Lesson 4

Postoperative Patient Care

Chapter 42: Assisting with Minor Surgery

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Define and spell the terms to learn for this chapter.

Explain the four types of wounds. Describe the stages of healing. Describe at least five surgical procedures

that can be performed in the physician’s office, and indicate the responsibility of the medical assistant for each procedure.

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Lesson Objectives

Upon completion of this lesson, students should be able to …

Elements of Postoperative Patient Care Monitoring the

patient during recovery from anesthesia

Wound care Applying dressings Communicating

patient instructions

Insert Figure 42-1 fromPCMA 2nd edition

Critical Thinking Question

How might the type of anesthesia used affect a patient’s recovery?

Topical and Other Local Anesthetics Affects usually wear off quickly Use of large amounts, beyond normal dosages,

may result in an adverse reaction If a patient is allergic, the patient may

experience an anaphylatic shock Drugs used to counteract shock should always

be available

Types of Local Anesthetics

Benzocaine - Topical use only Chloroprocaine – Nerve block epidural Lidocaine (Xylocaine) – Infiltration or topical Mepivacaine – Infilitration nerve block Procaine (novacaine) – Infiltration, seldom

used now Tetracaine – Infiltration, local nerve block,

spinal

Areas to Observe on a Patient Recovering from Surgery Signs of adverse reaction to the anesthetic Bleeding Circulatory problems Vitals

• Blood pressure, temperature, pulse, and respirations• Should be monitored immediately after surgery and then

every 15 minutes for the first hour

In ability recovery in a normal timeframeshould be report to the physician

Immediately!

Wounds

Defined as any break in the skin Can occur from injury or a surgical incision An invasive procedure, such as surgery,

creates a wound Wounds cause blood vessels to rupture and

blood to seep into tissues Changes in skin color can occur

Types of Wounds

Abrasion• Outer layers of skin are rubbed away due to

scraping• Will generally heal without scarring

Incision• Smooth cut resulting from a surgical scalpel or

sharp material, such as razor or glass• May result in excessive bleeding and scarring if

deep

Types of Wounds

Laceration• Edges are torn in an irregular shape• Can cause profuse bleeding and scarring

Puncture• Made by a sharp, pointed instrument such as a

bullet, needle, nail, or splinter• External bleeding is usually minimal• Infection may occur due to penetration with a

contaminated object• May be scarring

Phases of a Healing Wound

Inflammatory phase (3 days)• Blood clot forms to stop bleeding and plug the

opening of the wound• Eschar or scab forms to keep out microorganisms

Proliferating phase (3 to 21 days)• Fibrin threads extend across opening of the wound

and pull edges together• Cells multiply to repair the wound

Phases of a Healing Wound

Maturation phase (21 days to 2 years)• Tissue cells strengthen and tighten the wound

closure• A scar is formed• The scar eventually fades and thins

Wound Complications

Infection• Include signs of inflammation, purulent or puslike

drainage, fever

Hemorrhage or bleeding Dehiscense

• Separation of wound edges

Evisceration• Separation of wound edges and protrusion of

abdominal organs

Wound Drainage

Occurs as fluid and cells escape from the tissues during the inflammatory phase of wound healing

The amount and type of drainage observed on a dressing should be charted

Types of Wound Drainage

Serous drainage• Clear, watery drainage, such as the fluid in a blister

Sanguineous drainage• Bloody – bright red is fresh blood, dark red is older

blood. The amount and color are important

Serosanguineous drainage• Thin watery drainage tinged with blood

Purulent drainage• Thick puslike drainage that is green, yellow, or

brown

Cleansing a Wound

Must be done before a sterile dressing is applied The product used for cleansing is determined by the

physician Warm water and soap are used to remove surface dirt

around the wound When cleaning the wound, use a sterile gauze or

swab Work from the clean area near the wound outward to

less clean areas Wipe in one direction and then discard the sterile

swab or gauze.

Cleansing a Wound

Always clean at least 1 inch beyond the edge of the dressing to be applied

If no dressing is to be applied, clean 2 inches beyond the edges of the wound

Use a new gauze pad for each circle

Cleansing a Linear Wound

Start from top to bottom with one stroke per sterile gauze or swab.

Work outward from the wound in parallel lines

Insert Figure 42-27From Chapter 42

Cleansing an Open Wound

Wipe in one Work in circles, half or full

Begin in the center and work outward

Insert Figure 42-28From Chapter 42

Dressings

Size and shape depends on the size, location, and amount of drainage from the wound

Sterile 4 X 4 gauze pads (“four by fours”) are used for most dressings

If drainage is expected, a prepared dressing may be used to prevent the dressing from sticking to the wound

Insert Figure 42-29 fromPCMA 2nd edition

Chapter 42

Wound closure kit

Sutures

A thread used to sew together body tissues Sutures used to attach tissues beneath the

skin are often made of an absorbable material Skin sutures are made of nonabsorable

materials such as• Silk, cotton, linen, wire, nylon, Dacron (polyester

fiber)

Silver wire clips or staples can also be used

Suture Removal Times

Facial sutures• 24 to 38 hours to prevent scarring

Head and neck sutures• 3 to 5 days

Abdominal sutures• 5 to 7 days

Sutures over weight-bearing joints and large bones• 7 to 10 days

Critical Thinking Question

Prior to removing a patient’s dressing and sutures, how can you help the patient feel

more at ease?

