Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5519_Библиотеки_им_академика_М_И_Перельмана.pdf
Chapter 18 Assisting with Minor Ofce Surgery 391
The medical assistant is not responsible for informing
the patient, but often acts as a witness.
Answering the Patient’s Questions
Although the physician is responsible for obtaining
informed consent, the patient may ask you questions
about the procedure—for example:
How long will it take?
r
What preparations are needed?
r
Is fasting necessary?
r
You may answer these questions after verifying the
information with the physician.
Prior to the day of surgery, the patient may be given
instructions about how to prepare for surgery. The physician may prescribe medication for the patient to take
at home before the procedure. It is good practice to give
the patient written instructions to take home.
You need to notify the physician if the patient seems
confused or does not understand the instructions.
Encourage the patient to call the ofce if he thinks of
questions later. Of course, the instructions should be
documented in the patient’s medical record.
Positioning the Patient
Before positioning the patient for a minor surgical procedure, ask the patient to void, or urinate, to help prevent discomfort during the procedure.
Here are some other ways you can make the patient
more comfortable.
Offer to help the patient remove whatever clothing is
r
necessary to expose the operative site.
Provide the patient with extra sheets or a blanket. If
r
the ofce is air conditioned, it may be uncomfortably
cool for the patient’s exposed skin.
Help the patient into a comfortable position on the
r
examining table. While waiting for the physician,
there is no need for the patient to stay in an uncomfortable position, such as the lithotomy or the kneechest position.
Fenestrated drapes have an opening to expose the
operative site while covering other areas. They also
come in various sizes. Small fenestrated drapes may
be used for procedures such as inserting sutures. Large
fenestrated drapes might be used to cover the legs and
lower abdomen while exposing the perineal area—the
area between the anus and the genital organs.
Some sterile drapes are combined with adhesivebacked clear plastic. The plastic sticks to the patient’s
skin and eliminates the need for towel clamps.
Draping the Patient
After the surgical scrub has been done, follow these
steps for draping a patient with a sterile drape:
1. Pick up the drape on the 1-inch border that’s consid-
ered nonsterile. No gloves are needed.
2. Lift the drape over the surgical area without contam-
inating the drape.
3. Place the drape on the patient from his side farthest
away to closest. This way you will not have to reach
over the drape after you’ve placed it on the patient.
See Figure 18-19.
To remove contaminated drapes from the patient
after the procedure, put on clean examination gloves.
You need to follow standard precautions when removing soiled sheets, towels, or drapes after minor surgery.
They could be contaminated with blood or body uids.
Carefully roll the items away from your body, keeping
the contaminated edges inside. By surrounding the dirtier areas of the drape with the cleaner areas, your clothing is less likely to be contaminated.
Preparing Skin
Before surgery, you need to remove as many microbes
as possible from the patient’s skin in the operative area.
When the physician is ready to begin, help the patient
into a position that exposes the operative site and makes
it accessible to the physician. You may give the patient
pillows for support or comfort.
Types of Drapes
The procedure and the patient’s position determine the
type of drapes used to expose the operative site and
cover the patient. Disposable paper drapes are commonly used in the medical ofce. They come in many
sizes and shapes, depending on their specic use. Paper
drapes can be used alone or in combination with separate drape sheets and towels.
Figure 18-19 Applying a sterile drape.(Reprinted from
Kronenberger J, Ledbetter J. Lippincott Williams & Wilkins’
Comprehensive Medical Assisting. 5th ed. Philadelphia,
PA: Wolters Kluwer; 2016.)
392 Section IV Clinical Medical Assistant Skills
Preparing the skin decreases the chance of wound contamination and infection. Skin preparations may include
the following:
Applying antiseptic solution
r
Removing gross contaminants and hair
r
C
O
G
During minor surgery, your role will be to assist the physician as needed. You may be asked to hold supplies for
the physician, adjust the patient’s drapes, pass instruments to the physician, or help collect specimens. As
you become more experienced, you will nd it easier to
anticipate what is needed and have instruments and supplies ready before the physician asks for them.
ASSISTING WITH SURGERY
Local Anesthetics
A local anesthetic is a substance that numbs the operative area to minimize pain or discomfort to the patient.
Local anesthetic may be used occasionally if a wound
contains embedded debris. The anesthetic is injected in
the wound site to make the process of wound cleaning
more comfortable for the patient.
