CHAPTER 10 MINOR OFFICE SURGERY. Elsevier items and derived items © 2008 by Saunders, an imprint of...

CHAPTER 10CHAPTER 10MINOR OFFICE SURGERY

Elsevier items and derived items © 2008 by Saunders, an imprint of Elsevier Inc. 2

PRETESTPRETEST

True or False1. Surgical asepsis refers to practices that keep

objects and areas free from all microorganisms.

2. Something that is sterile is contaminated if it comes in contact with a pathogen.

3. Reaching over a sterile field is a violation of sterile technique.

4. An incision is a jagged tearing of the tissues.

5. The skin is the first line of defense of the body.


PRETEST, CONT.PRETEST, CONT.

True or False6. One of the local signs of inflammation is fever.

7. Sutures approximate the edges of a wound until proper healing occurs.

8. A biopsy is usually performed to determine if an infection is present.

9. An ingrown toenail can be caused by shoes that are too tight.

10. One of the functions of a bandage is to hold a dressing in place.


Introduction to Minor Office Surgery

Introduction to Minor Office Surgery

1. Minor office surgery (MOS) performed in medical office:

a. Insertion of sutures

b. Sebaceous cyst removal

c. Incision and drainage of infections

d. Mole removal


Introduction to Minor Office Surgery, cont.


e. Needle biopsy

f. Cervical biopsy

g. Ingrown toenail removal• Physician explains nature of surgical

procedure and risks to patient




2. MA responsible for:

a. Explaining patient preparation

b. Obtaining patient's signature on consent to treatment form




3. Additional responsibilities

a. Preparing treatment room

b. Preparing patient

c. Preparing MOS tray

d. Assisting the physician during procedure

e. Administering postoperative care to patient

f. Cleaning treatment room




4. Patient positioned and draped according to procedure

5. Skin is prepared as specified by physiciana. Shave skin around operative site

b. Cleanse skin

c. Apply antiseptic: reduces number of microorganisms

6. Prepare MOS tray using sterile technique




7. Instruments and supplies on tray vary based on:

a. Type of surgery

b. Physician preference

8. During the surgery:

a. Assist physician

b. Lend support to patient




9. Remain with patient after surgery

a. Safety precaution

b. To explain postoperative instructions

10.Remove and properly care for used instruments/supplies

11.Clean treatment room


Surgical AsepsisSurgical Asepsis

1. Also known as sterile technique

2. Refers to practices that keep objects and areas sterile or free from all living microorganisms and spores

a. Protects patient from pathogens that may enter and cause disease


Surgical Asepsis, cont. Surgical Asepsis, cont.

3. Surgical asepsis employed when:

a. Caring for broken skin (open wound)

b. Skin surface is penetrated (surgical incision for a mole removal)

c. Administration of an injection

d. Body cavity is entered that is normally sterile (insertion of urinary catheter)


Surgical Asepsis, cont.Surgical Asepsis, cont.

4. Sterility of instruments and supplies achieved:

a. Through use of disposable sterile items

b. Sterilizing reusable articles

5. Sterile object that touches any nonsterile object is considered contaminated: must not use

a. If in doubt about sterility of article: do not use it



6. Sanitizing hands renders them medically aseptic

a. Sanitize hands before and after surgical procedure

7. Sterile gloves must be worn when picking up or transferring sterile articles



8. Guidelines to Maintain Surgical Asepsis

a. Prevent sterile packages from becoming wet• Wet pack: draws microorganisms into pack

resulting in contamination

b. 1-inch border around sterile field is considered contaminated



c. Always face sterile field• If must leave: cover sterile field with a sterile

towel

d. Hold all sterile articles above waist level• If out of sight: might become contaminated

e. Place all sterile items in center of sterile field



f. Do not spill water or solution on sterile field• Draws microorganisms up onto field from area

beneath field, causing contamination

g. Do not talk, cough, or sneeze over sterile field• Water vapor from nose, mouth, and lungs

contains contaminates sterile field



h. Do not reach over sterile field• Dust or lint from clothes may fall onto the field

• Unsterile clothing may accidentally touch sterile field

i. Do not pass soiled dressings over the field

j. Always acknowledge if you contaminate the sterile field• Steps can be taken to regain sterility


Instruments Used in Minor Office Surgery

Instruments Used in Minor Office Surgery

1. Most instruments made of stainless steel

2. MA must know:

a. Names of instruments

b. Use

c. Proper care


Instruments Used in Minor Office Surgery, cont.


2. Scalpel: small, straight surgical knife consisting of a handle and thin, sharp blade

a. Used to:• Make a surgical incision

• Divide tissue with least possible trauma

b. Reusable and disposable available• Reusable handle with disposable blade: used

most frequently


ScalpelsScalpels

Courtesy Elmed, Addison, Ill.




3. Scissors: cutting instruments that have straight or curved blades

a. s/s: both blade tips are sharp

b. b/b: both blade tips are blunt

c. b/s: one tip blunt and the other sharp• Box lock: hinge joint where two parts come

together




d. Types of scissors

• Operating scissors

– Straight delicate blades with sharp cutting edges

– Used to cut through tissue

– Blades available

• s/s

• b/b

• b/s


Operating ScissorsOperating Scissors





e. Suture scissors• Used to remove sutures

• Hook on tip: for getting under suture

• Blunt end: prevents puncturing of tissues


Suture ScissorsSuture Scissors





• Bandage scissors

– Inserted beneath a dressing or bandage to cut it for removal

– Flat blunt prow: protects from puncturing patient's skin


Bandage ScissorsBandage Scissors





• Dissecting scissors

– Thick blades with a fine cutting edge

– Used to divide tissue

– Available with straight or curved blades

– Both blades are blunt


Dissecting ScissorsDissecting Scissors





4. Forceps: two-pronged instruments for grasping and squeezing

a. Spring handle: provides proper tension for grasping tissue (thumb forceps)

b. Ratchet: toothed clasps on handle (hemostatic forceps)• Holds tips securely together