Removing a Dressing

Each edge of the dressing is removed by pulling toward the suture line

If the dressing is adhering to the suture line, use a small amount of sterile saline or hydrogen peroxide to moisten the dressing to ease removal

Steps to Removing Sutures

1. Perform hand hygiene

2. Assemble equipment and check expiration dateon pack.

3. Identify the patient, explain the procedure, andassist patient into a comfortable position

4. Perform hand hygiene and remove olddressing using proper technique.

5. Perform hand hygiene. Open suture orstaple removal pack using proper technique.

6. Apply sterile gloves and cleanse thewound as needed.

Steps to Removing Sutures

7. Place a gauze square next to the wound for placementof sutures or staples as they are removed.

8. Grasp the knot of the suture with thumb forceps andlift gently.

9. Insert the suture scissors and cut suture at skinlevel. Pull out the sutures.

10. Place the cut suture on the gauze.

11. Repeat these steps until all the suturesare removed.

12. Count sutures to make sure that allHave been removed.

Bandages for a Wound

May be gauze, fabric, or elasticized Need not be sterile Available in various sizes, lengths, and shapes Some are self-adhering Elastic bandages are used to support an injured

part and reduce swelling

Minor Surgical Procedures Performed in a Medical Office Biopsy Cautery Colposcopy Cryosurgery Laser surgery Endocervical

curettage Endoscopic

procedures

Suture removal Removal of foreign

bodies Incision and drainage Vasectomy Removal of growths

and tumors

Electrosurgery

The application of high frequency electrical currents

Currents are used to heat tissue to cut, destroy, or remove it

Most often performed in dermatological, gynecological, cardiac, ocular, ENT, and orthopedic surgical procedures

Types of Electrosurgery

Electrocoagulation• Destroys tissues and controls bleeding by

coagulation

Electrodessication• Destroys tissue by creating a spark gap when the

probe is inserted into unwanted tissue

Electrofulguration• Destroys tissue with a spark emitted from the tip of a

probe positioned a short distance away from the unwanted tissue

Types of Electrosurgery

Electrosection• Uses electric current to incise and excise the tissue

Electrocautery (or cautery)• Uses high-frequency, alternating electric current to

destroy, cut, or remove tissue.• Also used to coagulate small blood vessels, thereby

reducing bleeding and cell loss

Laser Surgery

Laser is an acronym for Light Amplification by Stimulated Emission of Radiation

Laser was originally used to treat diseases of the retina

Laser surgery today is used to treat various diseases and conditions such as:• Vascular problems• Neurological problems• Orthopedic conditions• Dermatologic problems

Colposcopy

An examination of the vagina and cervix Performed using a colposcope Patient is in the lithotomy position Allows the physician to observe tissues of this

area in greater detail through light and magnification

Abnormal areas of tissue or cells can be removed for biopsy to detect cancer

Cryosurgery using freezing temperatures may be used to destroy cells

Endoscope

An instrument used to look into a hollow organ or body cavity

Used to examine the larynx, bladder, colon, sigmoid colon, stomach, abdomen, and some joints

Other attachments such as a light source, suction, or mirror may be used

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MEDB152 Health and Safety/Intro to Microbiology

Cryosurgery

Use of subfreezing temperatures to destroy tissue.

Also known as cyrocautery. Probe used in cryosurgery must be sterilized

immediately after use according to manufacturer’s instructions.

Endometrial Biopsy (EMB)

Performed with the patient in the lithotomy position After performing a bimanual examination of the

uterus the physician administers a local anesthetic. The specimen is taking by means of a curette or

with a suction device to aspirate a specimen which is then placed in a container of 10% formalin preservative solution.

After the procedure the patient may experience mild cramping for which a mild analgesic may be taken.

Reasons for Performing an EMB

To detect precancerous and cancerous conditions of the endometrial lining of the uterus

To detect inflammatory conditions To determine if polyps are present To assess abnormal uterine bleeding To assess the effects of hormonal therapy To screen for early detection of endometrial

cancer

Incision and Drainage

Performed to relieve the buildup of purulent (pus) material as a result of infection

The purulent discharge may be cultured to determine what microorganisms is causing the infection

The appropriate antibiotic can then be selected The procedure is performed using sterile

surgical technqiue

Tray Setup for an I&D

Scalpel handle and blades (No. 11) Curved iris scissors Tissue forceps Kelly hemostat Retractor Thumb dressing forceps 4 X 4 gauze squares

Foreign Bodies and Growths

Foreign bodies Can include a small

to large objects.

Growths Include tumors,

warts, moles, and cysts.

Insert Figure 42-38 inChapter 42 of the

textbook

Surgical tray setup for biopsy procedure

Vasectomy

Tying and cutting of the vas deferens Is most commonly performed in a urologist’s

office Provides a permanent form of birth control for

the male. As with all surgical procedures, a consent form

must be signed The patient should have someone to drive him

home after the surgery

Surgical Tray Set Up for a Vasectomy Scalpel handle and blade (No.15) Dressing forceps Towel clamp Straight and curved mosquito forceps Curved tissue scissors Tissue forceps Retractor Needle holder and suture material Suture scissors

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MEDB152 Health and Safety/Intro to Microbiology

Summary

Assisting with surgery includes maintaining aseptic technique, a thorough knowledge of gowning, gloving, surgical hand hygiene, setting up sterile instrument trays, passing equipment to the physician, packaging and surgical setup, and preparing the patient for the procedure. Assisting with surgical procedures carries with it a grave responsibility to maintain absolute sterile technique. The medical assistant incorporates a variety of clinical skills when assisting with a surgical procedure.

Questions?