Many different kinds of anesthetics are used in the
medical ofce. A few examples are:
Administering Anesthetic: Method 2
In the second method, the physician draws the anesthetic. This method is used if the physician puts on sterile gloves before administering the anesthetic.
1. Include a sterile syringe and needle on the sterile eld
setup.
2. When the physician is ready to administer the anesthetic, show the physician the label on the vial. Then
clean the rubber stopper of the vial with an alcohol
swab.
3. You hold the vial while the physician draws the
required amount into the syringe.
There are many ways to hold the vial securely while
the physician draws the anesthetic. You and the physician will work together to develop a method that maintains surgical asepsis. See Figure 18-20 for the proper
method of holding a vial for the physician.
Passing Surgical Instruments and
Supplies
Passing instruments to the physician requires careful
attention. You must maintain the integrity of the sterile
eld throughout the procedure. Tell the physician immediately if there is any possibility that the sterile eld
Lidocaine (Xylocaine or Baylocaine)
r
Mepivacaine (Carbocaine)
r
Bupivacaine (Marcaine)
r
Sometimes, epinephrine is added to local anesthetics
to cause vasoconstriction (the narrowing of blood vessels). It slows the absorption of the anesthetic by the
body and lengthens its effectiveness. Epinephrine may
be used when the physician expects a long procedure.
But in some cases, vasoconstriction can damage body
tissues. Anesthesia with epinephrine should never be
used on the tips of ngers or toes, the nose, the ear, or
the penis.
There are two methods for administering local anesthesia. The method used will depend on when the physician plans to administer the anesthesia.
Administering Anesthetic: Method 1
In the rst method, you will draw the anesthetic as the
physician’s assistant.
When you draw the anesthetic for the physician into
r
a syringe, it is important to keep the vial beside the
syringe for the physician’s approval.
When you draw the anesthetic, the outside of the
r
syringe and needle unit are not sterile. The anesthetic
is given to the patient before the physician puts on
sterile gloves.
Figure 18-20 Hold the vial containing the anesthetic
downward, supporting that wrist with the other hand.
(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 393
has been contaminated. Here are some tips for passing
instruments during minor surgery:
Watch the procedure closely so you can anticipate
r
the physician’s needs. For example, if the physician is
making an incision, have sterile sponges ready to soak
up any blood.
The physician may ask for an instrument verbally or
r
show you what is needed with her hands. After you
have worked together for a while, you will learn what
the physician is likely to ask for during different parts
of the procedure.
When passing an instrument to the physician, grip the
r
instrument rmly by its tips. Hold blades or sharp
edges down for safety. The handle end should be
directed toward the physician.
Place the instrument gently but rmly into the physi-
r
cian’s palm or ngers.
Wait until you feel the physician grasp the instrument
r
before you let go. You do not want the instrument to
drop onto the oor—or onto the patient.
Wound Closure
Figure 18-21 Suture material and needles are supplied
in see-through packages with the size of the suture
material and the type of needle listed on the packet.
The inside of the packet is sterile. (Reprinted from
Kronenberger J, Ledbetter J. Lippincott Williams & Wilkins’
Comprehensive Medical Assisting. 5th ed. Philadelphia,
PA: Wolters Kluwer; 2016.)
Many types of wounds need to be closed in order to heal
rapidly, with minimal scarring. This is accomplished by
approximation, or bringing the edges of the wound
as close together as possible to their original position.
There are several methods and materials for closing
wounds. The most common ones are:
Sutures
r
Adhesives
r
Staples
r
Sutures
Sutures are sterile, surgical materials for connecting
wounds and tissues. See examples in Figure 18-21.
Sometimes, incisions are necessary to bring tissue lay-
ers into close approximation. Sutures are inserted:
To bring tissues together after the removal of a cyst
r
or tissue sample
To close lacerations
r
To help skin surfaces heal
r
Some sutures are absorbed by the body, while others
must be removed. In the medical ofce, suturing is the
most common method for closing wounds.
In some cases, the physician may want them replaced
or removed if they become soiled with drainage. Strips
should not be pulled away from the wound. Tension on
the wound site may disrupt the healing process.
Staples
Skin staples are sometimes used to close large incisions
over areas where dehiscence can occur. Dehiscence is
the separation of wound edges.
