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Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 19 Minor Surgical Procedures
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 17, “Microorganisms and Asepsis,” has direct application to surgical procedures—be sure you understand those concepts before reviewing this chapter. Minor surgery is another area of the national exams that contains questions requiring identification, care, and usage of surgical instruments. Review Tip
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Most states define and regulate types of surgery that are considered appropriate for the medical office. Medical malpractice insurance carriers also play a role. Refer to Chapter 4, “Law and Ethics,” for issues concerning licensure, scope of practice, patient rights, informed consent, malpractice, and confidentiality. As in all areas of medical assisting, patient education is an important component (see Chapter 8). General anesthesia is not usually administered for surgery in the medical office and is not covered in this book. Overview
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Surgical asepsis must be maintained throughout the preparation and performance of surgical procedures. ■ Sterile field—a pathogen-free area containing sterile instruments, solutions, sponges, and other items that will come in direct contact with another sterile item or the surgical field; this includes the hands and anterior neck to waist of the surgical team Ensure sterile indicators and dates on instruments and solutions are intact and current before opening and placing on a sterile field Examine sterile items for signs of break in packaging or presence of moisture (discard item if either is noted) Preparation
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Open the sterile package(s) - Open the top flap first; open away from you to avoid reaching over sterile field - Open the right and left flaps to the sides - Open the last flap toward you Allow only sterile items to come into contact with other sterile items Keep all sterile items and hands above the waists of the surgical team Maintain a border of 1 inch between nonsterile and sterile areas Do not turn your back to a sterile field or leave it unattended Do not lean or reach over sterile field Do not pass contaminated or nonsterile items over a sterile field Preparation, cont’d.
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Pour liquids such as sterile saline or an antiseptic into a sterile waterproof container on the sterile field Do not touch the container with the nonsterile bottle Do not drip or spill liquid on the sterile field Do not talk, cough, or sneeze over a sterile field ■ Surgical handwashing (scrub)—remove all jewelry; use foot- or knee-controlled faucet; wash hands, wrists, and forearms for 10 minutes (first surgical scrub of day); hold hands in upward position while rinsing; use brush and cuticle stick on nails; do not apply lotion; dry with sterile towel; apply sterile gloves Preparation, cont’d.
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins ■ Personal protective equipment (PPE) for surgery Gloves—sterile Goggles or eye shields—nonsterile Masks—nonsterile Gowns—sterile Aprons—sterile if worn over surgical gown Preparation, cont’d.
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins ■ Surgical site preparation Hair removal—shave or cut hair at surgical site only with physician order (usually in procedure file); use only disposable blades; sterile instruments should be covered during hair removal; all loose hair should be removed before application of antiseptic Skin cleansing—using an antiseptic cleansing solution (check for patient allergies) such as Betadine ® or Hibiclens ®, cleanse the surgical site using a circular motion from the point of the incision outward; use a clean sponge to repeat Preparation, cont’d.
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins “Painting” and draping—after performing the previous steps, a sterile member of the surgical team will use a sterile sponge stick and sterile sponges to apply, or “paint,” an antiseptic solution on the surgical site, using circular motions beginning with the incision site and working outward (one sponge per layer of antiseptic); fenestrated drapes (a drape with a hole or opening) or sterile towels, held in place by sterile towel clips, are applied, as well as any other drapes (sterile coverings) required by the size of the sterile field When local anesthetic is required on a sterile field, the physician will hold the sterile syringe with sterile gloved hands; the medical assistant shows the physician the label on the vial and holds the vial upside down for the physician to draw out the required amount of medication Preparation, cont’d.
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins All instruments or parts of instruments that enter the sterile field must be sterile. Chapter 17 covered the two common procedures for sterilization: autoclaving and cold or chemical sterilization. Safety (e.g., the use of sharps containers and other biohazard receptacles) was also addressed in Chapter 17. Common Instruments ■ Curette—sharp or smooth spoon-shaped instrument used to scrape tissue or other substances from a body orifice or organ; the most common types are ear and uterine ■ Dilator—solid instrument used to stretch or widen the opening to an anatomic structure ■ Forceps—a two-handled instrument used to grasp, move, or crimp tissue; may be with or without “teeth” Instrumentation
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Splinter forceps—fine-pointed, tweezer-like forceps without teeth used to remove splinters and other foreign objects Thumb forceps—smooth (without teeth) forceps; the general- use forceps Adson forceps—tweezer-like forceps, with or without teeth, with a smaller tip for smaller areas Bayonet forceps—tweezer-like forceps shaped like a bayonet used for packing in areas (e.g., the nostrils) Ring (sponge) forceps—long, two-handled forceps with open ovals on the ends to grasp tissue, hold sponges, or transfer sterile instruments Instrumentation, cont’d.
