Lesson 24 - Minor Surgical Procedures

* What seven steps will you follow to prepare a treatment room for minor surgery?

1. Check all treatment room supplies prior to procedure. 2. Adjust lighting. Replace bulbs and batteries as necessary. 3. Check function of all electrical instruments such as electrocautery unit, electric exam table, other electrical instruments. 4. Be sure physician stool is available. 5. Adjust Mayo stand height for appropriate doctor. 6. Arrange nonsterile supplies on side counter in order of use. a. Sutures, bandages, dressings, ointments, tape b. Pathology container with preservative for biopsy, as needed c. Lab requisition, if needed 7. Waste receptacles should be nearby.

* Describe how to remove sutures.

1. Wash hands. 2. Identify the patient and explain the procedure. 3. Obtain physician's approval that sutures are ready to be removed. 4. Open suture removal kit. 5. Put on sterile gloves. 6. Using thumb forceps, carefully pick up one knot of a suture. Pull gently upward toward the suture line. 7. Use suture scissors to cut one side of the suture as close as possible to the skin. 8. Repeat procedure with each suture, noting the number of sutures removed. Place them on a sterile gauze sponge. 9. Examine the suture line to be certain all sutures have been removed. 10. Apply Betadine solution to the area with sterile q-tip or gauze sponge. 11. Apply dry dressing, if ordered. 12. Remove gloves and dispose of all biohazardous materials. 13. Explain wound care and provide written instructions to the patient. 14. Wash hands. 15. Document the procedure.

chemical tissue destruction

Chemical tissue destruction is similar to electrocautery in that tissues are destroyed and blood vessels cauterized. Instead of electrical current, however, chemical tissue destruction utilizes silver nitrate on the end of an applicator stick to seal friable (easily broken) blood vessels. For example, the doctor may treat frequent nosebleeds by using silver nitrate inside the nostrils. CRYOSURGERY: Cryosurgery refers to the destruction of tissues by freezing. The most common way to conduct cryosurgery is to apply liquid nitrogen to tissues. Some areas of the body heal faster when the tissue is destroyed by freezing rather than by burning (cautery). Liquid nitrogen is created by compressing nitrogen gas under cold temperatures. The liquid is volatile (unstable) and must be handled very carefully. Liquid nitrogen is usually kept in a canister in the doctor's office and transferred to the operating room in a thermos. Some cryosurgery is performed using nitrous oxide, which is less volatile than liquid nitrogen. Nitrous oxide is not as cold as liquid nitrogen, so patients experience less pain. However, because nitrous oxide isn't as cold, it's less effective in tissue destruction. Though cryosurgery is used to extract cataracts, remove anal lesions and treat throat lesions, it is most commonly used to remove warts. The procedure consists of applying the liquid nitrogen directly to the skin with a probe. Nitrous oxide is applied from a tank through a cryogun that uses a disposable tip to administer the treatment. As with electrocautery, the treated tissues slough. An unpleasant odor and local discomfort may result. The doctor may suggest a dressing and antibiotic ointment while the treated area heals. LASER SURGERY: Laser is actually an acronym: light amplification by stimulated emission of radiation. In the doctor's office, a laser creates a concentrated light that can destroy tissue. Lasers are used in surgery to burn or remove tissues or to cauterize blood vessels. The first medical uses of lasers focused on the eyes, but they are now used for many procedures throughout the entire body. Lasers are potentially hazardous light. The physician, patient and MA must wear protective goggles to prevent retina damage. A warning sign should be posted on the operating room door when the laser is in use. Other laser-related hazards include the following: • Lasers can "vaporize" tissues. Those in the operating room should avoid inhaling those vapors. • As with electrocautery, a fire hazard exists. Equipment should be inspected in advance. Flammable liquids should be removed from the operating field. • If the patient has been prepped with a flammable product, the patient's skin should be dry before the laser is used. • Sterile water should be available in the event of an accidental fire. Because of the variety of hazards, medical assistants are limited in their ability to assist in laser surgery. Your state may require that medical assistants undergo specific training on the type of laser the physician uses.

* Which of the following involves the destruction of tissue by freezing? a. Electrocautery b. Laser surgery c. Cryosurgery d. Suturing

Cryosurgery

* Which of the following is NOT likely to be a part of the MA's preoperative protocol for a planned minor surgery? a. Explore the cause of the wound and assess tetanus status. b. Identify dietary considerations to prepare for surgery. c. Identify postoperative special equipment needs. d. Provide a list of post-op medications the patient will need.

