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Chapter 18 Assisting with Minor Ofce Surgery 381
A
B
C
Figure 18-10 Scalpels. A. Scalpel handles. B. Surgical blades. C. Complete sterile disposable scalpel. (Courtesy of Sklar
Instruments, West Chester, PA.) (Reprinted from Kronenberger J, Ledbetter J. Lippincott Williams & Wilkins’ Comprehensive
Medical Assisting. 5th ed. Philadelphia, PA: Wolters Kluwer; 2016.)
packet and attach it to the scalpel handle. When you
are nished, you should use forceps to remove the used
blade to avoid injury. Scalpel blades removed from the
handle and disposable scalpels are discarded into a
sharps container.
Probes, Directors, and Retractors
Before performing a procedure, the physician may rst
explore a cavity or wound with surgical tools including
probes, directors, and retractors.
Probe
A probe is a thin, exible instrument that can help the
physician examine the angle and depth of the cavity or
wound. There are many different kinds of probes as
those shown in Figure 18-11.
The physician’s choice of probe depends on the area
being explored.
Director
The director guides the knife or instrument once a procedure has begun. In surgical incisions, the director helps
ensure correct depth and direction.
Retractor
Retractors are used to separate the edges of a wound
and to hold open layers of tissue. Their main purpose is
to expose areas beneath the surface tissues. Retractors
come in different sizes and shapes. They may be plain
or toothed. Toothed retractors may be sharp or blunt.
Some retractors are designed to be held by an assistant
during surgery. See Figure 18-12.
Self-retaining retractors can be screwed open and do
not need to be held manually.
Other Surgical Instruments
Various medical specialties require different kinds of
instruments for surgical procedures. Table 18-3 shows
some of these surgical instruments and explains the use
of each.
ABC
Figure 18-11 Probes. A. Director and tongue tie.
B.Double-ended probe. C. Probe with eye.(Courtesy
of Sklar Instruments, West Chester, PA.) (Reprinted from
Kronenberger J, Ledbetter J. Lippincott Williams & Wilkins’
Comprehensive Medical Assisting. 5th ed. Philadelphia,
PA: Wolters Kluwer; 2016.)
Care and Cleaning of Surgical
Instruments
Typically, the medical assistant is responsible for taking
good care of surgical instruments to help ensure that
they will function properly. Follow these guidelines to
keep surgical instruments in good working order.
Rinse instruments as soon as possible—Rinse instru-
r
ments right after minor surgical procedures to remove
obvious contamination. When substances, blood and
tissue, dry or harden on instruments, they are harder
to clean. Make sure you follow OSHA standards to
prevent contact with blood or body uids. This denitely includes wearing gloves.
382 Section IV Clinical Medical Assistant Skills
Figure 18-12 Retractors.
A.Volkman retractor.
B. Lahey retractor. C. Senn
retractor. (Courtesy of Sklar
Instruments, West Chester,
PA.) (Reprinted from
Kronenberger J, Ledbetter
J. Lippincott Williams &
Wilkins’ Comprehensive
Medical Assisting. 5th ed.
ABC
Philadelphia, PA: Wolters
Kluwer; 2016.)
Table 18-3
Medical Specialty Instruments Use
Dermatology (disorders of the
skin)
Obstetrics, gynecology (A) Graves vaginal speculum
Commonly Used Instruments and Equipment Listed by Medical Specialty
(A) Keyes cutaneous punch
(B) Schamberg comedone extractor
(B) Pederson vaginal speculum
(C) Duplay tenaculum forceps
(D) Schroeder tenaculum forceps
(E) Sims uterine sound
(F) Simpson uterine sound, malleable
(A sound is a long instrument for
exploring or dilating body cavities or
searching cavities for foreign bodies.)