• Allows closure at three or more positions




c. Types of forceps

• Thumb forceps

– Serrated tips

– Used to pick up tissue or hold tissue between adjacent surfaces

– Serrations: sawlike teeth that grasp tissue and prevent it from slipping out of the jaws of the instrument


Thumb ForcepsThumb Forceps





• Tissue forceps

– Teeth to prevent them from slipping

– Used to grasp tissue

– Identified by number of opposing teeth on each jaw

1) Example: 2 x 3

2) Teeth should approximate tightly when instrument is closed


Tissue ForcepsTissue Forceps





• Splinter forceps

– Sharp points that are useful in removing foreign objects from the tissues (splinters)





• Dressing forceps

– For application and removal of dressings





• Hemostatic forceps– Serrated tips, ratchets, and box locks

– Available with straight or curved blades

– Used to clamp off blood vessels and establish hemostasis

1) Until vessels can be closed with sutures

– Ratchets: keep hemostat tightly shut when closed

1) Should mesh together smoothly when instrument is closed

– Serrations: prevent blood vessels from slipping out of jaws of the hemostat


Hemostatic ForcepsHemostatic Forceps





• Sponge forceps

– Large serrated rings on the tips for holding sponges



Miscellaneous InstrumentsMiscellaneous Instruments

1. Needle holder

a. Serrated tips, ratchets, and box locks

b. Used to grasp a curved needle firmly• To insert through skin

flaps of an incision



Miscellaneous Instruments, cont.


2. Towel clamps

a. Two sharp points to hold edges of sterile towel in place





3. Retractors

a. Used to hold tissue aside• To improve exposure of

operative area





4. Probes

a. Long slender instruments used to explore wounds or body cavities



Gynecologic InstrumentsGynecologic Instruments

1. Speculum

a. Used to open or distend a body orifice or cavity• To permit visual

inspection



Gynecologic Instruments, cont. Gynecologic Instruments, cont.

2. Tenaculum

a. Hooklike instrument

b. Used to grasp and hold body parts• Uterine tenaculum: used to grasp and hold

cervix


Uterine TenaculumUterine Tenaculum




3. Sound

a. Long slender instrument

b. Introduced into a body passage or cavity to:• Dilate strictures

• Detect the presence of foreign bodies


Uterine SoundsUterine Sounds




4. Curette

a. Spoon-shaped instrument

b. Used to remove material from the wall of a cavity or other surface


Care of Surgical InstrumentsCare of Surgical Instruments

1. Surgical instruments will last for many years if handled and maintained properly.

2. Care given to an instrument depends on the parts making up the instrument (e.g., box lock, ratchet, serrations)

3. Guidelines

a. Handle instruments carefully• Dropping on floor or throwing into a basin:

could damage it


Care of Surgical Instruments, cont.


b. Do not pile in a heap• Become entangled: could be damaged when

separated

c. Keep sharp instruments separate from rest of instruments• Prevents damage or dulling the cutting edge




d. Keep instruments with ratchets in open position when not in use• Prolongs proper functioning of

ratchet

e. Rinse blood and body secretions off as soon as possible• Prevents from drying and

hardening on instrument





f. Always use instrument for intended purpose• Substituting instruments

could damage an instrument

g. Sanitize and sterilize using proper technique


Commercially Prepared Sterile Packages

Commercially Prepared Sterile Packages

1. Commercially prepared sterile packages: Frequently used in medical office

2. May contain:

a. One article (sterile dressing)

b. Complete sterile setup (suture removal)

3. Directions for opening package stated on outside of package

a. Carefully follow to prevent contamination of sterile contents


Commercially Prepared Sterile Package

Commercially Prepared Sterile Package


Commercially Prepared Sterile Packages, cont.


4. To open a peel-apart package

a. Peel-pack: has edge with two flaps that can be pulled apart:• Grasp each nonsterile flap between bent index

finger and extended thumb

• Roll hands outward to pull apart

b. Inside of wrapper is sterile: must not be touched with bare hands


Opening a Peel-Apart PackageOpening a Peel-Apart Package




5. Contents of peel-apart package can be placed on sterile field by:

a. Stepping back and ejecting or "flipping" contents on center of field




b. Removing contents with a sterile gloved hand• Used when physician needs additional

supplies

• MA opens pack: physician removes contents with gloved hand




6. Inside of peel-apart package can be used as sterile field


WoundsWounds

1. Wound: Break in continuity of an external or internal surface caused by physical means

2. Can be:

a. Accidental

b. Intentional: physician makes an incision during MOS


Wounds, cont. Wounds, cont.

3. Types of wounds

a. Closed wound: injury to underlying tissues without break in skin surface or mucous membrane (contusion)

• Contusion: tissues under skin are injured


Wounds, cont.Wounds, cont.

Contusion:

– Often caused by blunt object

– Commonly occurs with fractures, sprains, strains, black eyes

– Blood vessels: rupture; blood seeps into tissues

– Results in bluish discoloration of skin

– Color turns greenish-yellow after several days


ContusionContusion



b. Open wounds: break in skin surface or mucous membrane that exposes underlying tissue

• Incision: clean smooth cut caused by a sharp instrument (e.g., knife, razor, glass)

– Deep incision: accompanied by profuse bleeding; may damage muscles, tendons, nerves



• Laceration: tissues are torn apart, leaving ragged and irregular edges (e.g., dull knife, large objects driven into skin, heavy machinery)

– Deep lacerations:

1) Result in profuse bleeding

2) Scar often develops


LacerationLaceration



• Puncture: wound made by sharp pointed object piercing skin layers (e.g., needle, splinter, bullet, animal bite)

– Very small opening; bleeding is minor

– Tetanus bacteria: grow best in warm anaerobic environment like a puncture

– May need a tetanus booster


PuncturePuncture



• Abrasion (scrape): outer layers of skin are scraped or rubbed off (e.g., falling on gravel and floors)

– Blood oozes from ruptured capillaries

– Result in skinned knees and elbows


Wound HealingWound Healing

1. Skin: protective barrier for body; considered first line of defense

a. Once skin broken: easy for microorganisms to enter and cause infection


Phase I: Inflammatory Phase Phase I: Inflammatory Phase

2. Phases of Wound Healing

a. Phase 1: Inflammatory phase• Begins as soon as body is injured


Phase I: Inflammatory Phase, cont.