Explore the cause of the wound and assess tetanus status.

* Which of the following is a hazard of laser surgery? a. Splash and spatter pathogen transmission b. Ear damage c. Laser inhalation d. Eye damage

Eye damage

* Which method of bandage wrapping would you likely use on an ankle? a. Circle turn b. Spiral turn c. Figure-8 d. Reverse spiral

Figure-8

preparing for surgery - prepping the patient

If the patient is having a planned procedure, she will have time to make necessary preparations, such as making any special dietary changes ordered by the doctor, scheduling time off from work and purchasing special supplies she'll need post-op. Prior planning can also include contacting the insurance company for authorization and to arrange payment. Not every minor surgery can be planned. For example, a patient might suffer a laceration that needs immediate attention. Either way, the medical assistant must follow protocol to inform and prepare the patient for what is to come. If the patient is receiving treatment for an accident, the MA must determine how the wound occurred, in case special medication such as a tetanus shot is necessary. The MA must also determine the patient's allergies and find out what OTC and prescribed drugs the patient is currently taking. If the minor surgery is planned, the MA should instruct the patient on dietary considerations. For example, the procedure might require that the patient not eat or drink for several hours before the surgery. In addition, the MA can prepare the patient for any medication needed for post-operative care. For example, some procedures require the patient to take antibiotics afterward to prevent infections. Special supplies, such as crutches or a brace, might be necessary. These considerations often fall under the medical assistant's job description, depending on the office or clinic. INFORMED CONSENT: In addition to planning for the surgery, the MA must get the patient's consent. For all surgical procedures, the patient must sign a written, informed consent form. As you know, an informed consent form specifies the procedure and explains in straightforward terms what will occur. The form also lists alternatives and possible adverse outcomes. This form is not just a "rubber stamp." Knowing the alternatives and consequences constitutes an informed consent. Before the patient signs the form, the MA or the physician can also answer the patient's questions about the procedure. The informed consent form also covers the costs of the procedures. The MA will occasionally bring the office bookkeeper in to discuss payment options during the consent discussion, though financing itself is not part of the consent form. BEFORE THE OPERATION: It may be your duty to prepare the area of the body where the operation will be performed. As mentioned earlier in the lesson, skin cannot be sterilized. It is possible to minimize micro-organisms at the surgery site, however. This is accomplished by washing the site, shaving the area (if necessary), rinsing and drying. Then, you will paint antiseptic on the skin. You should always wear sterile gloves while preparing the patient's skin. For each subsequent step, from washing to shaving to rinsing and drying, you should start where the incision will be made and work outward. Apply the antiseptic with 4" × 4" gauze or sterile swabs. Allow the skin prep solution to air dry—do not blot dry with gauze. Then, you'll "frame" the surgical site using the draping materials we discussed earlier. If the draping is not fenestrated, the doctor will make a cut in the incision draping at the site of the actual surgery. Drapes may bracket the incision site, held in place by towel clamps or adhesive tape.