Sterile skin staples are commonly made of stainless
steel. Areas where staples might be used include the
knee, hip, or abdomen. Specialized staples made of sterling silver may be used in neurosurgery. Staples usually
are not inserted in the medical ofce. They are removed
when the wound is completely healed.
Suture Needles
The supplies used for suturing are needles and suture
materials. There are several kinds of suture needles.
Needles used for minor ofce surgery will depend on
the type of surgery being performed.
Needles are classied in these ways: by shape, by
point, or by eye.
Adhesives
Adhesive skin closures may be used to approximate the
edges of a small wound if sutures are not needed. Strips
are placed transversely across the line of the wound. In
most cases, the strips are left in place until they fall off.
Examples are shown in Figure 18-22A, B.
Classied by Shape
Needles may be curved or straight. Curved needles usually are clamped in a needle holder before being handed
to or used by the physician. Straight needles are not
clamped in a needle holder. They are handed to the physician with the point up. Straight needles rarely are used
in medical ofces.
394 Section IV Clinical Medical Assistant Skills
Figure 18-22 Adhesive skin closures. A. These lightweight lengths of porous tape are used for closing small wounds.
B. Strips are placed transversely across a wound. (Reprinted from Kronenberger J, Ledbetter J. Lippincott Williams &
Wilkins’ Comprehensive Medical Assisting. 5th ed. Philadelphia, PA: Wolters Kluwer; 2016.)
Classied by Point
Needle points are cutting, or round, and tapered. Cutting
needles have sharp edges and are used to cut through
tough tissues, such as skin. Straight cutting needles are
called Keith needles. Noncutting tapered or round needles are used on subcutaneous tissue. Subcutaneous tissue is located below the skin. They also may be used on
muscle or on the peritoneum, a thin membrane lining
the body cavity and covering some organs.
Classied by Eye
Traumatic needles have an eye and can be threaded with
any length of suture material. Atraumatic needles are
eyeless and come with a specic length of suture thread
attached. Atraumatic needles are also called swaged needles because the suture material is swaged, or fused, to
the needle in the manufacturing process.
Atraumatic needles cause less damage than traumatic
needles when they pass through body tissues. Needles
with eyes have a double thickness of suture where the
suture passes through the eye. This double thickness
makes a larger opening when pulled through tissues,
compared to the single thickness of suture in eyeless
needles.
Choosing a Needle
The physician usually selects the suture and the needle.
In medical ofces, curved swaged needles are used far
more often than any other type. Swaged needles are
selected based on the size and length of the suture material and the needle gauge. The needle gauge, or needle
diameter, is marked clearly on the packaging material.
When a suture must be threaded through an eyed needle, both the needle gauge and the suture size must be
selected.
Sutures, needles, and suture–needle combinations
come in peel-apart packages. The packages are sterile
on the inside. Sutures and needles can be added to the
sterile eld using sterile transfer forceps, a sterile gloved
hand, or by carefully ipping them onto the eld.
Types of Sutures
There are two main types of sutures: absorbable sutures
and nonabsorbable sutures.
Absorbable sutures are broken down by the body and
do not have to be removed. Here are some other useful
facts about these sutures.
These sutures are referred to commonly as catgut.
r
This suture material is made from the intestines of
sheep or cattle.
The two forms of absorbable gut suture are chro-
r
mic and plain. Chromic means the suture is chemically treated to delay absorption by the body. Plain
absorbable suture is not treated and is absorbed more
quickly.
Absorbable sutures are used most often in hospital
r
settings to hold deep tissue.
Nonabsorbable sutures either remain in the body permanently or are removed after healing.
They are made of natural bers such as silk or cotton;
synthetics such as nylon, Dacron, or polypropylene, or
stainless steel wire.
Nonabsorbable sutures come in many different
brands, lengths, sizes, and swaged needles, making them
very versatile.
Common Ofce Surgical Procedures
Two of the most frequently performed minor surgeries
in a general medical ofce are as follows:
Removing skin lesions
r
Draining abscesses
r
Chapter 18 Assisting with Minor Ofce Surgery 395
Biopsy (Bx), the removal of a tissue sample for diag-
nostic examination, is another procedure that’s commonly performed in some medical ofces. You must
follow standard precautions when you assist with any
of these procedures.
