Medical Surgical Procedures PDF

**48-1 Surgical Procedures in the Medical Office** ================================================== The medical assistant might have various roles while assisting the provider with minor surgical procedures. They must ensure the comfort and safety of the patient and be knowledgeable enough about...

**48-1 Surgical Procedures in the Medical Office** ================================================== The medical assistant might have various roles while assisting the provider with minor surgical procedures. They must ensure the comfort and safety of the patient and be knowledgeable enough about the procedures to assist during surgery with little or no direction, if required. Maintaining sterile technique, being knowledgeable about the provider's preferences and of the surgery being performed are critical. [Table 48--1](javascript://) lists some of the common surgical procedures performed in the medical office along with some general information about each. ### **In-Office Minor Surgical Procedures** -- -- -- -- Outpatient, or ambulatory, surgery in recent years has become more acceptable than ever before for a number of reasons. Local anesthetics are used for many of the surgical procedures performed in the clinic. Additionally, general anesthesia has been significantly improved and causes fewer side effects in patients following surgical procedures, so patients awaken faster and easier. Also, the required time for many surgeries has decreased due to improved techniques and instruments such as the scopes used in laparoscopic surgeries. For example, an abdominal laparoscopy requires two to three very small incisions for insertion of the scope, suction, and possibly a third instrument. The gallbladder, growths, and tumors can be removed with this advanced technology. Because patients naturally feel more comfortable at home following the same-day surgery, most patients of all ages are sent home to recover and do so more rapidly than when in the hospital. Postsurgical infection rate has also declined in those patients who go home immediately following surgery. All this is highlighted by the reduced cost from the elimination of a hospital stay. **48-2 Tray Setup for Common Surgical Procedures** ================================================== As discussed previously, a variety of surgical procedures are being performed in the medical office. Some procedures require very specific instruments to be used, so having a base knowledge of tray setup for a variety of the common procedures can be to your advantage. Although the types and sizes of instruments may vary from provider to provider and you should always check with their specific wants, [Table 48--2](javascript://) lists the instruments and supplies needed for a few of the more common procedures. ### **Tray Setup for Common Surgical Procedures** -- -- -- -- **48-3 Assisting with Minor Surgery** ===================================== Some providers prefer to perform minor surgical procedures themselves and have the medical assistant prepare the patient, the room, and the equipment only. However, other providers like to have the medical assistant directly involved in assisting with the procedure, and those providers usually have their own preference of how the instruments are set up and what duties the medical assistant is expected to perform. When assisting with a surgical procedure, it is critical to maintain strict sterile technique. A break in sterile technique or a breach of the sterile field can result in an infection for the patient. **48-3a Anesthetics** --------------------- Most in-office minor surgical procedures are performed under local [**anesthesia**without sensation, with or without loss of consciousness.](javascript://), which the provider administers. Local anesthesia causes a loss of sensation in a specific area of the body (the area in which the procedure will be performed) as opposed to general anesthesia, which causes a loss of sensation over the entire body (unconsciousness). ### **Practical Application** The most common local anesthetic agents are Xylocaine (lidocaine hydrochloride) and Novocain (procaine hydrochloride). The provider is the one to inject the anesthetic into the area, but you might be asked to hold the vial while the provider draws up the medication ([Figure 48--1](javascript://)). The anesthetic usually begins to numb the area within approximately 5 to 15 minutes and will keep the area anesthetized for up to three hours. Some providers prefer to use an anesthetic with epinephrine additive to help constrict the blood vessels in the area, which prolongs the effect of the anesthetic. **Figure 48--1** Hold the anesthetic solution in a convenient position so the provider can fill the syringe without contamination. **48-3b Specimen Collection** ----------------------------- In procedures requiring a biopsy for analysis, carefully labeling and handling the specimen are vital. The laboratory provides a formalin solution container for preservation of the tissue specimen. This container is sterile, and the specimen must be placed directly in the solution with sterile transfer forceps. A completed lab request form must accompany the specimen for analysis. In certain surgical procedures, such as the removal of warts or polyps, an electrocautery device may be used ([Figure 48--2](javascript://)). Often, this controls bleeding of the surgical site by electrocoagulation. Controlled high-frequency current is applied by the provider to the surgical area to [**coagulate**lessening of the fluidity of a liquid substance; clotting or curdling.](javascript://)the blood to close the incision. If the reusable tips are preferred by the provider for surgical procedures, they must be autoclaved to prevent possible cross-contamination. Disposable tips are available. **Figure 48--2** An electrocautery unit. Courtesy of Bovie Medical Corporation. Another method for removing skin tags, warts, and other skin disorders and growths such as seborrheic keratosis, molluscum contagiosum, and dermatofibroma is by cryosurgery. Often, certain gynecologic treatments and surgical procedures are performed with this method. This process uses subfreezing temperature to destroy or remove tissue. Generally, the most common substance used is liquid nitrogen. Skin lesions often can be treated in a single session, although some require several treatments. Some advantages of this treatment include low risk of infection, minimal wound care, and no