Surgical Procedures in the Medical Office Part 2

48-3d Postoperative Instructions Printed instructions should be given to the patient and explained to both the patient and family members. The patient should, of course, be given the provider’s phone number and urged to phone if there are any complications or concerns. You should have a standard set of printed instructions readily available for telephone screening of those outpatient surgery patients who call in with questions or concerns. Any calls that suggest a serious problem or condition should be referred to the provider immediately. Refer to the Patient Education box regarding what you should caution patients about following any surgery. Quick Tips Practical Application If a patient is being seen for a laceration repair, they may require a tetanus vaccine. According to the CDC, patients without a clear history of at least three tetanus vaccinations who have any wound other than clean and minor need tetanus immune globulin (TIG), not just a tetanus toxoid containing vaccine. Make sure you gather an updated immunization record as well as specific details as to how the laceration happened from the patient so the provider can order the appropriate vaccine if necessary. Patient Education Usual care of patient: 1. Keep site clean and dry. 2. Place no stress on the area. 3. Drink plenty of fluids. 4. Get proper rest. 5. Eat a sensible, well-balanced diet. 6. Return for follow-up appointment. Patients should report to the provider any of the following: 1. Unusual pain, burning, or other uncomfortable sensation 2. Swelling, redness, or other discoloration 3. Bleeding or other discharge 4. Fever above 5. Nausea and vomiting 6. Any other problem or symptom Make sure that return appointment visits are confirmed and reminder cards are given to patients before they leave the office. Phoning patients the next day is an excellent way to follow up and reassures them that you and the provider are genuinely concerned about their progress. It will also bring to the provider’s attention any problems that could be eliminated early. If patients do have complaints, it is best to have the provider check the problem as soon as possible. Follow-up visits are essential so that assessment of progress can be made by the provider and sutures or staples can be removed. Specific instructions, such as soaking or applying topical medications, will be given by the provider for certain individual cases. Providers generally instruct patients (or teach you how to instruct patients) about packing or special bandaging procedures such as with ingrown toenail removals. Providers can prescribe an analgesic for minor pain and discomfort the patient might experience following the procedure. 48-3e Documenting Surgical Procedures Like all procedures, surgical procedures are to be documented in the medical record thoroughly and completed immediately. The medical record entry should include:        A patient identifier: The patient’s name or patient ID number can be used. Informed consent: Informed consent should be obtained from the patient before the procedure. The date and time: The date and time of the procedure should be recorded. The provider might also request the start (time of incision) and stop time of the procedure to be recorded. The reason: The provider should record in the patient chart the reason for the surgical procedure. The procedure: The provider or the medical assistant should record the procedure to be done. If the medical assistant records the procedure, it should be rechecked with the provider. Specimen: Specimen removal should be documented. The medical assistant documents what the specimen is and its source. The medical assistant also labels the specimen container with the patient’s name and other patient-identifying information (name, date of birth). Postoperative instructions: The medical assistant is responsible for ensuring that the patient or their caregiver understands the postoperative instructions. Procedure 48–2 lists the general steps involved when assisting with a minor surgical procedure. Procedure 48–2 Assist with Minor Surgery Purpose: To demonstrate assisting with minor surgery. Equipment: Basic sterile setup: needle and syringe; needle holder; appropriate suture, disposable scalpel; thumb forceps; surgical scissors; hemostats; retractor; three or four pairs of vinyl gloves; gauze squares; cotton-tipped applicators; alcohol prep-pad; fenestrated sheet or towels; towel clamps; bandages; bandage scissors; tape; ordered anesthetic; antiseptic (small glass container for antiseptic solution); plastic biohazard sharps container and waste bag (and waste receptacle); patient’s EMR; pen; histology request form for laboratory analysis if a biopsy is indicated; Mayo tray table; proper lighting and extra backup sterile setup. Note: Some of the equipment might differ according to the procedure performed and provider preference. Skill: Instruct and prepare a patient for a procedure or treatment Skill: Demonstrate the medical assistant’s role in assisting with a minor surgical procedure Skill: Perform within a sterile field Procedure Steps Detailed Instructions and/or Rationales 1. Wash hands. 2. Assemble the appropriate equipment and supplies. Assemble supplies on a counter or table near a Mayo tray. Position the Mayo tray table next to the treatment table and check the condition and expiration dates of sterile items. If an item is expired or the package shows signs of improper conditions, items might no longer be sterile. 3. Correctly set up a sterile tray, maintaining sterile technique, and cover it with a sterile drape per office policy. Refer to Procedure 47–1 for setting up a sterile tray. 4. Introduce yourself and identify the patient. 