• Lasts 3 to 4 days

• Fibrin network forms

– Results in blood clot: "plugs" up opening and stops flow of blood

– Blood clot becomes scab




• Inflammatory process occurs

– Inflammation: protective response of the body to trauma and entrance of foreign matter (microorganisms)

1) Blood supply increases: brings white blood cells and nutrients to site to assist in healing process




– Four local signs of inflammation

1) Redness

2) Swelling

3) Pain

4) Warmth

– Purpose of inflammation: to destroy invading microorganisms and remove damaged tissue debris so proper healing can occur


Phase 2: Granulation Phase Phase 2: Granulation Phase

b. Phase 2: Granulation Phase• Lasts 4 to 20 days

• Fibroblasts migrate to wound: begin to synthesize collagen

– Collagen: white protein that provides strength to wound


Phase 2: Granulation Phase, cont.


– As amount of collagen increases:

1) Wound becomes stronger

2) Decreases chance that wound will open

• Growth of new capillaries: provide damaged tissue with blood supply

– Tissue becomes translucent red color: known as granulation tissue (fragile, shiny, bleeds easily)


Phase 3: Maturation Phase Phase 3: Maturation Phase

c. Phase 3: Maturation Phase• Can last for up to 2 years

• Collagen continues to be synthesized

• Granulation tissue hardens to white scar tissue

– Scar tissue not true skin: does not contain nerves or have blood supply


Phase 3: Maturation Phase, cont.

Phase 3: Maturation Phase, cont.


Wound Healing, cont. Wound Healing, cont.

3. Always inspect wound when providing wound care

a. Observe for:• Signs of inflammation

• Amount of healing

b. Chart in patient's record


Wound Drainage Wound Drainage

4. Wound Drainage

a. Exudate (drainage): material (fluid and cells) that has escaped from blood vessel during inflammatory process

b. Inspect wound for drainage and chart in patient's record


Wound Drainage, cont. Wound Drainage, cont.

c. Types of Exudates:

• Serous exudate: consists of serum

– Clear and watery

– Example: fluid in blister from a burn



• Sanguineous exudate: red and consists of red blood cells

– Results when capillaries are damaged and blood escapes

– Seen with open wounds

– Color:

1) Bright red: fresh bleeding

2) Dark red: older bleeding



• Purulent exudate: contains pus

– Pus: consists of leukocytes, dead tissue debris, dead and living bacteria

– Usually thick and has unpleasant odor

– White in color: may acquire tinges of pink, green, or yellow (depending on infecting organism)

– Suppuration: process of pus formation



• Mixed exudates

– Serosanguineous exudate: clear and blood-tinged drainage

– Purosanguineous exudate: pus and blood

1) Often found in infected wounds


Sterile Dressing ChangeSterile Dressing Change

1. Surgical asepsis must be maintained when applying a dry sterile dressing (DSD) to an open wound

2. Must prevent infection in clean wounds and decrease infection in infected wounds


Sterile Dressing Change, cont. Sterile Dressing Change, cont.

3. Function of a sterile dressing

a. Protect the wound from contamination and trauma

b. Absorb drainage

c. Restrict motion



4. Dressing material used (size, type, amount) depends on:

a. Size and location of wound

b. Amount of drainage



5. Sterile gauze pads used in medical office

a. Come in variety of sizes• 2 x 2

• 3 x 3

• 4 x 4 (most frequently used)

b. Have tendency to stick to the wound



6. Nonadherent pads

a. Surface impregnated with agents that prevent dressing from sticking to wound

b. Example: Telfa pads (shiny side placed next to skin)• Often used for burns


SuturesSutures

1. Used to:

a. Close a surgical incision

b. Repair accidental wound

2. Purpose of sutures

a. Approximate (bring together) edges of wound with surgical stitches• Holds in place until proper healing occurs


Sutures, cont.Sutures, cont.

b. Protect wound from contamination

c. Minimize amount of scar formation

3. Local anesthetic: to numb area before insertion of sutures


Types of SuturesTypes of Sutures

1. Absorbable sutures

a. Surgical gut• Made from submucosa of sheep/cow

intestines

• Gradually digested by tissue enzymes and absorbed by body (5 to 20 days after insertion)

• Plain surgical gut: rapid absorption

• Chromic surgical gut: slow absorption

• Mainly used in hospital setting during surgery


Types of Sutures, cont Types of Sutures, cont

b. Synthetic materials• Dexon

• Vicryl


Types of Sutures, cont Types of Sutures, cont

2. Nonabsorbable sutures

a. Not absorbed by body

b. Either remain in skin permanently or are removed

c. Used to suture skin• Frequently performed in medical office

d. Types: silk, cotton, nylon, polyester, polypropylene, stainless steel, surgical skin staples


Nonabsorbable SuturesNonabsorbable Sutures


Suture Size and PackagingSuture Size and Packaging

1. Measured by gauge: refers to diameter of the suture

2. Size ranges from numbers below 0 (pronounced "aught") to numbers above 0

a. Size increases with numbers above 0 and decreases with numbers below 0

b. Example:• 6-0: very fine sutures

• 4: heavy sutures


Suture Size and Packaging, cont.


3. Nonabsorbable sutures with smaller gauge (5-0 to 6-0)

a. Leave less scaring

b. Used for delicate tissue (face, neck)

4. Nonabsorbable heavy sutures

a. Used for firmer tissue (chest, abdomen)




5. Suture package

a. Outer peel-apart package

b. Sterile inner package

c. Labeled with:• Type of suture material (e.g., surgical silk)

• Size of suture (e.g., 4-0)

• Length of suture (e.g., 18 inches)




6. Type and size of suture used

a. Based on nature and location of tissue sutured

b. Physician's preference


Suture NeedlesSuture Needles

1. Type of point

a. Cutting needle: sharp point• Used for firm tissue (e.g., skin)

b. Blunt needle: round point• Used for tissues that offer little resistance

(e.g., intestines, muscle)


Suture Needles, cont. Suture Needles, cont.