minor surgical procedures

Medical assistants can participate in each of the following minor surgical procedures. In fact, the MA will have a series of specific responsibilities. Depending on the doctor's preference, the medical assistant may work sterile or nonsterile. When working nonsterile, the MA may not touch anything within the sterile field. The medical assistant will have plenty to do, however! Some of your tasks might include the following: • Tie the back of the surgeon's gown. Remember—the back of the gown is nonsterile. • Obtain additional supplies if they are needed. • Speak to the patient, offering support and reassurance. • Adjust the lighting. • Hold the container to receive a biopsy sample. When working sterile, the MA may be sterile and gloved for simple procedures. Or the medical assistant may be in gown and gloves. An MA working sterile may: • Hand instruments to the doctor. • Hold a retractor. • Use a sterile suction catheter or sterile gauze sponges to clear blood from the surgical site. • Prepare the suture material for the doctor. EXCISION OF LESIONS: A lesion is a skin irregularity. Irregularities like moles or skin tags are "dry." That is, they don't contain fluid. To remove a lesion, the doctor performs an excision. Remember that excision means "cutting out." It's standard procedure to send a sample of the skin irregularity for testing to ensure that the irregularity doesn't signal a bigger problem. The physician will take a small biopsy sample and store it in a bottle containing formalin, a tissue preservative. The MA holds the bottle, cap removed and the doctor places the sample in the bottle. After surgery, the labeled bottle is sent to a cytology lab for analysis. INCISION: An abscess is a localized, self-contained collection of pus, usually the result of the body's own immune system responding to a foreign body. Because the pus creates pressure on the surrounding tissues, the abscess may be painful. Sometimes if an oil duct becomes clogged it may cause a cyst. The cyst may become infected. Cysts are surrounded by a membrane and must be completely removed. Prior to removal, the cyst sac may have to be lanced and drained of sebum—the oily secretion of the sebaceous gland—so that it doesn't spatter the sterile field during removal. Incision and drainage (I&D) involves cutting into an infected area and allowing the pus or sebum to drain out under controlled conditions. Sometimes the liquid is collected and sent for examination. The patient's wound may be treated with oral antibiotics or antibiotic cream. After the abscess or cyst is cut into, the wound is not sutured. A small, lanced abscess will heal by itself. Larger abscesses may need to continue to drain, which allows healing from the inside out. If the skin closes too soon, the fluids will collect and cause pressure again and the abscess will reform. If a cyst needs to be lanced and drained, it will be removed entirely after the lancing. Again, no suturing is necessary. The skin will close and heal on its own. SUTURING: Not every wound closes on its own, however. A laceration is a medical term for a "cut." Some lacerations need to be sutured. There are four general signs that indicate suturing may be necessary. 1. If the edges of the wound are far apart rather than close together, the wound may need sutures. 2. If the wound is bleeding and the bleeding can't be controlled, sutures may stop the flow. 3. If the laceration is located on a part of the body that moves, risking reopening of the wound, sutures will protect the treated laceration. 4. If the laceration is deep, extending into underlying muscle tissues, it may require sutures. ELECTROCAUTERY: Electrocautery—also called electrosurgery—involves cutting or destroying tissue with a concentrated electric current. Electrocautery is used to remove skin tags and warts that don't require a living tissue sample for biopsy. Electrocautery has an advantage over excision—bleeding is controlled because blood vessels are sealed by the current. Electrocautery is accomplished with a handheld device with a tip that applies the current to the patient's skin tissue. The device might run on batteries or be connected to a wall power-source. Since the device uses electric current, it should be inspected for frayed wires before use. Any electrical equipment is a potential fire hazard, so flammable solutions such as alcohol and ethyl chloride should not be used in the area while the electrocautery is being performed. After the procedure, the treated tissues will slough—die and separate from the healthy tissue. The patient should be warned that for the first week or so, the sloughing tissue will have an unpleasant odor. The patient may need dressing on the affected area, depending on the location. Electrocautery is becoming rare as the use of cryosurgery increases.

assist with suturing a laceration steps:

Procedure Objective: To assist the physician in sealing a wound using sutures Equipment Needed: Sterile Tray: Syringe/needle for anesthetic, hemostats (curved), tissue forceps, iris scissors (curved), needle holder, suture material with needle, gauze sponges, sterile gloves Nonsterile items: Anesthetic medication, as ordered, dressings, bandages, ointments, tape, gloves Steps to Take 1. Reassure and support patient. Explain the procedure. Position the patient comfortably, lying or sitting on exam table. 2. Wash hands. Put on gloves. 3. Assess severity of wound and its cause. a. Ask about general health conditions. b. Ask about any known allergies, record. c. Inquire as to her last tetanus booster, record. d. Soak wound in antiseptic solution, as ordered. e. Clean and dry the wound. Apply pressure with sterile gauze if bleeding continues. 4. Prepare sterile laceration repair tray. Notify physician. 5. Remove the sterile cover from the surgical tray while the doctor is putting on sterile gloves. 6. Assist with placement of the stool and spotlight adjustment. Position Mayo stand for physician convenience. 7. Assist as needed during the skin prep and draping. a. When pouring the antiseptic solution, first pour a small amount into waste receptacle to sterilize the edge of the bottle. Then pour a small amount into the sterile container on the surgical tray, being careful not to touch any part of the sterile field. 8. Assist with drawing up local anesthetic, as needed. a. Hold the vial of medication upside down while physician withdraws the appropriate dose. 9. Apply clean gloves to protect yourself or sterile gloves if physician wants you to assist with the procedure. 10. Provide emotional support to patient, as needed. 11. When physician selects appropriate suture material, open the chosen packet, dropping the inner suture pack onto sterile field without touching any part of the sterile field. 12. At end of suturing, cleanse wound, as ordered. 13. Apply dressing/bandage, as ordered. 14. Dispose of biohazardous waste materials appropriately. 15. Review postoperative instructions as provided by physician with the patient. 16. Remove gloves. 17. Wash hands. 18. Document the procedure.