Excision of a Lesion
A lesion is a local area of diseased or abnormal tissue.
Some lesions that may be removed in a medical ofce
include the following:
Mole
r
Skin tag
r
Lentigine, a small, at, dark spot on the skin that
r
resembles a freckle
Keratosis, a horny growth, such as a wart or callus
r
To excise something is to cut it out. Physicians use
several techniques to excise lesions or remove them in
other ways.
Standard method refers to the process of excising the
r
lesion using a scalpel.
Electrosurgery is a process where high-frequency
r
electric current is used to excise the lesion or else
destroy it.
Laser surgery uses focused, intense beams of light to
r
penetrate and remove tissue.
Cryosurgery is a method that uses extreme cold to
r
either excise or destroy diseased or abnormal tissue.
Some lesions may be desiccated or fulgurated
(destroyed by drying up) by using electrosurgical or
cryosurgical methods. However, in many cases, samples
are sent to a pathology laboratory for diagnosis. If samples are required, the lesion is excised using one of the
above methods.
Physicians usually perform this procedure when a
patient’s Pap smear shows abnormal results, or when
the physician sees an abnormal area on the cervix during a routine examination.
Incision and Drainage
An incision and drainage (I&D) is performed to release
pus from an abscess. An abscess is a collection of pus that
has formed in a cavity surrounded by inamed tissue.
An abscess is the body’s response to an infection, when
pathogens have entered through a break in the skin.
Abscesses may be referred to as boils, furuncles (a single
lesion), or carbuncles (several lesions grouped closely
together). Abscesses are very painful for the patient. The
site of the abscess must be incised (cut into), and the
infected material drained before healing can take place.
Specimen Collection
Many minor ofce procedures yield specimens that
must be sent to a laboratory for examination. Specimens
include samples of tissue, foreign bodies, and samples of
wound exudate, or drainage. It is your job to choose a
proper container with an appropriate preservative for
the procedure being performed. The preservative helps
to prevent the sample from breaking down or decaying
before it can be examined.
The laboratory where the specimen is sent usually provides the appropriate containers with preservative. There
should be a stock of them on hand in the medical ofce.
You will need to assist the physician in collecting the specimen by holding the open container steady. The physician
must drop the specimen directly into the preservative without touching the sides of the container. See Figure 18-23.
You will be responsible for attaching a label to the
specimen. The label must contain the patient’s name and
Tissue Biopsy
Excision also can be used to remove tissue for biopsy.
The tissue is sent to the laboratory and examined under
a microscope to assist in diagnosis. Typically, only small
samples of tissue are needed for examination. When a
lesion is biopsied, however, the entire lesion is generally
excised for evaluation. In a punch biopsy, a small section is removed from the center of the abnormal tissue.
Although some biopsies are performed in a hospital,
skin biopsies can be performed in the medical ofce.
Cervical Biopsies
Another procedure that may be performed in the medical ofce is the cervical biopsy. This is a procedure in
which a small piece of tissue is removed from a female
patient’s cervix. The physician removes the tissue during a colposcopy—a visual examination of the cervix
using an instrument with a magnifying lens and a light
(colposcope).
Figure 18-23 Tissue samples are placed in the
preservative by the physician. (Reprinted from
Kronenberger J, Ledbetter J. Lippincott Williams & Wilkins’
Comprehensive Medical Assisting. 5th ed. Philadelphia,
PA: Wolters Kluwer; 2016.)
396 Section IV Clinical Medical Assistant Skills
the date. You will also need to complete a laboratory
request form to send with the specimen. Several pieces
of information must be included on the form:
The patient’s name, age, and gender
r
The patient’s identication number or social security
r
number
The date the specimen was taken
r
The type of specimen
r
The location the specimen was taken from
r
The type of examination requested
r
The physician’s name or laboratory contract number
r
Electrosurgery
Medical ofces often use electrosurgery to remove
moles, cysts, warts, and certain types of skin and cervical cancers. In electrosurgery, high-frequency alternating current is used to destroy or cut and remove tissue.
One advantage of this method is that the electricity seals
small bleeding vessels and reduces the blood and cell
uid lost in the process.
Electrosurgical units use disposable electrodes, or
devices that carry electricity. An example is shown in
Figure 18-24.
