic solution in a circular, outward motion, starting at the surgical site. This is the same motion used for cleaning the surgical site. For surgery on a hand or foot, swab the entire hand or foot. Allow the antiseptic to air-dry; do not pat it dry—that would remove some of the solution’s antiseptic properties. When the area is dry, treat it as a sterile field. Instruct the patient not to touch the area. Cover the area with a sterile fenestrated drape, from front to back. Avoid reaching over the field. At this point, notify the physician that the patient is ready. Then prepare yourself to assist with the surgery. Intraoperative Procedures LO 44.6 Intraoperative procedures are procedures that take place during surgery. You may be asked to perform a wide variety of unsterile and sterile tasks during surgery, such as preparing a local anesthetic, monitoring the patient, processing specimens, and handing instruments to the doctor. The doctor also may ask you to explain to the patient step by step what will be done next during the procedure. Administering a Local Anesthetic Before beginning the surgical procedure, the physician will administer a local anesthetic. Some local anesthetics are injected. An injected anesthetic is packaged in a sterile vial (a small glass bottle with a self-sealing rubber stopper). Other local anesthetics come in a cream, gel, or spray form. These anesthetics are topical (applied directly to the skin) and affect only the area to which they are applied. The choice of administration method depends on how invasive or painful the procedure is likely to be. Lidocaine (Xylocaine®) is the most commonly used anesthetic, used as an injectable or a topical gel anesthetic. Tetracaine hydrochloride (Pontocaine®), a long-acting anesthetic, is injected or topical. Topical Application A topical anesthetic is useful when the pain will be mild or when only the skin’s upper layers are affected. It is common to use such agents to anesthetize the area of a small laceration prior to suturing. Sometimes an anesthetic cream is applied before a local anesthetic is injected to reduce or eliminate the pain caused by the injection. A topical anesthetic must usually remain on the skin for 10 to 15 minutes for the area to become sufficiently anesthetized. Injections If a local anesthetic is to be injected, it is typically administered after the skin is prepared but before the patient is draped. In some cases, however, the anesthetic is injected prior to skin preparation to allow time for it to take effect. In either case, it is important to note the time of anesthetic administration in the patient’s chart. If the doctor is already wearing sterile gloves, you may be asked to assist in administering the anesthetic. Because administering an anesthetic is an unsterile task (the outside of the vial is unsterile), when performing it, follow proper procedure to protect the sterility of the doctor’s gloves and the anesthetic solution. First, check the label of the anesthetic vial two times to confirm that it is the correct solution. Then, clean the vial’s rubber stopper with a 70% isopropyl alcohol solution and leave the alcohol pad on top of the stopper. Present the requested needle and syringe to the doctor by peeling half the outer wrapper away and allowing the doctor to remove them from the wrapper. Remove the pad from the rubber stopper and hold the vial so that the doctor can verify it is the proper medication. Turn the vial upside down and hold it securely around the base, without touching the sterile stopper. Be sure to hold the vial in front of you at shoulder height. Because significant force will be necessary to push the needle through the rubber stopper, brace the wrist of the hand holding the vial with your free hand. Hold the vial firmly so that the doctor can withdraw the anesthetic from it (Figure 44- 12). Check the vial a third time to confirm that it is the correct solution. FIGURE 44-12 You must hold the anesthetic vial firmly to allow the physician to puncture the rubber stopper with the needle.© Cliff Moore Page 910 Potential Side Effects of the Anesthetic Patients sometimes have reactions to anesthetic medications and should be informed of this prior to the procedure. Although rare, reactions may include dizziness, loss of consciousness, seizures, or cardiac arrest. Adverse reactions can occur if the anesthetic dose is too high or if it is absorbed too quickly. Reactions can also occur if the patient is taking other medications that should not be mixed with the anesthetic. All medications (including over-the-counter medications) that a patient is taking at the time of surgery must be documented to avoid possible reactions. Use of Epinephrine Epinephrine is a sterile solution that is sometimes injected along with an anesthetic. It constricts the blood vessels, making them narrower, which reduces bleeding and prolongs the action of the local anesthetic. Epinephrine is used if the surgery site is an area with many small blood vessels that are expected to bleed profusely (such as the head). Reducing bleeding makes it easier to see and to repair the wound. Epinephrine should be used with caution, however, in patients with heart disease or respiratory disease. Epinephrine also prolongs the anesthesia because epinephrine slows the rate at which the anesthetic spreads