set up minor surgical tray steps

Procedure Objective: To prepare a minor surgical tray Equipment Needed: Sterile laceration tray (wrapped), sterile drape (if not included in sterile pack), Mayo stand, sterile gloves for self and physician, sterile transfer forceps, injectable medications, syringe/needle, alcohol wipes, skin antiseptic Set Up Minor Surgical Tray 1. Wash hands. 2. Sanitize and disinfect Mayo stand. 3. Place wrapped surgical tray on Mayo stand. 4. Open outer wrapper, keeping your body away from the edges of the sterile field. 5. Put on sterile gloves. Now you must keep your hands above waist level. 6. Continue to open inner wrap of instrument packs. 7. Arrange instruments and supplies in order of use. 8. Recheck for accuracy. 9. Remove gloves. Pour skin antiseptic into container on tray, if physician desires. 10. Cover with sterile drape. 11. Draw up local anesthetic or other medications as ordered by physician.

prepare treatment room steps

Procedure Objective: To prepare a treatment room for minor surgery Equipment Needed: Light bulbs, batteries, sutures, bandages, dressings, ointments, tape, pathology container with preservative for biopsy, lab requisition as needed, Mayo stand, sterile gloves, stool Steps to Take 1. Check all treatment room supplies prior to procedure. 2. Adjust lighting. Replace bulbs and batteries as necessary. 3. Check function of all electrical instruments such as electrocautery unit, electric exam table, other electrical instruments. 4. Be sure physician stool is available. 5. Adjust Mayo stand to the appropriate height for the doctor. 6. Arrange nonsterile supplies on side counter in order of use. a. Sutures, bandages, dressings, ointments, tape b. Pathology container with preservative for biopsy, as needed c. Lab requisition, if needed 7. Waste receptacles should be nearby.

remove sutures steps

Procedure Objective: To remove sutures from a patient's healed wound Equipment Needed: 4 × 4 or sterile gauze/sterile cotton tipped applicators, bandage scissors, biohazard container, tape/dressing, sponge forceps, gloves, Betadine solution/small bowl, sterile suture removal kit: suture scissors, thumb forceps, 4 × 4 gauze sponges), written wound care instructions Remove Sutures 1. Wash hands. 2. Identify the patient and explain the procedure. 3. Obtain physician's approval that sutures are ready to be removed. 4. Open suture removal kit. 5. Put on gloves. 6. Using thumb forceps, carefully pick up one knot of a suture. Pull gently upward toward the suture line. 7. Use suture scissors to cut one side of the suture as close as possible to the skin. 8. Repeat procedure with each suture, noting the number of sutures removed. Place them on a sterile gauze sponge. 9. Examine the suture line to be certain all sutures have been removed. 10. Apply Betadine solution to the area with sterile applicator or gauze sponge. 11. Apply dry dressing, if ordered. 12. Dispose of all biohazardous materials. 13. Remove gloves and wash hands. 14. Explain wound care and provide written instructions to the patient. 15. Document the procedure.

surgical supplies

SURGICAL DRAPING: Surgical draping is the placement of sterile materials on and around the patient to bracket the sterile field. Some physicians now use disposable draping made of paper. After the paper draping frames the site, a clear incisional drape is placed over the site. The incisional drape may have an adhesive back that keeps it in place. Some surgical drapes are fenestrated—they have a custom opening that fits exactly over where an incision is to be made. Fenestrated drapes may be made of cloth or paper. GAUZE: Gauze squares—also known as sponges—come in a variety of sizes, from 2" × 2" to 4" × 4". They come in sterile packs of two. They may be made of plain gauze or they may have a cotton pad backing for extra absorbency. They are used to clean and prepare skin for surgery, for padding and for cleaning and covering wounds. As you have learned, one type of gauze, called a wick, comes in narrow lengths stored in bottles and is used to pack an open wound. Because the wick is sterile, it must be removed from the bottle with sterile forceps and cut to length with sterile scissors. SOLUTIONS: Medical assistants use a number of different solutions in the operating room. Sterile water is used to dilute medication. Sterile saline solutions are used to clean wounds. Liquid soaps are used to scrub up before operations and to clean and prep the patient's skin at the operation site. Betadine (providone-iodine) is an antiseptic frequently painted on the skin prior to surgery. If Betadine is to be used, make sure the patient is not allergic to iodine. SUTURING MATERIALS: Stitches used to close an incision or wound are called sutures. During surgery, the medical assistant tears open the suture material package and empties the suture material onto the sterile field, avoiding contamination. Suture materials come in varying sizes. The finest (narrowest) suture material, called 6-0, is the kind most used in office-based surgeries. Suture materials are usually non-absorbable. Absorbable sutures are made of organic materials so they can decompose naturally and don't have to be removed. They are generally used for deep tissue layers. Non-absorbable suture materials are made from silk, rayon and other materials. These sutures must be removed after the wound is healed, usually in 6 to 10 days. Sometimes, only a small amount of tension is necessary to keep the edges of a wound sealed. In these cases, adhesive strips can be used instead of traditional sutures. NEEDLES: Suture needles often come swaged—fused to the suture material. The needles are often curved to assist in suturing while causing the least amount of damage to the skin. Needles are held with a needle holder, rather than with the gloved hand. This keeps the needle rigid, avoiding accidental injury. After use, the needle and unused attached materials should be disposed of in a sharps container. DRESSINGS: After a wound is closed, dressings are sometimes applied to the wound. Dressings are gauze patches that may be covered with medication. For example, gauze may be smeared with an ointment to help prevent infection. Some types of dressings have a special surface to prevent them from sticking to the wound when the dressing is changed. BANDAGES: A bandage is a nonsterile material that is applied over a dressing and wound in order to keep the dressing in place. Some bandages are gauze. Custom shaped or tubular bandages are designed to fit in hard to cover places like elbows or over appendages. Elastic bandages are also used to provide pressure.