5. Explain to the patient the rationale for performance of the procedure. Criteria: Say “Today I am going to be assisting the provider with a minor surgical procedure.” Then explain the procedure that A signature on the consent form is absolutely essential before any invasive procedure is performed. Emptying the bladder ensures the patient’s comfort during the procedure. Anxiety often results from the urge to void. is being performed and why. Ensure that the patient has signed the informed consent form. Advise the patient to empty the bladder. If a biopsy is to be taken, complete a lab request form for histology analysis. 6. 7. When the patient returns, take vital signs and record. Vital signs must be within acceptable limits to proceed with the procedure. Instruct the patient to disrobe as necessary for the procedure and advise where to place any belongings. Assist the patient if needed. Show awareness of the patient’s concerns related to the procedure being performed. Allow privacy and ask the patient to let you know when they are ready for positioning. Criteria: Ask “Do you have any questions or concerns?” 8. Assist the patient to the treatment table and into the desired position for surgery. Perform a skin prep procedure. Drape the patient appropriately. Refer to Procedure 47–4 for preparing a patient’s skin for minor office surgery. 9. When the provider is ready to begin the procedure, remove the sterile towel from the prepared sterile setup. Assist the provider by handing sterile gloves (if indicated) and assist with drawing up anesthesia as needed. Use an alcohol prep-pad to wipe the top of the anesthetic vial and hold it for the provider to draw out the amount needed. 10. If you are to assist with the surgical procedure, wash If additional sterile items are needed during the procedure, hands and put on sterile gloves. Hand instruments and other sterile items to the provider as needed; mop excessive blood with gauze sponges as needed. open the package and hand it to the provider for removal or drop it onto the center of the sterile field. 11. Assist with collecting any specimen as needed by the provider. If a biopsy is to be performed, take special care to preserve the specimen. Deposit the specimen directly into an open specimen container. Label and attach a completed laboratory requisition if using paper copies or complete in the computerized system when the procedure is completed. 12. Assist with suturing or stapling the incision as needed by the provider. You might assist the provider in suturing the incision by clipping each individual suture after the provider ties the knot. You should perform any other assistance as directed by the provider during the procedure. 13. When the surgery is completed, assist in (or perform) cleaning and bandaging the surgery site, remove gloves, and wash hands. If the patient is allergic to adhesive, use hypoallergenicunlikely to cause an allergic reaction.tape to secure the bandage. 14. Attend to the patient’s comfort by helping the patient into a sitting position to regain balance and, when stable, from the table. Assist in dressing if necessary. 15. Give the patient postoperative instructions. 16. Document the procedure in the patient’s chart. Instructions should include education regarding any return visit, care of surgery site, and any other orders from the provider. 17. Put on gloves and clean up the treatment area. Wash hands and restock treatment room. Clean up treatment table, discard contaminated items in a biohazard waste bag, rinse the instruments with cold water and place in a detergent solution, remove gloves and wash hands, and restock the room. Charting Example Courtesy of Harris CareTracker PM and EMR. 48-4 Sutures and Staples The term suture means a type of thread that joins the skin of a wound (either an accidental laceration or a surgical incision) together. A type of suture called catgut is eventually absorbed by the body and does not need to be removed (generally used in major surgeries). It is made from the intestines of sheep. Suture is also made of a material such as silk, nylon, or other manufactured substances that must be removed in a matter of days, depending on the area of the body in which they are inserted. For convenience, most providers prefer to use suture that has a needle already attached. Figures 48–3A and B show examples of different types of suture materials and needles used in closing wounds. Table 48–3 displays the different types of suture materials that may be used in the clinical facility. Figure 48–3A–B (A) A variety of suture packs and curved and straight surgical needles. (B) Various needle shapes used in the insertion of sutures to close wounds. Table 48–3 Types of Suture Material TYPE ABSORBABLE? NATURAL/ SYNTHETIC SIZES Polyglycoli c acid (Dexon) Yes Synthetic 2-0, 30, 4-0, 5-0, 6-0 Polyglacti n (Vicryl) Yes Synthetic 2-0, 30, 4-0, 5-0, 6-0 Polydioxa none (PDS II) Yes Synthetic 2-0, 30, 4-0, 5-0, 6-0 Poliglecap rone (Monocryl) Yes Synthetic 1, 0, 20, 3-0, 4-0, 50, 6-0 Polyglycon ate (Maxon) Yes Synthetic 2-0, 30, 4-0, 5-0, 6-0 Polyamide (Nylon) No Synthetic 2-0, 30, 4-0, 5-0, 6-0 Polyester (Dacron) No Synthetic 2-0, 30, 4-0, 5-0, 6-0 Polypropyl ene (Prolene) No Synthetic 2-0, 30, 4-0, 5-0, 6-0 Catgut Yes Natural 3-0, 40, 5-0, 9-0 Silk No Natural 2-0, 30, 4-0, 5-0, 6-0 Another commonly used method for skin closure of wounds and incisions is surgical staples. Some providers prefer staples over sutures because they are easier to use; however, some special care may be required as they can cause infection easier and they must be removed by you or the provider once the incision has healed. Staples generally need to stay in for a few days or up to a few weeks before they can be removed. 