anesthesia. Potential side effects include bleeding, blister formation, white skin where applied, and sometimes scarring. Cryosurgery is also used as a surgical treatment to freeze and destroy abnormal tissue in the cervix that causes precancerous conditions of the cervix known as cervical intraepithelial neoplasia or abnormal cell changes in the cervix that may develop into cervical cancer. This is accomplished by the provider inserting a device called a cryoprobe into the vagina and placing it firmly on the surface of the cervix, freezing the abnormal tissue and killing the abnormal cells. Generally, the freezing is done for three minutes, the cervix is allowed to thaw for five minutes, and then the freezing is repeated for another three minutes. It is sometimes referred to as cryotherapy. ### **Practical Application** **48-3c Bandaging** ------------------- Patients will present with skin sensitivities to various materials; the type of bandage the provider orders will vary and should be appropriate for the wound and for the patient's skin. For patients who are very active or who are employed in activities that could further injure or cause the wound to become dirty or wet, the wound should be wrapped in a very thick dressing to cushion and protect it and allow it to heal. Make sure you advise the patient to keep the dressing clean and dry. Remind the patient to place a plastic bag over the extremity to keep it dry during showers or baths. If the wound is on the trunk of the body, taking a shower or bath should be discouraged unless the provider has approved it. Usually, a sponge bath is preferred until the bandage comes off. This is important in minimizing the possibility of infection. If an infection should occur, you might be asked to obtain a specimen for laboratory analysis and culture. [Procedure 48--1](javascript://) explains wound collection procedures. Simply use a sterile swab and insert the tip into the center of the infected area of the wound. Then transfer the swab with the specimen into the culture medium. Provide patient education regarding care of the site and when to return for a follow-up appointment. In addition, providers advise using an elastic bandage to offer more protection and support of surgical areas of the extremities, especially for pediatric and physically active patients. Application of an ACE wrap increases circulation of the area, which hastens the healing process. Refer to [Chapter 54](javascript://) for more information on bandage types and techniques. ### **Perform Wound Collection** -- -- -- -- -- -- **48-3d Postoperative Instructions** ------------------------------------ Printed instructions should be given to the patient and explained to both the patient and family members. The patient should, of course, be given the provider's phone number and urged to phone if there are any complications or concerns. You should have a standard set of printed instructions readily available for telephone screening of those outpatient surgery patients who call in with questions or concerns. Any calls that suggest a serious problem or condition should be referred to the provider immediately. Refer to the Patient Education box regarding what you should caution patients about following any surgery. ### **Practical Application** 1. Keep site clean and dry. 2. Place no stress on the area. 3. Drink plenty of fluids. 4. Get proper rest. 5. Eat a sensible, well-balanced diet. 6. Return for follow-up appointment. 1. Unusual pain, burning, or other uncomfortable sensation 2. Swelling, redness, or other discoloration 3. Bleeding or other discharge 4. Fever above 5. Nausea and vomiting 6. Any other problem or symptom Make sure that return appointment visits are confirmed and reminder cards are given to patients before they leave the office. Phoning patients the next day is an excellent way to follow up and reassures them that you and the provider are genuinely concerned about their progress. It will also bring to the provider's attention any problems that could be eliminated early. If patients do have complaints, it is best to have the provider check the problem as soon as possible. Follow-up visits are essential so that assessment of progress can be made by the provider and sutures or staples can be removed. Specific instructions, such as soaking or applying topical medications, will be given by the provider for certain individual cases. Providers generally instruct patients (or teach you how to instruct patients) about packing or special bandaging procedures such as with ingrown toenail removals. Providers can prescribe an analgesic for minor pain and discomfort the patient might experience following the procedure. **48-3e Documenting Surgical Procedures** ----------------------------------------- Like all procedures, surgical procedures are to be documented in the medical record thoroughly and completed immediately. The medical record entry should include: - *A patient identifier*: The patient's name or patient ID number can be used. - *Informed consent*: Informed consent should be obtained from the patient before the procedure. - *The date and time*: The date and time of the procedure should be recorded. The provider might also request the start (time of incision) and stop time of the procedure to be recorded. - *The reason*: The provider should record in the patient chart the reason for the surgical procedure. - *The procedure*: The provider or the medical assistant should record the procedure to be done. If the medical assistant records the procedure, it should be rechecked with the provider. - *Specimen*: Specimen removal should be documented. The medical assistant documents what the specimen is and its source. The medical assistant also labels the specimen container with the patient's name and other patient-identifying information (name, date of birth). - *Postoperative instructions*: The medical assistant is responsible for ensuring that the patient or their caregiver understands the postoperative instructions. [Procedure 48--2](javascript://) lists the general steps involved when assisting with a minor surgical procedure. ### **Assist with Minor Surgery** -- -- -- -- -- -- **48-4 Sutures and Staples** ============================ The term *suture* means a type of thread that joins the skin of a wound (either an accidental laceration or a surgical incision) together. A type of suture called catgut is eventually absorbed by the body and does not need to be removed (generally used in major