The tips on the electrodes have different shapes and
sizes depending on their use. Electrode tips include
blades, needles, loops, and balls. The following procedures are considered electrosurgery.
Fulguration destroys tissue with controlled elec-
r
tric sparks. The physician holds the electrode tip 1
to 2 mm from the operative site. A series of sparks
destroys supercial cells at the site.
Electrodesiccation dries and separates tissue with an
r
electric current. The electrode is placed directly on the
site.
Electrocautery causes quick coagulation or clotting of
r
small blood vessels with the heat created by electric
current. This process is also called electrocoagulation.
Electrosection is the incision or excision of tissue.
r
Bleeding is minimal with this type of procedure.
However, it may increase damage to the surrounding
tissues.
During electrosurgery, you are responsible for the
safety and comfort of the patient. You will need to hand
the electrode to the physician as needed. Always pass the
electrode with the tip pointing down.
Electrosurgery Safety
The physician will power on and operate the electrosurgical unit. However, you could cause injuries to the
patient, the physician, and yourself if you do not follow
proper procedures. Pay close attention to these safety
measures when assisting with electrosurgery.
Make sure all working parts are in good repair. The
r
electrical current is carefully regulated. If the machine
is defective, the patient might be seriously injured.
Make sure all metal is removed from the patient. You
r
also need to ensure the patient does not have any metal
implants or a cardiac pacemaker. Metal conducts electricity and can cause serious burns. Metal implants may
become very hot, and pacemakers can malfunction.
Be sure the patient is grounded with a pad supplied
r
by the manufacturer. Attach the pad to the patient at
a site recommended by the manufacturer. Some manufacturers advise placing the pad near the operative site.
Others recommend placing it far away. Know what
the recommendations are for the device in your ofce.
Improper placement of the pad can lead to injury.
Place the grounding pad rmly and completely
r
against the patient’s skin. With some pads, you must
apply a conducting gel to the pad and to the patient.
Adhesive-backed pads facilitate conduction through
the grounding pad. If areas of the skin under the pad
do not have good contact with the pad, hot spots may
occur. Hot spots can burn the patient.
Figure 18-24 A disposable electrosurgical unit. The
blade is designed either to cut or to cauterize. (Reprinted
from Kronenberger J, Ledbetter J. Lippincott Williams
& Wilkins’ Comprehensive Medical Assisting. 5th ed.
Philadelphia, PA: Wolters Kluwer; 2016.)
Maintaining the Electrosurgical Unit
Here are some hints to maintaining the electrosurgical
unit properly.
The electrode tips for the unit are usually disposable.
r
They should be discarded after use.
Some medical ofces may still use reusable electrode
r
tips. These should be disinfected and processed in the
autoclave according to the manufacturer’s directions.
Reusable tips must be polished with steel wool if they
become dull.
The surfaces of the electrosurgical unit should be kept
r
clean and dry.
Machines should be covered when not in use.
r
Electrosurgical machines must be inspected from time
r
to time to ensure they are working properly. Check
Chapter 18 Assisting with Minor Ofce Surgery 397
the operating manual for the regular maintenance to
be performed by ofce staff. It also will contain information about how often routine inspections should
be performed by trained technicians. A maintenance
log should be kept.
Laser Surgery
Lasers also can be used to cut tissue and coagulate small
bleeding vessels. Lasers are devices that focus high-intensity light in a narrow beam to create extreme heat and
energy. Light from a laser usually is not visible. Colored
lters illuminate the laser’s target. This allows the physician to direct the laser beam to the surgical area.
There are many types of lasers, each with a specic
medical use. The most common types of lasers used in
the medical ofce are the:
Argon laser, used for coagulation
r
Carbon dioxide laser, used for cutting tissue
r
Nd:YAG, used for coagulation and to separate warts
r
and moles from surrounding tissues
You need to pay special attention when caring for
and handling the laser. It is important to read and follow the maintenance schedules and procedures in the
instruction manual. It is recommended that health care
workers complete a training program before assisting
with laser procedures. During a laser procedure, everyone in the room must wear goggles to protect their
eyes—including the patient.
C
O
G
The medical assistant has several other important
responsibilities once the surgery is complete.
r
r
r
r
r
tions prior to releasing the patient from the ofce. The
instructions will help the patient remember what to do
once they are home and assist in avoiding any postoperative problems.