care of surgical instruments

Some surgical instruments are disposable. These instruments come sterilized. After surgery, they are simply thrown away. As you are well aware, scalpels and needles are disposed of in a sharps container to avoid injuring anyone. Suture material is also disposed of in the sharps container, since the needle is often still attached. By contrast, reusable instruments are durable, but they have to be cleaned and sterilized.

instruments used in minor surgery

Surgical instruments can be made of metal, plastic or rubber. These instruments are used to cut, scrape, stitch or hold skin in place. FORCEPS: Forceps are used to grab, pull or pinch tissue or other instruments during surgery. Some are shaped like scissors and held by the ring-handles. Others are shaped like tweezers and held by the thumb and forefinger. Some have ratchet-stops in the handles so they can be locked into position. Hemostatic forceps have narrow, slender jaws so they can clamp blood vessels. Hemostasis means "control of bleeding." Hemostatic forceps achieve hemostasis. Two examples of hemostatic forceps are Kelly forceps and mosquito forceps. The latter are for smaller blood vessels. Foerster forceps are designed to hold the suturing needle used to stitch wounds. This kind of forceps has strong jaws to grip the needle. The jaws may have a groove in the middle to keep the needle in place. Needle holders come in varying lengths. Foerster sponge forceps and Bozeman forceps are used to hold sterile squares of gauze called sponges. During surgery, these sponges are used to clean up excess blood. These forceps can also be used to transfer other sterile items on the operating tray. Dressing forceps are used to pick up gauze squares or dressings for transfer or for disposal. The names of these forceps illustrate a point: surgical instruments are often named after the function they perform or the person who invented them. Tissue forceps are used to grasp tissue after an incision has been made. These forceps don't have ring-handles so they're sometimes called thumb forceps. Tissue forceps may have teeth that can grasp skin with a pincer grip without damaging the tissue. Splinter forceps are used to remove foreign materials from wounds. They are also used to put gauze into wounds. Splinter forceps are usually thumb forceps in varying shapes. The sharp tip helps remove even the tiniest foreign objects. Some forceps have curved tips. Tenaculum forceps have long handles made to grasp tissue during surgery. Towel clamps are used to hold drapes in place during the operation. Biopsy forceps have a long, narrow stem with a cutting instrument at the end. Biopsy forceps can pass through an endoscope and take a tiny sample of tissue for testing. SCISSORS: Scissors are ring-handled tools with two flat blades pivoting on an axis pin. In surgery, they're used to cut skin and muscle tissue, as well as bandages and other dressings. Some scissors have a sharp upper blade and a blunt lower blade. The lower blade can slide under a bandage, next to the skin, without injuring the patient. SCALPELS: A scalpel is a surgical knife. A scalpel has a straight handle with various removable blades. Some scalpels come in a single disposable unit. Different shaped blades are available for various procedures. An incision is a cut made with a scalpel. Incisions may be the initial cut in a surgery or they may lance the skin to ensure drainage. RETRACTORS: A retractor is an instrument used to hold a flap of tissue or an incision open so that the doctor can see beneath. Some retractors have smooth tips and some are toothed. Some are self-locking. Others need a medical assistant to hold them in place. PROBES: A probe is an instrument used to palpate inside an incision. Probes can also be used to test the depth of a cavity during surgery. They can also help locate foreign objects in a wound. CURETTES: A curette is a scraping instrument. A curette has a handle, stem and a looped end that does the actual scraping. For example, ear curettes remove earwax. Uterine curettes scrape fetal tissue from the uterus.