48-4a Applying Sutures Most offices have a policy regarding the treatment of lacerations. If the injury is severe and might result in serious blood loss, it is usually treated in the emergency room or trauma center. However, many patients will come to their primary care physician to have a laceration sutured. Working these patients into an already full schedule can present delays for other patients waiting for scheduled appointments. Prepare the patient for the provider and assist as needed. After the suturing is complete, the provider can see other patients while you take care of the laceration patient and clean up the work area. Your efficiency and expedient preparation of setting up the treatment room will be appreciated by both the provider and the patient in this situation. Follow the steps in Procedure 48–3 for assisting with suturing a laceration. Always make sure that you record the number of sutures (stitches) the provider inserts and the anatomical location. Go over patient education and any additional instructions from the provider before the patient leaves the office. If the patient is given instructions by the provider to re-dress and bandage the wound at home, show the patient how to do this and alert them to call with any questions or concerns. Procedure 48–3 Assist with Suturing a Laceration Purpose: Demonstrate each of the steps required in the procedure to assist with suturing a laceration while maintaining sterile technique. Equipment: Alcohol prep-pads, cotton balls, PPE, biohazard bag, gauze squares, bandages and tape, bandage scissors, antiseptic, ordered anesthetic, appropriate tetanus vaccine if needed, patient’s EHR, pen. Sterile items: swabs, needle and syringe, vinyl gloves, fenestrated drape, ordered suture material, gauze squares, hemostats, needle holder, scissors, sharps container. Skill: Instruct and prepare a patient for a procedure or treatment Skill: Demonstrate the medical assistant’s role in assisting a provider to apply sutures Skill: Perform within a sterile field Procedure Steps Detailed Instructions and/or Rationales 1. Wash hands and assemble all needed items, using sterile technique. 2. Introduce yourself and identify the patient. Speaking to the patient by name and checking the chart ensure that you are performing the procedure on the correct patient. Explain to the patient the rationale for performance of the procedure. Emptying the bladder ensures the patient’s comfort during the procedure. Anxiety often results from the urge to void. 3. Criteria: Say “Today I will be assisting the provider with applying sutures to close your incision.” Advise the patient to empty the bladder. 4. 5. When the patient returns, take and record vital signs. Vital signs must be within acceptable limits to proceed with the procedure. The patient might have lost a considerable amount of blood, which could alter vital signs. Show awareness of the patient’s concerns related to the procedure being performed. The patient might experience weakness and might not feel well enough to be left alone. Criteria: Ask “Do you have any questions or concerns?” Ask the patient to remove necessary clothing. Explain where the patient should place any belongings. Assist the patient if needed. Allow privacy if needed. 6. Assist the patient into the appropriate position for skin prep of the wound. Proceed with the steps for preparing skin for minor surgery and then drape the patient appropriately. Refer to Procedure 47–4 for preparing a patient’s skin for inoffice minor surgery. 7. Put on PPE and sterile gloves. Arrange the instruments and other sterile items in the order the provider will use them. Remove gloves and wash hands. Do not reach, cough, sneeze, wave, talk, or cross over the sterile field, or it can become contaminated. Carefully cover the sterile field with a sterile towel until the provider is ready to begin. 8. When the provider is ready to begin the suturing procedure, remove the sterile towel from the prepared sterile setup. Assist the provider by handing sterile gloves (if indicated) and Use an alcohol prep-pad to wipe the top of the anesthetic vial and hold it for the provider to draw out the amount needed. assist with drawing up anesthesia as needed. 9. If you assist with the suturing procedure, wash hands and put on sterile gloves. Hand instruments and other sterile items to the provider as needed; absorb excessive blood from the wound with sterile gauze as needed. Assist the provider by clipping each individual suture as directed by the provider. 10. When the wound has been closed with sutures, assist with (or perform) cleaning and bandaging the site per the provider’s orders. When bandaging is done, remove and properly dispose of gloves and wash hands. If cleaning and bandaging the site, you might need to reglove to keep from soiling the dressing and bandage. Some individuals are allergic to adhesive; hypoallergenic tape is then preferred. 11. Administer appropriate tetanus vaccine if ordered by provider. If administered, ensure that this is documented in the patient’s chart as part of the entry. 12. Tend to the patient’s needs and comfort. Assist with sitting up, getting dressed, and helping from the treatment table as needed. Allow the patient sufficient time to regain balance before standing alone because dizziness can occur. 13. Give the patient postoperative instructions. Instruct the patient in the care of sutures and provide a return appointment for their removal. 14. Document the procedure in the patient’s chart. 15. Put on gloves and clean up the treatment area. Wash hands and restock treatment room. Clean up the treatment table, discard contaminated items in a biohazard bag and sharps container, rinse the instruments with cold water and place in detergent solution, remove gloves and PPE, and dispose of them in the biohazard bag.