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Hemostat—sometimes referred to as a forceps; straight or curved instrument used to compress or crimp capillaries and other blood vessels to stop bleeding; also referred to as a clamp or a crile; types are - Kelly hemostat—a medium-size hemostat; may be curved or straight - Mosquito hemostat—a small hemostat used for pediatric, plastic, or microsurgery; may be curved or straight ■ Needle holder—a two-handled instrument that clasps a suture needle, allowing the physician to push and pull the needle with suture material through various anatomic structures ■ Probe—a straight instrument with ends of various shapes, used primarily to explore ducts, canals, and other anatomic structures Instrumentation, cont’d.
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins ■ Retractors—instruments of various shapes used to hold back tissue and organs to facilitate exposure to the operative site ■ Scalpels—knives of various blade shapes and sizes, used to make surgical incisions; the blade is always disposable; the knife handle may or may not be disposable ■ Scissors—two-bladed instrument used to cut tissue and materials during surgical procedures Surgical/operating scissors—scissors used during surgery to cut and dissect tissue; may be curved or straight, blunt or sharp (e.g., Mayo scissors) Suture scissors—scissors used to cut suture material; straight- bladed suture scissors are used in suturing; suture scissors with a hook on the end of one side are used to remove sutures Bandage scissors—angled scissors with a blunt knobbed end to insert under dressings to remove them without injuring tissue Instrumentation, cont’d.
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins ■ Sound—a straight or curved instrument used to explore body cavities for measurement of depth and presence of masses or foreign bodies ■ Tenaculum—a long, two-handled instrument with pointed ends used to grasp tissue during surgery; a cervical tenaculum is commonly used in well-woman exams ■ Towel clamps (clips)—small instruments of various shapes used to keep sterile towels used as drapes in place during surgery Instrumentation, cont’d.
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Figure Common surgical instruments. Instrumentation, cont’d.
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Common Surgical Tray Instruments Each office maintains a file of all instruments, supplies, and equipment needed for each surgical procedure. The following are select surgical trays and their instruments: ■ General minor surgery tray used for procedures such as removal of lesions—towel clips (four), scalpel and blade, curved and straight hemostats (two each), surgical scissors, thumb forceps, forceps with teeth, suture scissors, needle holder (retractors and other instruments may be added as needed), specified type of surgical sponge; sutures and sizes may be on the file card or requested by the physician during the procedure ■ Suture tray—towel clips (four), curved hemostat, forceps with teeth, thumb forceps, suture scissors, needle holder, sterile 4 × 4 gauze; sutures identified by the physician and added to the setup ■ Suture or staple removal tray—suture scissors or staple remover, thumb forceps, sterile 4× 4 gauze Instrumentation, cont’d.
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Endoscope An endoscope is a special instrument used to examine the interior of canals and hollow viscus; the specific design and name is dependent on the organ (e.g., gastroscope, bronchoscope). The instrument usually contains fiberoptic technology that allows lighting, video transmission, and other technologic procedures; biopsies and select surgical procedures may be performed through the endoscope, eliminating or minimizing a surgical incision. Other Common Instrumentation with Power Sources ■ Electrosurgery—a method of dissection and cauterization using an electric current directed to a specific anatomic area to cut, destroy, or coagulate; the power source is initiated and controlled through a boxlike unit that transmits to a hand piece with sterile removable tips that come in direct contact with the surgical site; the patient must be grounded and safety precautions enforced Instrumentation, cont’d.