AFTER SURGICAL
PROCEDURES
Applying dressings and bandages to surgical wounds.
A dressing is a sterile material or cloth used to cover
a wound and stop bleeding. A bandage is a material
used to secure a dressing.
Instructing the patient about postoperative wound care.
This care includes observing the wound for changes
that indicate infection or other problems with healing.
Assisting with postoperative instructions such as prescriptions, medications, and scheduling return visits.
Removing and caring for instruments, equipment,
and supplies. You need to dispose properly of waste,
including disposable items, sharps, and contaminated
or unused supplies.
Preparing the room for the next patient.
Most ofces provide detailed written patient instruc-
Wound Care
Dry sterile dressings (DSD) and bandages protect
wounds during the healing process. Sterile dressings
have several purposes in wound care:
To protect the wound from contamination
r
To exert pressure on an open wound to control
r
bleeding
To absorb drainage such as blood, pus, or serum (a clear,
r
sticky part of blood that remains after coagulation)
To hold medications against the wound and facilitate
r
healing
To hide temporary disgurement
r
Bandages are strips of woven material typically used
with sterile dressings. The purposes of bandages are:
To hold dressings in place
r
To provide additional pressure to control bleeding
r
To provide protection from contamination
r
To keep an injured body part immobile during healing
r
To support an injured body part
r
To improve circulation
r
Sterile Dressings
A sterile dressing is considered contaminated if it is
damp or outdated, if the wrapper is damaged, or if it
has been improperly removed from the wrapper. Sterile
dressings are items such as 4 × 4-inch absorbent gauze
sponges and nonadhering dressings that are made for
use on open wounds. They typically are prepackaged in
small numbers. They come in various sizes and shapes,
each for a specic use. You will choose the dressing to
use based on the size of the wound and the amount of
drainage. You must use sterile technique when handling
dressings. A sterile dressing may be held in place by different kinds of bandages.
Changing Sterile Dressings
When you remove a sterile dressing or change an existing
one, always wear clean examination gloves. Observe the
wound carefully for any drainage or exudates. Note the
characteristics of the wound drainage in the patient’s chart.
It is normal to see serum or bloody drainage in small
or moderate amounts immediately following the closure of a wound. If you notice
is, drainage with a color other than pink—notify the
physician while the wound is still uncovered. The physician can then examine the wound and make a decision
about how well healing is progressing.
Wound Drainage
When observing wound drainage and documenting it in
the patient’s chart, be sure to note the color and amount
as described below.
purulent drainage—that
398 Section IV Clinical Medical Assistant Skills
Color
Serous drainage is clear.
r
Sanguineous drainage is blood tinged.
r
Serosanguineous drainage is pinkish, or a mixture of
r
clear and red.
Purulent drainage is white, green, or yellow tinged.
r
It’s usually accompanied by an unpleasant odor. This
type of drainage is a sign of infection.
Amount
Copious is a large amount.
r
Medium describes a moderate amount.
r
Scant refers to a small amount.
r
You also can quantify the amount by noting the size
of the drainage (e.g., 2-inch diameter, entire 4 × 4 dressing saturated) or the size of the dressing.
Types of Bandages
There are several different types of bandages, including
roller, elastic, or tubular gauze. A bandage may be used
to hold a sterile dressing in place. The type of bandage
used depends on the nature of the wound or injury.
Roller Bandages
These bandages are soft, woven materials packaged in a
roll. They are available in various lengths and widths, from
1 to 6 or more inches. The bandage size used depends on:
The part being bandaged
r
The desired thickness of the completed bandage
r
Most bandages are made of a porous, lightweight
material. Some may be sterile. Others are just clean. Gauze
bandages conform easily to body surfaces. Stretchy gauze
is made to adjust to body contours. It resists unrolling
much better than plain types of gauze. Kling and Conform
are two frequently used brands. Paper or surgical tape is
used to hold the ends of the bandage in place.
Elastic Bandages
These are special bandage rolls with elastic woven
through the fabric. They are generally brownish tan in
color. Unlike other types of roller gauze, elastic bandages
can be given to the patient to take home to be washed
and reused many times. Ace is one brand of elastic bandage that is widely available.
Elastic bandages should be applied without wrinkling
in partly overlapping layers. Some elastic bandages have
adhesive backing, which helps keep the layers in place
and provides a secure, snug, and comfortable t. Adjust
the bandage if it seems too loose or if the patient says it
is uncomfortable or tight.