(G) Hand uterine dilator
(H) Hegar uterine dilator
(I) Thomas uterine curettes, (J) Sims
uterine curettes
Remove a small circle of skin for microscopic study; available in different sizes
(2–8 mm); disposable or reusable
Remove blackheads or open pustules
Widen the vaginal opening to view vaginal walls and/or the cervical os, or opening; available in various sizes; reusable or
disposable plastic
Grasp and hold tissue with its hook-like tips
Explore and dilate the uterus to assess its
depth
Widen the cervical os, usually by 3–18 mm
Scrape endometrium (lining of uterus);
may be blunt or sharp
Chapter 18 Assisting with Minor Ofce Surgery 383
Commonly Used Instruments and Equipment Listed by
Table 18-3
Medical Specialty Instruments Use
Medical Specialty
(continued )
Ophthalmology (A) Desmarres lid retractor,
(B) Bailey foreign body remover
(C) Schiötz tonometer Measure intraocular pressure to diag-
Otology (disorders of the ear,
a subspecialty of otolaryngology); rhinology (disorders of
the nose, a subspecialty of
otolaryngology)
(A) Wilde ear forceps
(B) Lucae bayonet forceps
(C) Buck ear curet
(D) Vienna nasal speculum
Hold eyelids open for removal of foreign
bodies
nose glaucoma
Insert or remove materials from ear or
nose canal
Remove cerumen from deep ear canal
Opens, extends nostrils for visualization of
nasal passages
(continued )
384 Section IV Clinical Medical Assistant Skills
Table 18-3
Commonly Used Instruments and Equipment Listed by
Medical Specialty (continued )
Medical Specialty Instruments Use
Orthopedics (disorders of the
skeletal system, including the
bones, joints, and spine)
Proctology (disorders of the
colon, rectum, and anus)
(A) Oscillating plaster saw
(B) Stille plaster shears
(C) Hennig plaster spreader
(A) Ives rectal speculum
(B) Pratt rectal speculum
(C) Hirschman anoscope, proctoscopes
Sigmoidoscope
Punch biopsy
Alligator biopsy
Remove casts
Remove casts
Separates the edges of a cast that has
been cut
Visualize lower intestinal tract; most have
an obturator for ease of insertion. (An
obturator is a smooth, rounded, removable inner portion of a hollow tube that
allows for easier insertion.)
Visualize lower sigmoid colon; may be
rigid or exible and has a ber-optic light;
some have a suction device
Remove small, circular piece of tissue for
study
Grasp and excise tissue with jaws of
instrument
Chapter 18 Assisting with Minor Ofce Surgery 385
Table 18-3
Commonly Used Instruments and Equipment Listed by
Medical Specialty (continued )
Medical Specialty Instruments Use
Urology (disorders of the urinary system)
(A) Otis-Dittel urethral sound
(B) Dittel urethral sound
Prostate biopsy
Explore bladder depth and direction;
dilate urethral meatus (opening); comes
in different sizes (Fr 8–26)
Removes tissue for microscopic study
Images used with permission from Sklar Instruments.
Discard disposable instruments promptly—Disposable
r
scalpel blades should be removed from reusable handles
and placed in sharps waste containers. If a disposable
scalpel is used, the whole unit is placed in the sharps
container. Syringes with needles attached and suture
needles also must be discarded in the sharps container.
Sanitize instruments before they are sterilized—
r
Sterilization is more effective when instruments have
been cleaned of visible contamination.
Check instruments before sterilization—You need to
r
make sure instruments stay in good working order.
Watch for instruments in need of repair.
Checking Instruments
Surgical instruments should be checked carefully to make
sure they are working properly. Here is what to look for.
Blades or points should be free of bends and nicks.
r
Instrument tips should close evenly and tightly.
r
Instruments with box locks should move freely, but
r
should not be too loose.
Instruments with spring handles should have enough
r
tension to grasp objects tightly.
Scissors should close in a smooth, even manner with
r
no nicks or snags. Scissors may be checked by cutting
through gauze or cotton to be sure there are no rough
areas.
Reducing Damage to Surgical Instruments
Surgical instruments are delicate. You can help minimize
the chance of damage to instruments by following simple guidelines.
Use instruments appropriately. Only use instruments
r
for their specic purpose. For example, never use
surgical scissors to cut paper or open packages. This
could damage their cutting edges.
Don’t toss or drop instruments into a basin or sink.
r
Blades or tips are easily damaged. Keep delicate instruments, such as tissue forceps or scissors, separate.
Avoid stacking instruments in a pile. They may tangle
r
and be damaged when separated.
Always store sharp instruments separately. This helps
r
prevent dulling or damaging sharp edges. It also helps
prevent accidental injuries.
Keep ratcheted instruments open when not in use. That
r
way, the ratchet mechanism is less likely to be damaged.
Maintaining Surgical Equipment
You need to be familiar with the manufacturer’s recommendations for each instrument or piece of equipment.