into the tissue. This effect may or may not be desirable. There is some concern that epinephrine may increase wound infection rates. If the wound is highly contaminated, the physician may choose to use anesthetic without epinephrine. Assisting the Physician During Surgery Your role in surgical assisting depends on the type of surgery and the physician’s preference. You may assist the physician in one of two capacities with different duties: as a floater—an unsterile assistant who is free to move about the room and attend to unsterile needs—or as a sterile scrub assistant—who assists in handling sterile equipment during the procedure. The Floater If you are assisting as a floater (sometimes called a circulator), you will perform a routine handwash and don exam gloves. Remember, you cannot touch sterile items in the sterile field because you have not performed a surgical scrub and are not wearing sterile gloves. Procedure 44-4, at the end of this chapter, outlines the tasks performed by a floater (unsterile assistant). Monitoring and Recording One of a floater’s most important duties is to monitor the patient during the procedure. You must measure vital signs regularly and observe the patient for reactions to the anesthetic. Record all observations in the patient’s chart. Also, write down any information or notes the doctor requests. You must keep a record of time, including when the anesthetic is administered, when the procedure begins, and when the procedure is completed. Processing Specimens When you serve as a floater during surgery, the doctor may ask you to receive and process specimens for laboratory examination. Most tissues are placed in a 10% formalin solution to preserve them before they are sent to the laboratory. If the container is not prefilled, half-fill the specimen container with the formalin solution ahead of time. Remove the lid of the specimen container without touching the rim. Hold the container out toward the doctor so that she can place the tissue directly into it without contaminating the sample (Figure 44-13).  FIGURE 44- 13 Be sure to hold the specimen container so that the doctor can place the tissue in it without touching the rim or outside of the container with the tissue.© McGraw-Hill Education/David Moyer/photographer The container should be labeled with the following information: The patient’s name and the doctor’s name The date and time of collection The body site from which the specimen was obtained Your initials If more than one specimen is obtained from a patient, place each specimen in a separate container. Label each container with the necessary information, along with a number to indicate the order in which the specimens are obtained (no. 1, no. 2, and so on). The physician will usually tell you the exact location of each specimen taken. You will also fill out a laboratory requisition slip to send along with the specimen(s). Specimen containers should be placed in a special transport bag labeled with the biohazard symbol. Most transport bags have an outside pouch for the lab requisition form. The form should accompany the sample but not be placed in contact with the specimen container. This protects lab personnel when they handle the requisition form. Other Duties As a floater, you also may be asked to perform a number of other duties, including: Assisting with the injection of additional anesthetic Adding additional sterile items to the sterile tray Pouring sterile solutions Keeping the surgical area clean and neat during the procedure  Repositioning the patient as necessary Adjusting lighting Page 911 The Sterile Scrub Assistant When serving as a sterile scrub assistant, you must perform a surgical scrub and wear sterile gloves. You may be asked to perform a variety of tasks under sterile conditions. Follow the rules of sterile technique listed earlier in this chapter, and remember not to touch unsterile items after putting on sterile gloves. Procedure 44-5, at the end of this chapter, and the sections that follow outline the tasks performed by a sterile scrub assistant. Handling Instruments Your first duty as a sterile scrub assistant is, typically, to close the instruments on the sterile tray because they are left in the open position during sterilization. Your next duty is to rearrange the instruments on the tray in the order in which they will be used or according to the doctor’s preference. Instruments are generally used in the following sequence: Cutting instruments Grasping instruments Retractors Probes Suture materials Needle holders and scissors Prepare for swabbing by placing several sterile gauze squares in the dressing forceps, to be ready when needed. As the sterile scrub assistant, you will be asked to pass instruments to the doctor during the procedure. You must hold instruments so that the doctor can grasp them safely and securely, without needing to reposition them in her hands. At the same time, the instruments must be handled properly to maintain their sterility. When passing scissors and clamps, hold them by the hinge (Figure 44-14). You will have a clear view of the instrument’s tip and the doctor will have full use of the handles. Firmly slap the instrument handles into the doctor’s extended palm. The doctor’s hand will close around the handles as a reflex action to the slapping. This technique reduces the risk of dropping an instrument. If the scissors or clamp is curved, the curve should follow the same curve as the doctor’s hand. FIGURE 44-14 Holding the scissors by the hinge, slap the handles into the doctor’s hand.