You must take care in applying this type of bandage
because of the elastic bers. The bandage must be applied
snugly to give support to the injured part. But a bandage
that is too tight can slow or cut off blood circulation.
The bandage should be wrapped in the direction of
blood ow from the distal to proximal area of the limb.
Never stretch or pull on an elastic bandage during application because you might apply it too tightly.
Ask the patient how tight the bandage feels as it is
being applied. Instruct the patient on signs of impaired
circulation. The patient should check an extremity (a
limb such as an arm or leg) distal (farthest away) from
the bandage for these signs:
Increased swelling or pain
r
Pale skin
r
Cool skin when compared to the other extremity
r
Bluish coloring to toenails or ngernails
r
Most manufacturers of elastic bandages have removed
the separate metal clips that were used to hold the end
of the bandage in place. These small clips are dangerous if they are lost and swallowed by a small child. Use
paper or surgical tape to hold the bandage in place.
Tubular Gauze Bandages
Tubular gauze bandages are used to enclose rounded
body parts. The bandage looks like a hollow tube and
is very stretchy. These bandages come in various widths
from 5/8 to 7 inches. They can be used to enclose the
ngers, toes, arms, legs, and even the head and torso.
Tubular gauze is applied using a tubular, frame-like
applicator. The applicator is made of metal or plastic and
is available in various sizes. The size of the applicator
should be slightly larger than the body part to be covered. This allows the gauze to slide easily over the body
part. Applicators are marked according to a size number
that corresponds to different sizes of tubular gauze.
Applying Bandages
When properly applied, bandages should feel comfortably snug. They should be fastened securely enough to
remain in place until they are removed. Bandages may
be fastened using safety pins or adhesive tape.
Here are the basic techniques to use when wrapping
a gauze or elastic roller bandage.
Circular turn—This technique is used mainly to
r
anchor the bandage or to provide extra support. The
bandage is wrapped around the body part two or
more times, with each turn completely overlapping
the previous turn.
Spiral turn—After the circular turn anchors the ban-
r
dage, the wrapping continues in a spiral manner up
the body part. Each turn overlaps the previous one by
one-half to two-thirds the width of the bandage. The
spiral turn is a useful technique for bandaging parts
like the wrist, ngers, and trunk.
Reverse spiral turn—This wrapping technique also
r
begins with a circular turn. Then each time the bandage
Chapter 18 Assisting with Minor Ofce Surgery 399
is spiral wrapped around the limb, it is twisted once.
This method helps to t limbs like forearms or lower
legs that get larger as the bandaging continues.
Figure-eight turn—This technique involves making
r
slanting, overlapping turns that alternate moving up
and down the limb in a crisscross pattern that looks
like a gure eight. This is an effective method for bandaging joints, such as a knee, elbow, ankle, or wrist.
Steps for Applying Bandages
Here are some other important guidelines for applying
bandages:
1. Observe the principles of medical asepsis. Surgical
asepsis is not necessary. The bandage may be used to
cover a sterile dressing or may be used alone if there
is no open wound.
2. Keep the area to be bandaged and the bandage itself
dry and clean. Moisture could wick bacteria into the
wound. A moist bandage encourages the growth of
pathogens.
3. Never place a bandage directly over an open wound.
Apply a sterile dressing rst. The bandage should
extend approximately 1 to 2 inches beyond the edge
of the dressing.
4. Never allow the skin surfaces of two body parts to
touch each other under a bandage. Wound healing
can cause opposing surfaces to stick together. This
would lead to the formation of scar tissue. For example, burned ngers must be dressed separately then
bandaged together. A gauze pad can also be inserted
between digits before applying a bandage.
5. Pad joints and any bony prominences to help prevent
skin irritation. Without padding, the bandage may
rub against the skin over a bony area.
6. Bandage the affected body part in the normal position. Joints should be slightly exed to avoid muscle
strain, discomfort, or pain. Muscle spasms may occur
if the part is bandaged in an unnatural position.
7. Apply bandages by beginning at the distal part and
extending to the proximal part of the body. Bandage
turns that extend distal to proximal (farthest to nearest) help to return venous blood to the heart. They
also help to make the bandage more secure.