Maintenance records should include any service provided by the manufacturer’s representative. There also
should be a place to record recommended or daily maintenance for keeping equipment in optimum working
386 Section IV Clinical Medical Assistant Skills
condition. Specic items in the maintenance record for
each piece of equipment include the following:
Date of purchase
r
Model and serial number of equipment
r
Time of recommended service
r
Date service was requested
r
Reason for the service request
r
Name of the person requesting the service
r
Description of the service performed and any parts
r
replaced
Name of the person performing the service and the
r
date the work was completed
Signature and title of the person who acknowledged
r
completion of the work
Warranties and guarantees should be kept with the
equipment records, along with the name of the manufacturer’s contact person. You need to know whom to
call if there’s a problem.
Maintaining Surgical Supplies
Clinical medical assistants need to keep an up-to-date
master list of all supplies, including purchases and
replacements. Parts and supplies that are vital to the
operation of the facility always should be kept on hand.
Check instruction manuals for each piece of equipment
when you order supplies for replacement or maintenance.
There are several factors to keep in mind when you
decide which items to keep in inventory:
Shelf life of the item
r
Storage space available
r
Time required to order and receive the item
r
If a piece of equipment cannot function without all
of its components and some of the components have
short lives, you need to have replacements on hand. For
example, an ophthalmoscope without a light is basically
useless.
Name or initials of the operator
r
Results of the sterilization indicator
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Expiration date of the load (usually 30 days)
r
C
O
G
One of your responsibilities may be to prepare the treatment or examination room and the supplies needed for
surgery. Many medical ofces keep a box with index
cards or a loose-leaf binder listing surgical procedures
commonly performed in the ofce. It will include the
items you will need to set up for the procedure.
surgery requires clean hands and careful technique to
avoid contaminating the items inside the sterile area.
GETTING READY FOR
SURGERY
Preparing the examination room and the supplies for
Case Question
A
F
F
tion of the suturing procedure to repair the laceration that Mr. Barnes has on his forearm?
What type of equipment, instruments,
and supplies will the medical assistant,
Ms. Bridges, need to gather in prepara-
Sterile Surgical Packs
Many of the basic supplies and equipment for a surgical
procedure may be packaged together in a sterile surgical pack. Surgical packs may be prepared in the medical ofce or purchased from a commercial supplier. An
example of a commercial pack is shown in Figure 18-13.
Storage and Records
Clean and sterile supplies must be kept away from
soiled items and waste. Sterile instruments, equipment,
and supplies are usually kept in specic storage areas in
the medical ofce. It is helpful if the storage area is near
the rooms where the supplies will be used. The storage
area should be kept neat and dust free.
Medical assistants are responsible for keeping accurate records of sterilized items and equipment. Typically,
these records are kept in a log. The records include
maintenance information about the equipment and load
or sterilization information, including the following:
Date and time of the sterilization cycle
r
General description of the load
r
Exposure time and temperature
r
Figure 18-13 A wrapped sterile surgical package.
(Reprinted from Kronenberger J, Ledbetter J. Lippincott
Williams & Wilkins’ Comprehensive Medical Assisting.
5th ed. Philadelphia, PA: Wolters Kluwer; 2016.)
Chapter 18 Assisting with Minor Ofce Surgery 387
Packs Prepared in the Medical Ofce
Sterile setups are wrapped in a suitable wrapper and
prepared in the ofce using autoclave sterilization.
Packs are labeled according to the type of procedure.
Each pack contains the general instruments needed
for the procedure. Some basic supplies, such as gauze,
cotton balls, and towels, also may be included before
autoclaving.
Disposable Surgical Packs
Disposable surgical packs are popular because they are
convenient and come with a variety of contents. They
may contain one sterile item, such as a 4 × 4 sterile
dressing, or a complete sterile surgical setup. Many are
packaged with peel-apart wrappers. These wrappers
have two loose aps that can be pulled apart. They are
designed to make it easy to drop the items carefully onto
the operative eld.
In some cases, the insides of the wrappers may be
opened out and used as a sterile eld. Some packages are
enclosed in plastic and wrapped inside a barrier material
that can be used as a sterile eld.
Opening Surgical Packs
Labels for packs prepared in the ofce may only state
the type of setup. However, labels on disposable sterile
packs list the contents item by item. Disposable packs
are generally more expensive than packages prepared in
the ofce, so it is important to check that you have the
right one for the procedure before you open it. You also
need to check the expiration date on the package. If the
pack has expired, don’t use it. It may not be sterile.
Once a sterile pack has been opened, the procedure
is similar whether the pack has been prepared commercially or in the ofce. Keep the following points in mind.
Use clean hands to open the sterile items or packages.
r
The outside surface of the outside wrapper is not
r
sterile.