2. Shape of needle:

a. Curved needle: can dip in and out of tissue• Needle holder must be used

b. Straight needle: used when tissue can be displaced to permit needle to be pushed and pulled through tissue• Does not require needle holder



Modified from Perspectives on sutures, courtesy Davis & Geck, Danbury, Conn.


Suture Needles, cont. Suture Needles, cont.

3. Design of needle

a. Eyed needle: has eye through which suture is inserted

b. Swaged needle: suture and needle are one continuous unit• Advantages:

– Suture does not slip off needle

– Tissue trauma is reduced (only one strand of suture pulled through tissue)



Modified from Nealon TF Jr: Fundamental skills in surgery, ed 4, Philadelphia, 1994, Saunders.


Insertion of SuturesInsertion of Sutures

1. MA responsible for:

a. Suture tray setup

b. Assisting physician


Insertion of Sutures, cont. Insertion of Sutures, cont.

2. Physician designates: size and type of suture and needle required

a. Sutures added to field by:• Flipping onto field

• Placing on field with sterile gloved hand


Transferring Sutures Transferring Sutures


Suture Insertion SetupSuture Insertion Setup

3. Items placed on side tray

a. Clean disposable gloves

b. Antiseptic solution

c. Surgical scrub brush

d. Antiseptic swabs


Suture Insertion Setup, cont. Suture Insertion Setup, cont.

e. Sterile gloves

f. Local anesthetic

g. Alcohol wipe to cleanse vial

h. Tetanus toxoid with needle and syringe


Suture Insertion Side TraySuture Insertion Side Tray



4. Items on sterile field

a. Fenestrated drape

b. Syringe and needle

c. Hemostatic forceps

d. Thumb forceps



e. Tissue forceps

f. Dissecting scissors

g. Operating scissors

h. Needle holder

i. Sutures


Suture Insertion Sterile FieldSuture Insertion Sterile Field


Suture RemovalSuture Removal

1. Once wound healed: no longer needs support of sutures

2. Length of time sutures remain in place depends on:

a. Location of the sutures

b. Amount of healing that must occur


Suture Removal, cont. Suture Removal, cont.

3. Face and neck:

a. Have a good blood supply: area heals more rapidly

b. Sutures usually removed in 3 to 5 days

4. Chest, arms, legs, hands, and feet

a. Sutures usually removed in 7 to 10 days


Surgical Skin StaplesSurgical Skin Staples

1. Fastest method for closing long skin incisions

2. Trauma to tissue reduced

a. Tissue does not have to be handled very much during insertion

3. Consist of stainless steel


Surgical Skin Staples, cont. Surgical Skin Staples, cont.

4. Inserted into skin with a special skin stapler

a. Reusable and disposable available


Surgical Skin Staples, cont. Surgical Skin Staples, cont.

5. Removed with a special staple remover

6. MA usually responsible for removing sutures and staples

a. Written or verbal order must be given by physician

From Nealon TF Jr: Fundamental skills in surgery, ed 4, Philadelphia, 1994, Saunders.


Adhesive Skin ClosuresAdhesive Skin Closures

1. Approximate the edges of a laceration or incision

2. Consist of sterile, hypoallergenic tape

3. Available in variety of widths and lengths


Adhesive Skin Closures, cont. Adhesive Skin Closures, cont.

4. Brand names: Steri-Strip; Proxi-Strip



5. Used when not much tension exists on skin edges

6. Applied transversely across line of incision

a. To approximate edges of wound



7. Advantages

a. Sutures and local anesthetic not needed

b. Can be easily applied and removed

c. Lower incidence of wound infection compared with sutures

d. Results in less scarring than skin sutures


Adhesive Skin ClosuresAdhesive Skin Closures



8. Disadvantages:

a. Less precision in bringing wound edges together

b. Cannot be used on certain areas of body: where adhesive has difficulty adhering to skin• Areas that harbor moisture

– Palms of hands

– Soles of feet

– Axilla


Adhesive Skin Closures, cont.Adhesive Skin Closures, cont.

• Hairy areas

– Scalp

– Chest of male patient

8. MA frequently responsible for applying and removing

a. 5 to 10 days after application: closures may spontaneously lift off

b. If removal is required: MA should follow proper procedure


What Would You Do?What Would You Not Do?



Assisting with Minor Office Surgery

Assisting with Minor Office Surgery

1. MA must:

a. Know instruments/supplies for each setup

b. Know type of assistance required by physician

c. Be able to work quickly and efficiently

d. Be able to anticipate physician's needs

Tray Setup


Tray Setup, cont. Tray Setup, cont.

2. Instruments/supplies are set on a sterile field

3. Many offices maintain index cards indicating:

a. Instruments/supplies for each MOS

b. Skin preparation



c. Patient position

d. Physician's glove size

e. Type of suture material

f. Preoperative and postoperative instructions



4. Tray can be set up before or after preparing patient's skin

5. Do not allow sterile setup to become contaminated:

a. If must turn away or leave the room:• Place sterile towel over tray


Covering Sterile TrayCovering Sterile Tray



6. Methods Used to Set Up a Sterile Tray:

a. Prepackaged sterile setups• Commonly used

• Setup wrapped in:

– Disposable sterilization paper

– Muslin (prepared through autoclave sterilization)

• Labeled according to use (e.g., cyst removal pack)


Tray Setup, cont.Tray Setup, cont.