8. Always talk to the patient during bandaging. If the
patient complains that the bandage is too tight or too
loose, adjust the bandage. Instruct the patient to do
the same at home. The bandage should t snugly but
not too tightly.
9. When bandaging hands and feet, leave the ngers
and toes exposed whenever possible. Visible ngers
and toes make it easier to check for impaired circulation. If the skin feels or looks cold or pale, the nail
beds look cyanotic (bluish), or the patient complains
of swelling, numbness, or tingling in the toes and
ngers, remove the bandage immediately. Reapply it
correctly.
Study Skill
know why you are learning the skill and when you
will use it in the medical eld. Learning skills can
be fun if you use the method of learning that was
originally used for military training. It is the “See
one, do one, teach one method.” First you watch the
procedure being performed so you can see how it is
properly done. Then, you perform the procedure and
repeat the process until you thoroughly understand
how to correctly do the procedure and know the
sequence of steps that are used to complete the skill.
Now it is time for you to teach someone else how to
do the procedure. You act as the instructor, demonstrating to a fellow classmate how to do the skill. You
also answer any questions that student may have. If
you can successfully teach someone else, you have
mastered the procedure. Try writing procedures in
the form of writing a recipe. You will have an easier
time learning the proper sequence of steps.
Suture and Staple Removal
As a medical assistant, you may be the one who removes
sutures from a wound. Keep the following points in
mind if you are removing sutures.
Explain to the patient that it is normal to feel a pull-
r
ing sensation during suture removal, but there should
not be pain.
Cleanse the area with an antiseptic solution. Wear
r
sterile gloves or use sterile transfer forceps. Clean the
area using circular motions away from the wound or
in straight wipes away from the suture line. The wipe
should be discarded after each sweep. Use a new one
for the next sweep across the area.
Use a disposable suture removal kit or sterile reusable
r
equipment. See example in Figure 18-25.
Figure 18-25 A disposable suture removal kit.
(Reprinted from Kronenberger J, Ledbetter J. Lippincott
Williams & Wilkins’ Comprehensive Medical Assisting. 5th
ed. Philadelphia, PA: Wolters Kluwer; 2016.)
400 Section IV Clinical Medical Assistant Skills
Metal staples may be used to close some incisions
after hospital surgery. Patients often leave the hospital
before the staples can be removed safely. They return
later to the physician’s ofce to have the staples removed.
Frequently, it will be your responsibility to remove
staples. Most medical ofces use staple removal kits
that are similar to the kits supplied for suture removal.
Instead of suture scissors, the kit will include a special
instrument for removing staples.
Case Question
A
F
F
and bandage his arm. She instructs him that he
needs to return in 7 to 10 days to have the sutures
removed. He states that he will not be able to do
that since he is going to be working out of town
for some time. He then states that when he had
stitches put in for a previous injury, he just took
them out himself. How should the medical assis-
tant handle his response and this situation?
When the physician is nished suturing Mr. Barnes arm, Ms. Bridges, medical assistant, begins to apply a dressing
The Healing Process
How a wound heals can depend on the type of wound
and how it is treated. There are three classications
including primary, secondary, and tertiary intention. See
examples in Figure 18-26.
Healing by Primary Intention
Healing by primary intention is the simplest form of
healing. It occurs in wounds with edges that are closely
approximated. Little or no bacteria enter the wound to
complicate the healing process. Because the edges of the
wound lie close together, new cells form quickly to bind
the edges. Capillaries or tiny blood vessels grow across
the tissue break to restore circulation to the tissues.
Scarring is usually minimal.
Healing by Secondary Intention
In wounds where skin edges are not closely approximated,
the edges of the wound cannot join directly. Rough, pink tissue forms between the wound edges. This process is called
granulation. The tissue contains new cells and capillaries.
Nerves may not rejoin across the wound, which results in
decreased nerve stimulus in the area. A large scab forms to
process. Primary intention: the simplest
form of healing (A); Secondary intention:
the edges of the wound do not come
together, a scab forms and a more severe
scar remains (B); Tertiary intention: wound
is left open for healing, large scar results
(C). (Reprinted from Kronenberger J,
Ledbetter J. Lippincott Williams & Wilkins’
Comprehensive Medical Assisting. 5th ed.
Philadelphia, PA: Wolters Kluwer; 2016.)