Take care not to touch any sterile areas with your
r
hands or other surfaces. The sterile area includes the
inside surface of the outside wrapper, the inside wrapper (if any), and the contents of the package.
If any sterile area or item does contact another sur-
r
face, the pack is considered contaminated and must
be replaced.
Check the sterilization indicator inside the sterile
r
pack. It indicates whether the items inside the package have been sterilized properly.
Maintaining a Sterile Field
Even in minor surgery, it’s important to prevent pathogens from entering the patient’s body during the procedure. This requires that the surgical area or eld remains
sterile. Remember that “sterile to sterile is sterile,” and
“sterile to unknown is contaminated.” Here’s what to do
and what to avoid to maintain a sterile eld.
1. Always face a sterile eld. That way, you can be sure
it hasn’t been contaminated. If you need to turn your
back or leave the area, cover the eld with a sterile
drape. Make sure you use sterile techniques.
2. Hold all sterile items above waist level. When sterile
items aren’t where you can see them, you’ll have to
presume they’ve become contaminated.
3. Place sterile items in the middle of the sterile eld.
A 1-inch border around the eld is considered
contaminated.
4. Don’t spill any liquids, even sterile liquids, onto a
sterile eld. The surface below the eld isn’t sterile.
Moisture can be wicked up into the eld—along with
microorganisms.
5. Don’t cough, sneeze, or talk over the sterile eld.
Microbes from your respiratory tract can contaminate the eld.
6. Never reach over the sterile eld. Dust or lint from
your clothing might enter the sterile eld.
7. Don’t pass soiled supplies, such as gauze or instruments, over the sterile eld.
8. If you know or suspect the sterile eld has been
contaminated, alert the physician. Sterility must be
established before the procedure can continue.
Watch for Signs of Contamination
When you work with sterile surgical items, you need to
know when items are considered contaminated—even if
they have not been used. Contaminated items must be
repackaged and sterilized again if any of the following
situations occur.
Moisture is present on the pack. Microbes can be
r
drawn into the package in liquid absorbed through its
wrap. If a package sterilized in the medical ofce gets
moist, it must be repackaged in a clean, dry wrapper
and sterilized again. If a damp pack is disposable, it
must be discarded.
Items are dropped outside the sterile eld. If an item
r
touches a surface outside the sterile eld, it is considered contaminated.
Expired date. The date on the outside of the pack
r
should not be over 30 days old for packs prepared
in the ofce. Commercially prepared packs should
not be used after the expiration date listed on the
pack.
The wrapper is damaged or torn. Damaged or torn
r
wrappers could allow microbes into the package.
Items should be discarded or rewrapped and sterilized again.
When any area is known or thought to have been
r
touched by a contaminated item.
388 Section IV Clinical Medical Assistant Skills
Figure 18-14 Sterile transfer forceps may be used to
add or move items on the sterile eld.
Using Sterile Transfer Forceps
One way to move sterile items or place them on the
sterile eld is to use sterile transfer forceps. When using
sterile transfer forceps, the tips of the forceps and items
being moved must stay sterile. See Figure 18-14. The
handles of the forceps are considered medically aseptic, but not sterile, because they are touched by the bare
hands of the person using them.
Storing Sterile Transfer Forceps
Sterile transfer forceps can be stored in one of three
ways.
In a dry, sterile container. The forceps and the con-
r
tainer must be sanitized and autoclaved every day.
In a wrapped sterile package. The wrapping protects
r
the forceps from being exposed to microorganisms
and maintains sterility.
In a sterile solution in a closed container system. A
r
closed container helps to protect tips of forceps from
contamination. The forceps and the container must
be sterilized every day. Fresh solution must be added
daily.
Peel-Back Packages and Solutions
Sometimes, the sterile pack will contain all the supplies needed for a procedure, including gauze squares
or cotton balls. In other cases, additional supplies are
required.
Usually, small supplies are provided in commercially
prepared, peel-apart packages. These packages contain
small or single items to add to the sterile eld. The packaging is designed with two aps. The aps allow the
package to be opened without contaminating its sterile
contents as demonstrated in Figure 18-15.
To open the peel-pack package properly, you must
use both hands. Here is how.
Place your thumbs just inside the tops of the aps’
r
edges.
Separate the aps using a slow, outward motion of
r
the thumbs and aps.
Keep in mind that the inside of the sealed package
r
and its contents are sterile. When you open the pack,
nger and airborne droplets from talking or sneezing
can contaminate the pack rendering it unsterile.
Once the peel-back package is opened, there are three
ways to add its contents to the sterile eld.