• Contains most of instruments/supplies required for the MOS

• Package opened on flat surface (e.g., Mayo tray)

– Inside of wrapper used as sterile field

– Add additional articles if needed (e.g., 4 x 4 gauze, sutures)



b. Place articles on a sterile field individually• Place sterile towel over a tray

– To prevent contamination:

1) Handle towel by corners

2) Do not fan towel through air

• Flip articles onto field from peel-apart packages


Placing Sterile Towel on TrayPlacing Sterile Towel on Tray



7. Side Table

a. Articles that are not sterile must not be placed on sterile field• Set on an adjacent table or counter



b. Examples:• Surgical scrub brush

• Vial of local anesthetic

• Physician's sterile gloves (outside wrapper is not sterile)


Skin PreparationSkin Preparation

1. Skin contains an abundance of microorganisms

a. If microorganisms enter operative site: could cause wound infection

2. Operative site must be cleaned and prepared

a. Remove as many microorganisms as possible• Reduces risk of surgical wound contamination


Skin Preparation, cont. Skin Preparation, cont.

3. Shaving the Site

a. Hair supports growth of microorganisms

b. Skin may need to be shaved around operative site

c. Disposable shave prep trays available

d. Pull skin taut to prevent nicks

e. Once shaved, rinse and dry area thoroughly



4. Cleansing the site

a. Cleanse with antiseptic solution (e.g., Betadine Surgical scrub)



b. Scrub site with surgical scrub brush• Use circular motion: moving from inside

outward

c. Rinse using gauze pads saturated with water

d. Blot dry with sterile gauze


Cleansing the SiteCleansing the Site



5. Antiseptic application

a. Decreases number of microorganisms

b. Betadine commonly used



6. Fenestrated drape applied

a. Opening placed directly placed over operative site

b. Provides sterile area around operative site

c. Decreases contamination of the surgical wound


Fenestrated DrapeFenestrated Drape


Local AnestheticLocal Anesthetic

1. Types of anesthetics:

a. Lidocaine hydrochloride (Xylocaine)

b. Procaine hydrochloride (Novocain)


Local Anesthetic, cont. Local Anesthetic, cont.

2. Local anesthetic injected around operative site (infiltration)

a. Produces a loss of sensation

3. Begins working: 5 to 15 minutes



4. Duration of action: 1 to 3 hours

5. Local anesthetic containing epinephrine may be ordered

a. Epinephrine: Prolongs effect of anesthetic and decreases rate of systemic absorption (by constricting blood vessel in the area)

6. Physician informs MA of type, strength, and amount of anesthetic required

a. Example: 1 ml of Xylocaine 2.0% with epinephrine



7. Preparing the Anesthetic

a. Cleanse vial with alcohol wipe

b. Methods to draw anesthetic into syringe• MA draws anesthetic up and hands it to

physician, who has not yet applied sterile gloves

– Physician injects anesthetic and then applies sterile gloves

• Physician draws up with sterile gloved hands

– Show label of vial to physician



– Hold vial while physician withdraws med

1) Vial is medically aseptic and cannot be touched by physician's sterile gloved hands



c. If MA draws up: needle and syringe placed on side table

d. If physician draws up: needle and syringe placed on sterile field


Assisting the PhysicianAssisting the Physician

1. Type of assisting required based on:

a. Type of surgery

b. Physician's preference


Assisting the Physician, cont. Assisting the Physician, cont.

2. MA may apply sterile gloves and assist directly

a. Hand instrument to physician:• In a firm, confident manner so it does not slip

out of physician's hand

• In its functional position (position in which it is to be used)


Handing InstrumentHanding Instrument



3. Add instruments and supplies to sterile field as needed

4. Tissue specimen may be obtained and sent to laboratory

a. Hold container while physician inserts specimen

b. Label with patient's name, date, and type of specimen

c. Complete biopsy request form


Holding Specimen ContainerHolding Specimen Container


Biopsy Request FormBiopsy Request Form

Courtesy Diagnostic Pathology Associates, Columbus, Ohio.



5. Once MOS completed

a. Physician may instruct MA to place dry sterile dressing over site• Protects wound from contamination or injury

• Absorbs drainage

b. MA responsible for assisting patient and cleaning examination room


Medical Office Surgical Procedures

Medical Office Surgical Procedures

1. Sebaceous cyst: thin, closed sac or capsule that contains secretions from a sebaceous or oil gland

a. Forms when outlet of gland becomes obstructed

b. Built-up secretions of sebum from gland cause swelling

c. Cyst is soft to firm in consistency

Sebaceous Cyst Removal


Sebaceous Cyst Removal, cont. Sebaceous Cyst Removal, cont.

d. Cyst is elevated, and filled with an odorous, cheesy material

e. Can occur anywhere on body except: palms of hands or soles of feet• Most frequently occur: scalp, face, ears, neck,

and back

f. Usually painless and nontender

g. May become infected


Sebaceous Cyst Removal, cont. Sebaceous Cyst Removal, cont.

2. Procedure:

a. Local anesthetic used to numb area

b. Incision is made and cyst is removed

c. Sutures inserted to close incision

d. Cyst placed in specimen container and sent to laboratory

e. Sterile dressing applied


Sebaceous Cyst RemovalSebaceous Cyst Removal



Sebaceous Cyst Removal Setup

Sebaceous Cyst Removal Setup

3. Items Placed to the Side of the Sterile Field:




d. Antiseptic swabs


Sebaceous Cyst Removal Setup, cont.


e. Sterile gloves

f. Local anesthetic

g. Alcohol wipe

h. Specimen container

i. Laboratory request form

j. Surgical tape


Sebaceous Cyst Removal Side Tray

Sebaceous Cyst Removal Side Tray




4. Items Included on the Sterile Field


b. Needle and syringe (for drawing up local anesthetic)

c. Scalpel and blade

d. Dissecting scissors

e. Hemostatic forceps




f. Tissue forceps

g. Thumb forceps

h. Operating scissors

i. Needle holder

j. Sutures

k. Sterile 4 x 4 gauze


Sebaceous Cyst Removal Sterile Tray

Sebaceous Cyst Removal Sterile Tray


Surgical Incision and Drainage of Localized Infections

Surgical Incision and Drainage of Localized Infections

1. Abscess: collection of pus in a cavity surrounded by inflamed tissue



Surgical Incision and Drainage of Localized Infections, cont. Surgical Incision and Drainage of Localized Infections, cont.