postoperative procedures

The operation is successful. The procedures are complete. What's next for the medical assistant? From cleaning the operating room to postoperative care of the patient, the medical assistant has important responsibilities. CARE OF THE OPERATING ROOM: After minor surgery is performed, the medical assistant may be required to care for the room and equipment. Surgical instruments are delicate and must be handled by a professional. Needles and other biohazards must be disposed of in a safe manner. After donning gloves, gown and goggles, the medical assistant may perform some or all of the following tasks: • Dispose of all drapes and covers. When appropriate, use a biohazard waste receptacle. • Remove all needles and blades from the operating field using forceps. Dispose of used instruments in a sharps container. • Place instruments in a plastic soak bin. • Dispose of all used gloves and gauze in a biohazard waste receptacle. • Sanitize Mayo equipment tray and all other operating surfaces, including the operating table, doctor's stool, countertops, sink and stationary equipment. • Disinfect all surfaces and allow to air dry. WOUND HEALING: Like the old saying says, time heals all wounds. But all wounds aren't the same. Wounds vary by type. Wounds also vary by how far along in the healing process they are. Finally, wounds vary by how well the healing process succeeds. Understanding each of these three variables will help you to fully understand the healing process. Let's begin by reviewing wounds by type. As you have learned, there are five basic types of wounds. One of them does not involve penetration of the skin. This type of wound is called a closed wound, or contusion. A contusion is the result of trauma that damages the underlying tissues, but leaves the skin intact. If you've ever had a bruise, you have had a contusion! Open wounds are those that involve tearing of the skin. Lacerations are deep, uneven tears. This type of wound is often more difficult to suture. Incisions are deep, even tears. This kind of wound is often intentional—the physician may make an incision during a procedure, for example. Punctures are deep cuts with a small entry point. Because of that small entry point, punctures may bleed less than other open wounds. Finally, abrasions are accidental wounds that tear back the skin's surface without damaging the subcutaneous layer. All wounds need to heal. Suturing a wound holds the wound in place, but there is a biological process that must follow. This process happens in three phases. The first phase, called the inflammatory response, lasts for three to four days. Blood vessels contract, slowing the bleeding. Blood platelets begin to bind the wound by forming a natural glue. Fibrin is released, collecting red blood cells into a clot that will become a scab. Under the scab, the edges of the wound will begin to pull together. The second phase of wound healing is called proliferation. This phase lasts from 5 to 20 days. Tissue continues to contract under the scab. Clean, shallow cuts usually heal completely by the end of this phase. The third phase of wound healing is called remodeling. If the wound is serious enough, a thick protein material called collagen forms into scar tissue. Scar tissue is stronger than skin, but it has no blood supply and it's not as elastic as skin. A final way to regard the process of wound healing is to examine the results of the healing process. Wounds that heal by primary intention see very little scarring. The edges of the wound seal evenly and eventually disappear. Wounds that heal by secondary intention heal by granulation—the filling up of the wound with granulated tissue from the bottom up. This kind of healing can leave a large, obvious scar. Wounds that heal by tertiary intention are kept open for a while to avoid infection. Once cleaned or drained, the wound is sutured. Like secondary intention wounds, tertiary intention wounds have a greater chance of scarring. DRESSING THE WOUND: Dressing a wound has two purposes. First, the dressing provides a direct application of medicine to the affected area. Second, the dressing absorbs drainage. When placing a dressing on a wound, the MA should be certain to choose a dressing large enough to completely cover the wound. The dressing should be placed directly on the wound, rather than placed off-center and slid into place. Always, the dressing and wound should be treated as a sterile field to avoid infections. Finally, the MA may wish to tape the dressing in place. This last step does not require gloves, as the dressing already covers the wound when the tape is applied. BANDAGING: After placing dressing over a wound, the wound should be bandaged. Follow these basic guidelines to cover the dressing with a protective bandage: • Bandages should be snug but comfortable. If they are too tight, they will restrict circulation and inhibit wound healing. • The bandage should be secure enough to endure normal activity. • The bandaged area should be in its normal position before being bandaged. Skin surfaces shouldn't touch under the bandage to avoid scarring that keeps skin surfaces connected. • Bandages should be wrapped from the distal point of the dressing to the proximal point. This means beginning the wrap from the furthest part from the body's center, toward the body. For example, from the ankle to the knee or the wrist to the elbow. This promotes circulation and results in a more secure wrap. there are several methods of bandage wrapping. They include the circular turn, the spiral turn, the spiral reverse, the figure-8 and the recurrent turn. We will briefly review those here. The circular turn wraps the bandage several times around a fixed position, like a wrist, anchoring the bandage. A spiral turn is used to wrap the straight part of an appendage, moving from the distal to the proximal point in a spiral. A similar wrap is the reverse spiral, which starts like a spiral turn, but then comes back down the other way to provide a more secure wrap. This sort of wrap provides more padding and protection, since it uses more bandaging. The figure-8 turn works best on joints, like ankles or knees. The bandage starts with a circular turn then proceeds in a figure-8 to brace and cover the bending joint. Finally, the recurrent turn is used for appendages or extremities like an amputation. The bandage is folded back and forth across the dressing and anchored with circular turns. Finally, you'll use clips to hold the end of the bandage in place. CHANGING A STERILE DRESSING: Some wounds require that the dressing be changed and fresh medication applied as healing progresses. Use the principles of surgical asepsis when you change sterile dressings and always wear gloves. The first step in changing a sterile dressing is to remove the old one. Tape may be pulled off, but it should be pulled in the direction of the incision, so as not to reopen the wound. Cut bandages free using scissors, but be careful not to go near the incision to prevent the wound from accidentally reopening. If the dressing sticks because of dried blood or fluids, soak the dressing with sterile water or saline solution to work the dressing free. After the wound is uncovered, the physician will inspect the wound. At this time, change gloves to avoid contaminating the wound with bacteria from the old bandage. Finally, redress and bandage the wound as directed by the doctor. REMOVING SUTURES: Eventually, non-absorbable sutures used to hold the edges of a wound together must be removed. The wound is not completely healed when this occurs. If sutures are left too long, they are more difficult to remove and can cause unnecessary skin marks and even scarring. The MA often performs the removal of sutures. OUTPATIENT DOCUMENTATION: It's almost impossible to overemphasize the importance of documentation. Every procedure must be logged, annotated and initialed. This includes minor surgery, dressing changes, wound cleaning and any instructions given to the patient. It also includes progress notes on the wound healing process. This duty is usually the responsibility of the medical assistant.