Using sterile transfer forceps. Once the package is
r
opened, hold down the two edges. Lift the contents
up and away with sterile forceps as demonstrated in
Figure 18-16.
Figure 18-15 A. Open sterile packets by grasping the edges and rolling the thumbs outward. B. Opening the packet
properly forms a sterile eld. (Reprinted from Kronenberger J, Ledbetter J. Lippincott Williams & Wilkins’ Comprehensive
Medical Assisting. 5th ed. Philadelphia, PA: Wolters Kluwer; 2016.)
Figure 18-16 The physician may use sterile forceps
to remove small supplies from peel-back packages.
(Reprinted from Kronenberger J, Ledbetter J. Lippincott
Williams & Wilkins’ Comprehensive Medical Assisting. 5th
ed. Philadelphia, PA: Wolters Kluwer; 2016.)
Chapter 18 Assisting with Minor Ofce Surgery 389
the package edges down and away from the contents.
Carefully drop or ip item onto the middle of the sterile eld without touching the 1-inch border around
the edge of the sterile eld.
Most items in peel-back packages are disposable
items. This means they cannot be resterilized after being
opened. They must be discarded, even if they have not
been used. Because they are relatively expensive, sterile
packs of disposable items should not be opened until
they are needed. You might place a small supply near
the area where the procedure is being performed, to be
opened only if necessary.
Some additional small items and solutions used during the surgical procedure must be added to the sterile
eld at the time of setup. Some procedures may require
sterile water, saline, or an antiseptic solution such as
Betadine. Solutions need to be poured into sterile basins
or containers.
This process often requires two people—one to hold
r
the package open and the other to remove the contents with the sterile forceps.
Using a sterile gloved hand. This method requires two
r
people. The medical assistant opens the package and
holds the edges carefully to avoid touching the physician’s gloves. The physician uses a gloved hand to
remove the contents (Fig. 18-17).
Flipping the contents onto the sterile eld. To do this,
r
you need to step back from the sterile eld so that
your hands and the outer wrapper of the package,
which isn’t sterile, don’t cross the sterile eld. Pull
Figure 18-17 Sterile gloved hands may be used to
remove sterile items. (Reprinted from Kronenberger J,
Ledbetter J. Lippincott Williams & Wilkins’ Comprehensive
Medical Assisting. 5th ed. Philadelphia, PA: Wolters
Kluwer; 2016.)
C
O
G
PREPARING THE PATIENT
FOR SURGERY
As a clinical medical assistant, you will play an important role in preparing the patient before the physician
performs minor surgery. You may need to:
Help obtain the patient’s consent for the procedure
r
Answer questions about instructions to the patient
r
Position and drape the patient for the procedure
r
Prepare the patient’s skin
r
Cultural Connection
As we discover different cultures and beliefs, we
must examine some of the religions of the world
and the practices that need to be considered and
respected as we provide health care to the follow-
ers. The Sikh faith was established in India in the
1400s. It is the fth largest religion in the world.
A true follower of the Sikh religion believes that
body hair should be naturally preserved. When
providing medical care to a Sikh, it is important
to consult with the patient before cutting any hair
or shaving any part of the body. To a Sikh, uncut
hair represents spirituality. A Sikh may actually
refuse to have medical treatment if required to cut
or shave hair from the body. This is particularly
important if the patient needs to have a surgical
procedure that requires removing hair from the
body.
390 Section IV Clinical Medical Assistant Skills
Informed Consent
It is necessary to obtain informed consent from the
patient before performing a surgical procedure in the
medical ofce. An
ument that explains the course of treatment, including
the risks and benets to the patient. This form may be
signed on a visit prior to the day of surgery or on the day
of the surgery. The procedure cannot go ahead unless
the patient signs the form.
It’s the physician’s legal responsibility to give the patient
a full explanation of any surgical procedure. By signing the
informed consent form is a legal doc-
informed consent document, the patient agrees that she
has received this explanation. The document must state:
The procedure
r
The purpose of the procedure
r
The expected results of the procedure
r
Any possible side effects, risks, and complications
r
The form should have spaces for the date and signatures of the patient, physician, and witness or witnesses.
By signing the document, the patient voluntarily accepts
the risks involved and agrees to the procedure. See sample form in Figure 18-18.
Figure 18-18 Sample consent form. (Reprinted from Kronenberger J, Ledbetter J. Lippincott
Williams & Wilkins’ Comprehensive Medical Assisting. 5th ed. Philadelphia, PA: Wolters Kluwer;
2016.)