a. Caused by pathogen that invades tissues• Usually by way of break in the skin

b. Serves as defense mechanism to keep infection localized• By walling off microorganisms: Prevents them

from spreading through the body



2. Furuncle (boil): localized staphylococcal infection that originates deep within a hair follicle

a. Produces pain and itching

b. Skin becomes red

c. Turns white and necrotic over top

d. Surrounded by erythema and induration



3. Procedure

a. Local anesthetic administered

b. Scalpel used to make incision



c. Penrose drainage tube or gauze wick inserted into wound• Keeps edges of tissues apart

– Facilitates drainage of exudate

1) Exudate contains pathogens

2) Avoid contact with exudate



d. Sterile dressing applied• Absorbs drainage

4. Postoperative Instructions

a. Instruct patient to apply warm moist compresses• Promotes healing


Incision and Drainage SetupIncision and Drainage Setup

4. Items Placed to the Side of the Sterile Field




d. Antiseptic swabs


Incision and Drainage Setup, cont.


e. Sterile gloves

f. Local anesthetic

g. Alcohol wipe

h. Rubber Penrose drain or gauze wick

i. Iodoform packing material

j. Surgical tape


Incision and Drainage Side Tray

Incision and Drainage Side Tray







c. Scalpel and blade

d. Dissecting scissors




e. Hemostatic forceps

f. Tissue forceps

g. Thumb forceps

h. Operating scissors

i. Sterile 4 x 4 gauze


Incision and Drainage Sterile Field

Incision and Drainage Sterile Field


Needle BiopsyNeedle Biopsy

1. Biopsy: removal and examination of tissue from the living body

a. Often performed to determine if tumor is malignant or benign

2. Tissue from deep within the body is obtained

a. By insertion of a biopsy needle through skin


Needle Biopsy, cont. Needle Biopsy, cont.

3. Needle consists of:

a. Outer needle: makes the puncture

b. Forked inner needle: obtains specimen

Modified from Nealon TF Jr: Fundamental skills in surgery, ed 4, Philadelphia, 1994, Saunders.



4. Procedure

a. Performed under local anesthetic

b. Incision not required

c. Patient does not have discomfort of an operative recovery



5. Tissue specimen placed in a container and sent to laboratory

a. Examined by a pathologist

6. Small dressing placed over puncture site

a. Protects site and promotes healing

7. After procedure:

a. Patient is observed for complications


Needle Biopsy SetupNeedle Biopsy Setup





d. Antiseptic swabs


Needle Biopsy SetupNeedle Biopsy Setup

e. Sterile gloves

f. Local anesthetic

g. Alcohol wipe

h. Specimen container/label

i. Laboratory request form

j. Surgical tape


Needle Biopsy Setup, cont. Needle Biopsy Setup, cont.



b. Needle and syringe

c. Biopsy needle

d. Sterile 4 x 4 gauze


Ingrown Toenail RemovalIngrown Toenail Removal

1. Occurs when toenail grows deeply into nail groove and penetrates surrounding skin

a. Results in pain and discomfort

b. Inflammation

From Nealon TF Jr: Fundamental skills in surgery, ed 4,

Philadelphia, 1994, Saunders.


Ingrown Toenail Removal, cont.


2. Caused by:

a. External pressure from tight shoes

b. Trauma

c. Improper nail trimming

d. Infection




3. Protruding nail: Acts as a foreign body

a. Usually results in secondary infection

4. Mild cases

a. Small piece of cotton packing inserted under toenail

b. Raises edge away from tissue


Ingrown Toenail PackingIngrown Toenail Packing





5. Severe/recurring cases

a. Part of nail is surgically removed• Relieves pain by decreasing the nail pressure

on soft tissues



Ingrown Toenail SetupIngrown Toenail Setup






Ingrown Toenail Setup, cont. Ingrown Toenail Setup, cont.

d. Antiseptic swabs

e. Sterile gloves

f. Local anesthetic

g. Alcohol wipe

h. Surgical tape


Ingrown Toenail Setup, cont. Ingrown Toenail Setup, cont.




c. Surgical toenail scissors

d. Hemostatic forceps

e. Operating scissors

f. Sterile 4 x 4 gauze




8. Procedure

a. Foot soaked in antibacterial solution for 10 to 15 minutes• Softens nail plate

• Decreases possibility of infection

b. Patient placed in reclining position with foot supported

c. Toe is shaved to remove hair• Hair acts as a contaminant




d. Antiseptic applied

e. Local anesthetic administered

f. Wedge of nail removed with surgical toenail scissors

g. Sterile gauze dressing or strip of surgical tape applied• Protects operative site


ColposcopyColposcopy

1. Colposcopy: Visual examination of the vagina and cervix with a colposcope

a. Colposcope: lighted instrument with a magnifying lens• Used to examine the vagina

and cervix

From Apgar BS, Brotzman GL, Spitzer M:

Colposcopy: principles and practice—an integrated textbook and atlas,



Colposcopy, cont. Colposcopy, cont.

2. Purpose

a. Examine vagina and cervix for abnormal tissue growth

3. When performed

a. Following abnormal Pap test results

b. To evaluate vaginal or cervical lesion observed during a pelvic examination

c. After treatment for cancer of cervix


Colposcopy, cont. Colposcopy, cont.

4. Patient Preparation:a. Do not insert anything into vagina for 24 to 48

hours before procedure• Tampons• Vaginal medications• Spermicides

5. Lens positioned 12 inches from opening of vaginaa. Magnifies tissue which facilitates:

• Inspection of cervical cells• Obtaining a biopsy

b. Magnification of 6x to 15x generally used


Colposcopy SetupColposcopy Setup


a. Colposcope

b. Sterile gloves

c. Normal saline

d. Acetic acid (3%)

e. Lugol's iodine solution

From Apgar BS, Brotzman GL, Spitzer M:

Colposcopy: principles and practice—an integrated textbook and atlas,



Colposcopy Setup, cont. Colposcopy Setup, cont.

