Assisting with Minor Surgery Lesson 4: Postoperative Patient Care 42
Lesson Objectives Upon completion of this lesson, students should be able to … • 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.
Elements of Postoperative Patient Care • Monitoring the patient during recovery from anesthesia • Wound care • Applying dressings • Communicating patient instructions
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
Areas to Observe on a Patient Recovering from Surgery Inability to recover in a normal timeframe should be reported 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 • Includes signs of inflammation, purulent or puslike drainage, fever • Hemorrhage or bleeding • Dehiscence • 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 pus-like 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
Cleansing a Wound • 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 – 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
Cleansing an Open Wound • Work in circles, half or full • Begin in the center and work outward
Dressings • Size and shape depends on the size, location, and amount of drainage from the wound • Sterile 4 × 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 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 6. Apply sterile gloves and cleanse the wound as needed. 5. Perform hand hygiene. Open suture or staple removal pack using proper technique. 4. Perform hand hygiene and remove old dressingusing proper technique. 3. Identify the patient, explain the procedure, and assist patient into a comfortable position. 2. Assemble equipment and check expiration date on pack. 1. Perform hand hygiene.
Steps to Removing Sutures 12. Count sutures to make sure that all have been removed. 11. Repeat these steps until all the sutures are removed. 10. Place the cut suture on the gauze. 9. Insert the suture scissors and cut suture at skin level. Pull out the sutures. 8. Grasp the knot of the suture with thumb forceps and lift gently. 7. Place a gauze square next to the wound for placement of sutures or staples as they are 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
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 Minor Surgical Procedures Performed in a Medical Office
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
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 taken by means of a curette or with a suction device to aspirate a specimen • 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 microorganism is causing the infection • The appropriate antibiotic can then be selected • The procedure is performed using sterile surgical technique
Tray Setup for an I&D • Scalpel handle and blades (No. 11) • Curved iris scissors • Tissue forceps • Kelly hemostat • Retractor • Thumb dressing forceps • 4 × 4 gauze squares
Foreign Bodies and Growths • Foreign bodies • Can include small to large objects • Growths • Include tumors, warts, moles, and cysts 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