© MIXA/Getty Images RF When passing a scalpel, hold it above and just behind the cutting edge of the blade with the blade facing away from your palm so that the doctor can grasp the entire handle (Figure 44-15). You should wait until the doctor has fully grasped the handle before taking your hand away. The doctor will wait until your hand is fully out of the way before moving the scalpel. This requires good communication between you and the doctor and helps avoid any injury while passing the scalpel. Pass a needle holder with suture material so that the needle is pointing up, and hold the end of the suture material with your other hand to prevent the material from becoming tangled in the handles. You may also use a sterile tray called a passing tray when passing sharp instruments to the doctor. Using a passing tray reduces the likelihood of having an exposure incident while passing instruments (Figure 44-16).  FIGURE 44- 15 Hold a scalpel above and just behind the cutting edge as you pass the handle into the palm of the doctor’s hand.© Alexey Poprotskiy/Shutterstock FIGURE 44-16 A passing tray may be used to safely pass sharp instruments during a surgical procedure. Other Duties As a sterile scrub assistant, you also may be asked to swab fluids from a wound or to retract the edges of a wound to help the doctor view the area. While the doctor is closing the wound, you may be required to cut the suture material after each stitch. The doctor may not verbalize every request to you. With practice and after experience with a particular doctor, you will learn how to respond to the doctor’s actions. Page 912 When cutting suture materials, leave ⅛ inch of the material above the knot. This length prevents the suture from coming untied but is short enough that it does not bother the patient. Postoperative Procedures LO 44.7 You will be responsible for the patient’s postoperative (“post-op”) follow-up after the surgical procedure. Your duties may include immediate care of the patient, proper cleaning of the surgical room, and follow-up care of the patient. Procedure 44-6, at the end of this chapter, outlines the tasks performed after a minor surgical procedure. Immediate Patient Care Patient care is your top priority as a medical assistant. Except for intravenous medications, you will administer postoperative medications the physician requests for the patient. You also will ensure that the patient remains lying down on the examining table for the prescribed length of time after the procedure. During this period, continue to monitor the patient’s vital signs and watch for adverse reactions. Document your observations in the patient’s chart. Dressing the Wound You also may dress the wound during the monitoring period. Dressings are sterile materials used to cover an incision. They serve a number of functions. They protect the wound from further injury and keep the wound clean, thus preventing infection. Dressings also reduce bleeding, absorb fluid drainage, reduce discomfort to the patient, speed healing, and reduce the possibility of scarring. Gauze dressings are the most common type and come in a variety of sizes and shapes. Before dressing the wound, don clean exam gloves. Place the sterile dressing over the site and secure it appropriately. Bandaging the Wound It may be necessary to apply a bandage (a clean strip of gauze or elastic material) over the dressing to help hold it in place. Tube gauze may be needed for bandaging wounds on fingers or other extremities. Application of this type of gauze requires an applicator. The applicator is a wire cage on which the gauze is loaded. Bandages also may be used to improve circulation, to provide support or reduce tension on a wound or suture and prevent it from reopening, or to prevent movement of that area of the body. Adhesive tape also may be used for these purposes. Some patients are allergic to the adhesive, but most tapes are now hypoallergenic. The patient is usually more comfortable after a bandage or adhesive tape has been applied. Postoperative Instructions After the procedure, provide oral postoperative instructions to the patient. You may do this during the monitoring part of the postoperative period or afterward. These instructions include guidelines for pain management and instructions for wound care. Postoperative information also includes dietary or activity restrictions, if any, and when to come in for a follow-up appointment. It is a good idea to ask patients to repeat what you have said so that you know they understand the information. Instructions should be provided in writing as part of a complete postoperative information packet. You may be asked to help prepare or update packet materials, especially if you routinely assist patients as they recover from minor surgery. A postoperative information packet might include the following information: Proper wound care instructions  Suggestions for pain relief and reduction of swelling, such as medications and hot or cold packs Dietary restrictions Activity restrictions Timing for a follow-up appointment or an appointment card Wound care instructions include