7. Items Included on Sterile Field

a. Vaginal speculum

b. Long, sterile cotton-tipped applicators

c. Uterine tenaculum

d. Uterine dressing forceps


Colposcopy, cont.Colposcopy, cont.

8. Performed as follows:

a. Patient assisted into lithotomy position

b. Physician inserts vaginal speculum



c. Applicator moistened with saline used to wipe cervix:• Removes mucus film for better visualization of

cervix

d. Colposcope focused on cervix

e. Physician inspects cervix

From Apgar BS, Brotzman GL, Spitzer M: Colposcopy: principles and practice—an integrated textbook and atlas,




f. Cervix swabbed with acetic acid• Dissolves cervical mucus and other secretions

• Provides best contrast between normal and abnormal tissue



g. Cervical epithelium may be stained with Lugol's iodine solution• Healthy epithelium: absorbs iodine, causing

epithelium to stain dark brown color

• Abnormal epithelium: unable to absorb iodine

h. If abnormal area observed: cervical biopsy is obtained using punch biopsy forceps


Cervical Punch BiopsyCervical Punch Biopsy

1. Performed in combination with colposcopy: to remove cervical tissue

2. Purpose

a. Determine if a specimen is benign or malignant

3. Often performed after abnormal Pap test result


Cervical Punch Biopsy, cont. Cervical Punch Biopsy, cont.

4. Performed a week after end of menstrual period

a. Cervix is least vascular

5. Patient preparation (begin 2 days before examination)

a. Do not douche

b. Do not use vaginal creams, medications, or spermicides

c. Do not have intercourse


Cervical Punch Biopsy SetupCervical Punch Biopsy Setup


a. Colposcope

b. Sterile gloves

c. Lugol's iodine solution




Cervical Punch Biopsy Setup, cont.


d. Monsel's solution

e. Specimen container/label

f. Laboratory request form

g. Sanitary pad





a. Vaginal speculum

b. Long, sterile cotton-tipped applicator

c. Cervical punch biopsy forceps

d. Uterine dressing forceps

e. Uterine tenaculum

f. Sterile 4 x 4 gauze



8. Procedure

a. Patient put in lithotomy position

b. Anesthetic not needed: cervix has few pain receptors• Patient experiences little discomfort:

– Mild cramping and pinching as specimen removed



c. Physician inserts vaginal speculum

d. May stain cervix with Lugol's solution

e. Colposcope focused on cervix and inspected




Cervical Punch Biopsy, cont.Cervical Punch Biopsy, cont.

f. Cervical biopsy punch forceps used to obtain several tissue specimens from abnormal epithelium




g. Specimen placed in container and sent to laboratory• Examined by a pathologist

h. If bleeding occurs, controlled with:• Gauze packing

• Hemostatic solution

• Electrocautery

i. Patient given sanitary pad to absorb any discharge




a. Instruct patient that minimal bleeding may occur• Contact office if bleeding is heavier than

normal menstrual bleeding

b. Foul smelling gray-green vaginal discharge• May occur several days after procedure and

continue for 3 weeks

• Results from normal healing of cervical tissue

• Will gradually diminish


CryosurgeryCryosurgery

1. Cervical cryosurgery (cryotherapy): often used to treat chronic cervicitis and cervical erosion through use of freezing temperatures

a. Performed without an anesthetic

2. Cryosurgery unit: consists of long metal probe attached to cooling-agent tank


Cryosurgery UnitCryosurgery Unit

From Zakus S: Clinical skills for medical assistants, ed 4, Philadelphia, 2001, Saunders.


Cryosurgery, cont. Cryosurgery, cont.

a. Cooling agents: • Liquid nitrogen (used most often)

• Nitrous oxide

• Carbon dioxide gas

3. Probe: placed in contact with infected area



4. Cooling agent flows through probe: freezes tissue to –40° to –80° C

a. Causes cells to die and slough off

5. Cervical covering is eventually replaced with new, healthy epithelial tissue

6. Regeneration of cervical tissue: occurs 4 to 6 weeks after procedure


Cryosurgery SetupCryosurgery Setup

7. Items Placed to Side of the Sterile Field

a. Cryosurgery unit

b. Sanitary pads

8. Items Included on Sterile Field

a. Vaginal speculum

b. Acid-saline solution

c. Long, cotton-tipped applicators



9. Performed as follows:

a. Patient placed in lithotomy position

b. Vaginal speculum inserted

c. Cervix swabbed with acid-saline solution• Removes mucus and other contaminants



d. Metal probe placed in contact with affected area and unit turned on

e. Cooling agent flows over area for 3 minutes• Patient may experience pain resembling

menstrual cramping (for about 30 minutes)

f. Once completed• Assist patient as needed

• Observe for signs of discomfort and vertigo

g. Patient given sanitary pad to absorb discharge




a. First postoperative day• Patient develops heavy, clear, watery vaginal

discharge

• Reaches maximum by sixth day

b. Instruct patient to wear sanitary pads rather than tampons



c. Vaginal cream may be prescribed to promote healing

d. Continuation of discharge for 4 weeks is normal

e. Foul odor should be reported

f. Instruct patient:


Cryosurgery, cont.Cryosurgery, cont.

• Next menstrual period will be heavier

• May involve cramping

• Abstain from intercourse for 4 weeks

• Douche with a solution of diluted vinegar and water

g. Return visit scheduled in 6 weeks• To make sure proper healing has taken place


Skin LesionsSkin Lesions

1. Cryosurgery can be used to remove skin lesions (e.g., warts)

2. Small amount of cooling agent used

3. Liquid nitrogen: in small, pressurized canister with attached probe


Skin Lesions, cont. Skin Lesions, cont.