preparing for surgery - prepping the room

To prepare the room for surgery, you'll gather the instruments and supplies and prepare the surgery tray. Planning for the surgery begins with surgery cards—3 × 5 cards that list the equipment, supplies and instruments necessary. Some physicians store this information in computer files to be printed out in advance of the procedure. The computer will have a separate printout for each procedure, discussing the needs of the procedure in great detail, including the physician's glove size, preoperative procedures, postoperative procedures and special requirements for both the surgeon and the patient. Both printouts and surgery cards are wonderful resources for medical assistants preparing for a surgery.

* When assisting the physician during a surgical procedure, how can you ensure that liquid antiseptics remain sterile?

When I pour the liquid, I'll first pour a small amount from the bottle into a trashcan to sterilize the lip of the bottle. Then I'll pour the amount needed into a sterile bowl on the surgical tray.

surgical asepsis

You know from previous lessons that asepsis means sterility. So you can probably imagine that surgical asepsis is sterility in the surgical setting. Specifically, surgical asepsis is a series of principles designed to keep detrimental microorganisms from entering the body during surgery. This means that surgery must be performed with sterilized equipment in a sterilized environment. Aseptic techniques are procedures used to achieve asepsis. The one major component of surgery that can't be sterilized is skin. The patient's own body, as well as the hands of the surgeon, can't be sterilized. Microorganisms live on the skin. Surgery involving any incision provides an opening to those organisms. The patient's skin must be washed and treated with an antiseptic across the area of the incision. To further minimize the risk, the surgeon and medical assistant must wash and glove their hands using the surgical techniques you learned in Steps to Take Lesson 5. Take a moment to review these now before we move on. Surgical equipment and the surgery room itself must be sterilized to achieve surgical asepsis. Since microorganisms can't be seen, you should assume they're present—and that they're a danger. The critical concerns of any surgery are the sterility of the instruments, the patient's skin and the surgical team. To maintain sterility, the following basic rules must be followed. • If you touch a sterile object with a nonsterile object, the sterile object is no longer sterile. Only use sterile objects to touch sterile objects. • If you can't see it, it isn't sterile. Keep the sterile field—the area where sterile instruments and supplies are staged—in plain sight. If you must turn away, cover the field with a sterile towel. • Only the area above the waist is sterile. If you drop your hands below waist level, they are no longer sterile. Anything that falls on the floor is nonsterile. • Sterile equipment and supplies should be kept in the middle of the sterile field. Anything outside the sterile field is considered nonsterile. • Don't pass nonsterile items over a sterile field. • When handling liquids, don't pour directly onto the sterile field. Spills pick up microorganisms. Pour liquid into a bowl or onto a dressing with a waterproof wrapper. Do not let the bottle that holds the liquid touch either the bowl or the dressing. • Don't sneeze, talk or cough when facing the sterile field. • If you are wearing a sterile gown, everything behind your field of vision or below the waist of the gown is considered nonsterile. Maintaining surgical asepsis will ensure a safe environment for your patients.