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins ■ Cryosurgery—a method of destroying tissue by freezing (cryogenics) using liquid nitrogen applied from a tank with a gauge and removable hand pieces (e.g., for removal of cervical lesions), or other cryomaterials requiring simple spray canisters (e.g., for removal of skin lesions) ■ Laser surgery—a method using high concentrations of electromagnetic radiation in narrow beams for surgical and diagnostic applications (e.g., coagulation of retinal hemorrhage); uses vary and are dependent on the color spectrum; common terms associated with laser surgery are argon, continuous wave, pulsed wave, excimer, krypton, KTP, YAG, and Q- switched; goggles should be worn and special training provided before assisting in laser surgery Instrumentation, cont’d.
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins The type of material used for closure is dependent on several factors. Is the closure on an internal anatomic structure or on the skin? What are the depth, thickness, and length of the closure site? What are the healing capacity factors of the patient (e.g., nutritional status, diabetes, recent history of steroid administration, smoking)? ■ Suture—derived from Latin, meaning “a sewing”; threadlike materials (ligature) and needle used to close a wound; the needle and ligature used in the medical office are usually mechanically attached (swaged) by the manufacturer Closure Materials
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins ■ Ligature Absorbable—material that dissolves in the body (e.g., catgut); used for internal suturing Nonabsorbable—material that does not dissolve (e.g., silk, nylon and other synthetics, wires); generally for external use, although some wires may be used internally; most nonabsorbable sutures are removed after healing takes place Size—determined by the thickness of the diameter; the range is approximately from 7, the largest, to 11-0, the smallest Closure Materials, cont’d.
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Common Assessment Measurements, cont’d.
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins ■ Needle Cutting—needle with sharp, flat edge used on tough tissue (e.g., skin) Noncutting—needle with sharp, smooth, rounded edge used on finer tissue, such as peritoneum Curved—the shape of the needle; may have cutting or noncutting edge; needle holder used Straight (Keith)—the shape of the needle; may have cutting or noncutting edge; no needle holder required Size—determined by the size of the ligature to be used; physician will ask for ligature size on a cutting or noncutting, curved or straight needle Closure Materials, cont’d.
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins ■ Staples—metal clips used to approximate skin edges during healing or occlude internal structures; materials vary per use (e.g., stainless steel used on skin, silver used for neurosurgery); external staples must be removed with a staple remover ■ Steri-Strips—adhesive strips of material used in minor lacerations or as a follow-up to sutures to hold wound edges together during healing ■ Glue—bonding material used externally to approximate skin edges or internally to affix structures; often used in neurologic or orthopaedic surgeries Closure Materials, cont’d.
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Wounds are traumas to body tissues caused by physical means. The trauma may be unintentional, such as a fall, or intentional, such as surgery. The type of wound determines the treatment and the potential for healing. Surgical wounds are considered clean wounds because they are initiated under sterile conditions. Dirty wounds are those sustained under contaminated conditions (e.g., a knife wound while preparing a meal). ■ Abrasion—outer layers of skin scraped off, resulting in a small amount of sanguineous or serosanguineous drainage, such as a “skinned” knee ■ Contusion—bleeding below unbroken skin caused by blunt trauma; a bruise ■ Incision—a smooth cut as in surgery or as made with a razor; the amount of bleeding depends on the location and depth Wounds
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins ■ Laceration—a jagged traumatic cut resulting in irregular wound edges ■ Puncture—a hole in the skin made by a sharp pointed object ■ Healing—physiologic process of wound closure; there are two predominant types First intention (primary)—wound edges are approximated and healing process occurs in all layers (e.g., incision, laceration) Secondary intention (granulation)—wound edges do not approximate and healing begins at wound bottom, forming granular projections on the wound surface (e.g., a wound from a drain) Wounds, cont’d.
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins ■ Dressings—defined as sterile coverings placed over a wound but often used synonymously with bandaging; types of dressing include gauze, occlusives (e.g., Vaseline gauze), nonstick (e.g., Telfa), nonopaque (e.g., BioDerm), and commercial gauze impregnated with medication (e.g., NuGauze); dressings should be applied using sterile technique ■ Bandages—sterile or nonsterile materials that splint or protect injured tissue (e.g., Kerlix, Ace bandages, triangular slings, tube gauze [frequently used on digits]), maintain pressure over an area (such as abdominal pads, Coban), and hold sterile dressings in place (e.g., Montgomery straps, rolled gauze) Wounds, cont’d.
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