details on changing the dressing, keeping the wound clean, recognizing signs of infection, and protecting the wound. The instructions may vary depending on the depth and size of the wound. In general, the bandage should be removed after the first 24 hours or if it becomes soaked with blood, wet, or dirty. A wet dressing allows bacteria and other contaminants to enter the wound. In most cases, the wound may be cleaned with soap and water after 24 to 48 hours. Once cleaned, gently dry the incision with a sterile gauze and cover with a clean, dry bandage. You should teach the patient about the signs of infection. For more information, see Educating the Patient: When to Call the Doctor About a Wound. Encourage the patient to protect the incision from sun exposure for the first 6 months; doing so helps prevent the incision line from becoming darker than the surrounding skin. The length of time it takes for a wound to heal varies with the site, the patient’s age and health status, and the severity of the wound. So each patient needs specific instructions on how long to continue with the dressings and when to return for suture or staple removal. He or she also may need specific information about limiting activities. EDUCATING THE PATIENT When to Call the Doctor About a Wound Whether a wound is postsurgical or from an accident, it is important for patients to know when they should call the doctor. Understanding when a wound needs medical attention can reduce the instances of scarring and infection. You can help by teaching them what to look for when they have a wound. Patients with any wounds should call the office if they have any of the following: Jagged or gaping edges A face wound Limited movement in the area of the wound Tenderness or inflammation at the wound site Purulent drainage A fever greater than 100°F Red streaks near the wound A puncture wound Bleeding that does not stop after 10 minutes of pressure Sutures coming out on their own or too early Page 913 Patient Release Notify the doctor when the patient is stabilized and ready to leave. The doctor may want to further observe and instruct the patient. Be sure to offer assistance if the patient needs help getting dressed. Then help the patient check out. Schedule the next appointment for the patient. Make sure the patient has the correct discharge packet. Confirm arrangements to transport the patient home. Finally, assist the patient to the car or other transport if this is part of office procedure. If a patient insists on driving himself home, enter this information on the chart. Indicate the time and have the patient initial the entry. This documentation is important for legal reasons. It would clarify liability, should an accident occur as a result of a reaction to the surgery or the anesthetic. SUMMARY OF LEARNING OUTCOMES LEARNING OUTCOMES KEY POINTS 1. 44.1Define the medical assistant’s role in minor surgical procedures. The medical assistant’s role in minor surgery includes both administrative and clinical tasks. These include but are not limited to completing insurance forms, obtaining signed patient consent, preparing the surgical room, and assisting during a procedure. 1. 44.2Describe surgical procedures performed in an office setting. Several surgical procedures are performed in an office setting, including laser surgery, cryosurgery, and electrocauterization. 1. 44.3Identify the instruments used in minor surgery and describe their functions. Various categories of instruments are used in minor surgery, including instruments for cutting and dissecting, grasping and clamping, retracting, dilating and probing, suturing, injecting, withdrawing fluids, and obtaining specimens. 1. 44.4Describe the procedures for medical and sterile asepsis in minor surgery. Medical asepsis involves reducing the number of microorganisms to prevent the spread of disease. The goal of surgical asepsis is to eliminate all microorganisms. 1. 44.5Summarize the medical assistant’s duties in preoperative procedures. A medical assistant’s preoperative duties include providing preoperative instructions to the patient, ensuring that all necessary paperwork is completed, easing the patient’s fears, and preparing the surgical room. 1. 44.6Describe the medical assistant’s duties during an operative procedure. A medical assistant may serve in one of two capacities during a surgical procedure: either as an unsterile assistant known as a floater or as a sterile scrub assistant. 1. 44.7Implement the medical assistant’s duties in the postoperative period. A medical assistant’s postoperative duties include giving immediate patient care, dressing and bandaging the wound, giving postoperative instructions, assisting with patient release, and cleaning the surgical room. C A S E S T U D Y C R I T I C A L T H I N K I N G  © Image Source/Getty Images RF Recall Peter Smith from the beginning of the chapter. Now that you have completed the chapter, answer the following questions regarding his case. 1. What is the medical assistant’s role during this minor surgical procedure? 2. Why is it important to document the number of sutures Dr. Buckwalter uses to close Mr. Smith’s wound? 3. How should you answer Mr. Smith’s question about his trip to the Bahamas? 4. Knowing that Mr. Smith started swimming last week, what should you tell him about protecting his sutures?