* Which of the following situations requires incision? a. Lesion b. Abscess c. Laceration d. Electrocautery

abscess

anesthetics

an anesthetic is any substance that causes a loss of feeling. When a doctor performs minor surgery, the patient needs protection from the pain involved in the procedure. Anesthetics can be inhaled, injected or applied topically. The most common anesthetics used in minor office surgery are injected into the subcutaneous tissues. Nerves are temporarily prevented from sending sensations to the brain, preventing pain due to the surgery. These anesthetics include Xylocaine, Novocain and Carbocaine. In addition, the anesthetic may also include epinephrine, a vasoconstrictor that acts locally to control bleeding. Anesthetics with epinephrine should not be used on extremities (fingers, toes, nose) because the constricting action can damage the tissues. When preparing an anesthetic injection, the MA should always bring the vial of requested medication to the operating room so that the physician can triple-check the medication before the injection. Some anesthetics are topical—applied directly to the site, either by spray or liquid. For example, physicians use ethyl chloride to freeze the skin for a few seconds to allow the doctor to pierce or lance the skin. If the doctor is giving a patient a deep injection, he may use the spray to take the sting out of the shot!

* When a wound remodels, scar tissue is formed out of a protein called _____.

collagen

* (n) _____ is a clogged oil duct that needs to be completely removed.

cyst

* What part of the postoperative supplies holds the medication?

dressing

* _____ is a vasoconstrictor found in some injectable anesthetics.

epinephrine

* Only the area above the arms is sterile. If you drop your hands below hip level, they are no longer sterile. Anything that falls on the floor is sterile.

false

* true or false? If you are wearing a sterile gown, everything behind your field of vision or below the knees of the gown is considered nonsterile.

false

* true or false? Don't sneeze, talk or cough anywhere in the treatment area.

false

* true or false? If you touch a sterile object with a nonsterile object, the sterile object is still sterile. You can use nonsterile objects to touch sterile objects.

false

* true or false? Sterile equipment and supplies should not be kept in the middle of the sterile field. Anything entering the sterile field should be considered nonsterile.

false

* Which of the following information is NOT on an informed consent form? a. Alternative treatment options b. Financing alternatives c. Plain-language explanation of the procedure d. Potential adverse reactions

financing alternatives

* A surgical instrument that clamps tissues together is called a _____.

forceps

* Which of the following is NOT a nonsterile duty of a medical assistant in the operating room? a. Speak to the patient, offering support and reassurance. b. Adjust the lighting. c. Adjust the doctor's mask and glasses. d. Hand instruments to the doctor.

hand instruments to the doctor

* _____ means "control of bleeding."

hemostasis

* A(n) _____ is a dry skin irregularity that can be excised without prior lancing.

lesion

* _____ forceps are small, narrow forceps used to clamp small blood vessels.

mosquito

* _____ —a surgical instrument used to make an incision.

scalpel

* Four inch squares of gauze used to clean up blood during surgery are sometimes called _____.

sponges

* The basic principles of sterile surgery are called _____ _____.

surgical asepsis

* A(n) _____ needle comes fused to suture materials.

swaged

* _____ forceps are made to clamp tissues during surgery.

tenaculum

* true or false? Don't pass nonsterile items over a sterile field.

true

* true or false? If you can't see it, it isn't sterile. Keep the sterile field—the area where sterile instruments and supplies are staged—in plain sight. If you must turn away, cover the field with a sterile towel.

true

* true or false? When handling liquids don't pour directly onto the sterile field. Spills pick up microorganisms. Pour liquid into a bowl or onto a dressing with a waterproof wrapper. Do not let the bottle that holds the liquid touch either the bowl or the dressing.

true