4. Liquid nitrogen applied until lesion turns white (indicates freezing of tissue has taken place)

a. Patient feels slight burning or stinging

5. Blister develops and dries to a scab in 7 to 10 days and eventually sloughs off

a. Patient should keep area clean and dry until scab sloughs off

6. In some cases: two or more treatments may be required to completely destroy lesion


BandagingBandaging

1. Bandage: strip of woven material used to wrap or cover a part of the body

2. Function

a. Apply pressure to control bleeding

b. Protect wound from contamination

c. Hold a dressing in place

d. Protect, support, or immobilize an injured part of the body


Guidelines for ApplicationGuidelines for Application

1. Apply bandage so that it feels comfortable to patient

2. Fasten securely with metal clips or adhesive tape

3. Guidelines

a. Observe medical asepsis

b. Area should be clean and dry


Guidelines for Application, cont.


c. Do not apply bandage directly over open wound• Apply sterile dressing first

– To prevent contamination of the wound

• Bandage should extend 2 inches beyond edge of dressing




d. To prevent irritation: do not allow skin of two body parts to touch• Insert piece of gauze between body parts

(e.g., between fingers)

e. Pad joints and prominent parts of bones• Prevents bandage from rubbing the skin and

causing irritation




f. Bandage body part in its normal position with joints slightly flexed• Avoids muscle strain

g. Apply bandage from distal to proximal part of the body• Aids in venous return to heart




h. Ask patient if bandage feels comfortable• Should fit snugly so will not fall off

• Not too tightly: impedes circulation

• If possible: leave fingers and toes exposed

– Circulation can be checked




1) Signs indicating bandage is too tight:

a) Coldness

b) Pallor

c) Numbness

d) Cyanosis of nailbeds

e) Swelling

f) Pain

g) Tingling sensations




• If signs occur: loosen bandage immediately

i. If bandage roll dropped: • Obtain a new bandage

• Begin again


Types of BandagesTypes of Bandages

1. Roller bandage: long strip of soft material wound on itself to form a roll

a. Ranges from ½ to 6 inches wide, and from 2 to 5 yards long

b. Width used depends on part being bandaged

c. Usually made of sterile gauze


Types of Bandages, cont. Types of Bandages, cont.

d. Advantages:• Porous and lightweight

• Molds easily to body part

• Inexpensive

• Easily disposed of

e. Disadvantage: gauze may slip and fray easily


Types of Bandages, cont.Types of Bandages, cont.

2. Kling gauze: special type of gauze that stretches

a. Allows it to cling: molds and conforms better

3. Elastic bandage: made of woven cotton that contains elastic fibers

a. Common brand name: Ace bandage

b. Expensive, but can be washed and used again


Types of Bandages, cont. Types of Bandages, cont.

c. Be extremely careful when applying• Easy to apply too tightly: can impede

circulation

d. Elastic adhesive bandages available• Have an adhesive backing to provide secure

fit


Bandage TurnsBandage Turns

1. Five basic turns: can be used alone or in combination

2. Type of turn used depends on:

a. Body part to be bandaged

b. What the bandage is being used for (support, immobilization, or holding a dressing in place)


Bandage Turns, cont.Bandage Turns, cont.

• Circular turn

– Applied to body part of uniform width (toes, fingers, head)

– Each turn completely overlaps the previous turn

– Use:

1) Two circular turns: used to anchor a bandage


Circular TurnCircular Turn


Spiral Turn Spiral Turn

• Spiral turn

– Applied to body part of uniform circumference (fingers, arms, legs)


Bandage Turns, cont. Bandage Turns, cont.

• Spiral-reverse turn– Used for a body part that varies in width

(forearm, lower leg)

– Reversing the spiral turn allows for smoother fit and prevents gapping

– Thumb is used to make the reverse halfway through each spiral turn

– Bandage directed downward and folded on itself

– Each turn overlaps the previous by two thirds


Spiral-Reverse TurnSpiral-Reverse Turn



• Figure-eight turn

– Used to hold dressing in place or to support and immobilize an injured joint

– Consists of slanting turns that alternately ascend and descend around the part and cross over one another in the middle

– Each turn overlaps previous turn by two thirds


Figure-Eight TurnFigure-Eight Turn

From Leake MJ: A manual of simple nursing procedures, Philadelphia, 1971, Saunders.



• Recurrent turn

– Bandage anchored by using two circular turns and then passed back and forth over tip of the part to be bandaged

– Each turn overlaps previous turn by two thirds



• Used to bandage:

– Tips of fingers or toes

– Stump of an amputated extremity

– Head


Recurrent TurnRecurrent Turn


Tubular Gauze BandageTubular Gauze Bandage

1. Consists of seamless elasticized gauze fabric dispensed in a roll

2. Used to cover round body parts (fingers, toes, arms, legs)

3. Fits like a sleeve


Tubular Gauze BandageTubular Gauze Bandage

4. Easier to apply than roller bandage, and adheres more securely

5. Not sterile: never apply over open wounds

a. First apply a sterile dressing


Tubular Gauze Bandage, cont. Tubular Gauze Bandage, cont.

6. Available in a variety of widths

7. Applied by means of plastic or metal applicator

a. Comes in different sizes

b. Must be larger than body part

c. Each applicator marked with a size• Corresponds to the size on the tubular gauze

bandage box


POSTTESTPOSTTEST

True or False1. Measuring a patient's temperature requires the

use of surgical asepsis.

2. Hemostatic forceps are used to clamp off blood vessels.

3. An instrument with a ratchet should be kept in a closed position when not in use.

4. The physician would be most likely to order a tetanus booster for an abrasion.

5. Inflammation is the protective response of the body to trauma and the entrance of foreign substances.


POSTTEST, CONT.POSTTEST, CONT.

True or False6. A serous exudate is red in color.

7. Size 4-0 sutures have a smaller diameter than size 3 sutures.

8. Sebaceous cysts are commonly found on the palms of the hand.

9. Colposcopy is frequently used to evaluate lesions of the cervix.

10. Cryosurgery is used in the treatment of cervical cancer.

CHAPTER 10 MINOR OFFICE SURGERY. Elsevier items and derived items © 2008 by Saunders, an imprint of...

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Transcript of CHAPTER 10 MINOR OFFICE SURGERY. Elsevier items and derived items © 2008 by Saunders, an imprint of...