Chapter 44 Textbook - Heath Science ch 44 PDF

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Assisting with Minor Surgery C A S E

44

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. 2. 3. 4. 5. 6. 7.

K

44.1Define the medical assistant’s role in minor surgical procedures. 44.2Describe surgical procedures performed in an office setting. 44.3Identify the instruments used in minor surgery and describe their functions. 44.4Describe the procedures for medical and sterile asepsis in minor surgery. 44.5Summarize the medical assistant’s duties in preoperative procedures. 44.6Describe the medical assistant’s duties during an operative procedure. 44.7Implement the medical assistant’s duties in the postoperative period. 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

1.

Introduction

2. 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.

3. The Medical Assistant’s Role in Minor Surgery LO 44.1 4. 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. 5. 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. 6. 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, ...