surgeries). It is made from the intestines of sheep. Suture is also made of a material such as silk, nylon, or other manufactured substances that must be removed in a matter of days, depending on the area of the body in which they are inserted. For convenience, most providers prefer to use suture that has a needle already attached. [Figures 48--3A](javascript://) and [B](javascript://) show examples of different types of suture materials and needles used in closing wounds. [Table 48--3](javascript://) displays the different types of suture materials that may be used in the clinical facility. **Figure 48--3A--B** \(A) A variety of suture packs and curved and straight surgical needles. (B) Various needle shapes used in the insertion of sutures to close wounds. ### **Types of Suture Material** -- -- -- -- -- -- -- -- Another commonly used method for skin closure of wounds and incisions is surgical staples. Some providers prefer staples over sutures because they are easier to use; however, some special care may be required as they can cause infection easier and they must be removed by you or the provider once the incision has healed. Staples generally need to stay in for a few days or up to a few weeks before they can be removed. **48-4a Applying Sutures** -------------------------- Most offices have a policy regarding the treatment of lacerations. If the injury is severe and might result in serious blood loss, it is usually treated in the emergency room or trauma center. However, many patients will come to their primary care physician to have a laceration sutured. Working these patients into an already full schedule can present delays for other patients waiting for scheduled appointments. Prepare the patient for the provider and assist as needed. After the suturing is complete, the provider can see other patients while you take care of the laceration patient and clean up the work area. Your efficiency and expedient preparation of setting up the treatment room will be appreciated by both the provider and the patient in this situation. Follow the steps in [Procedure 48--3](javascript://) for assisting with suturing a laceration. Always make sure that you record the number of sutures (stitches) the provider inserts and the anatomical location. Go over patient education and any additional instructions from the provider before the patient leaves the office. If the patient is given instructions by the provider to re-dress and bandage the wound at home, show the patient how to do this and alert them to call with any questions or concerns. ### **Assist with Suturing a Laceration** -- -- -- -- -- -- **48-4b Suture and Staple Removal** ----------------------------------- Patients usually see the family or general practitioner for suture removal following laceration repair from an injury. In many offices, it is the medical assistant's responsibility to remove the sutures or staples. It is vital to check the emergency center's report regarding the number of sutures or staples put in so you can be sure to remove all of them. Be sure to remove the same number of sutures or staples as were inserted by the provider. Sutures or staples that are not removed can become infected, so care in removing all the material is vital. Occasionally patients report that one or two stitches have already come out during a bandage change at home. This should also be noted in the patient's chart. Follow the steps in [Procedure 48--4](javascript://) for suture or staple removal. Removal of staples is performed with a staple extractor as described in the procedure for removal. Before you remove the sutures or staples, check the number of days the provider who put them in recommended as the time to wait before removal. Ask the provider to inspect the healing wound. After the sutures or staples have been removed, providers might order additional closure materials to cover healing incisions or lacerations ([Figures 48--4A](javascript://), [B](javascript://), [C](javascript://), and [D](javascript://)). A support skin closure might be necessary to keep the skin together until the wound is completely healed. The type of supportive closure should be noted in the patient's chart. **Figure 48--4A--D** \(A) Care of an incision or wound with a closure application: Use transfer forceps with sterile gauze to apply antiseptic. (B) Apply Steri-Strip closure to the center of the incision. (C) Apply closures to each side for evenness and then fill in and cover the full wound area. If ordered, apply a topical medication and a sterile bandage. (D) For additional support, closures can also be applied parallel to the incision or wound. ### **Remove Sutures or Staples** -- -- -- -- -- -- Advances in skin closures offer a sutureless substance applied to small lacerations. This type of closure is an adhesive material and is used frequently with children, who can be frightened and thus uncooperative. A sutureless procedure is much quicker and less traumatic for the child and staff as well. Skin closures give support to the wound and offer the patient more flexibility. 1. Keep the site dry for at least 24 hours. 2. Cover the area to keep it clean. 3. Apply supportive bandaging as needed. 4. Report any sign of infection immediately to the provider. **48-5 Chapter Review** ======================= **48-5a Chapter Summary** ------------------------- - Medical assistants should have a general knowledge of the procedures performed in their place of employment and be able to assist the provider with little or no direction. Some common procedures include laceration repair, sebaceous cyst removal, incision and drainage, biopsy, needle biopsy, cryosurgery, electrocautery, chemical destruction, laser surgery, loop electrosurgical excision procedure (LEEP), vasectomy, circumcision, and debridement. - Most procedures are performed under local anesthesia, which the provider administers. The medical assistant might be asked to hold the vial while the provider draws up the anesthesia. - If a biopsy is taken, careful labeling and handling of the specimen is vital. A completed lab request form must accompany the specimen for analysis. - After a procedure, printed instructions should be given to the patient and verbally explained to both the patient and family members. - Complete documentation includes a patient identifier, informed consent, the date and time, the reason, the procedure, any specimen collected, any postoperative instructions given, and the medical assistant's signature and credentials.