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Chapter 18 Assisting with Minor Ofce Surgery 401
protect the area while healing occurs below it. Scarring is
more severe than with primary intention healing.
Healing by Tertiary Intention
A wound may be left open at rst if there is a possibility that it is already contaminated with microorganisms.
Closing it would only trap microorganisms, increasing
the likelihood of infection. Eventually, the open wound
lls in with granular tissue. There is considerable scarring.
Phases of Wound Healing
Wound healing occurs in three main stages. The length
of each phase may be different for different patients and
different types of incisions.
1. Phase I (inammatory, lag, or exudative phase). This
phase usually lasts from 1 to 4 days.
The body attempts to heal itself by increasing cir-
r
culation to the part and by beginning to repair or
reroute blood vessels that supply the tissues.
The increased circulation brings more white blood
r
cells to defend against pathogens.
Serum and red blood cells brought by the extra
r
blood form a glue-like brin, a type of protein that
works to block the wound.
As the brin dries, it pulls the edges of the wound
r
closer together and forms a scab.
Signs that this phase is working include the following:
Edema, or swelling from the tissue uid
r
Warmth from the extra blood
r
Redness from the vasodilation
r
Pain from the pressure on the nerve endings caused
r
by the edema
2. Phase II (proliferative, healing, or granulation phase).
This phase may last from several days to several
weeks.
The blood vessels continue to repair themselves. If
r
the damage is severe, they may reroute.
The scab from phase I continues to dry and pull
r
the edges of the wound closely together.
3. Phase III (remodeling, maturation, or scarring phase).
This phase may take from weeks to years, depending
on how severe the wound is.
Patient Education Postoperative
Instructions
After any surgical procedure, the patient should
receive written and verbal instructions. They
should include information about:
Caring for the postoperative wound
r
Taking prescribed medications correctly
r
Returning to the ofce for follow-up visits,
r
dressing changes, and suture removal
Recognizing signs and symptoms of infection
r
Contacting the medical ofce if there are any
r
problems, including an after-hours number
The patient should be informed of the signs and
symptoms of infections. You need to make sure the
patient understands these warning signs:
Excessive bleeding from the wound
r
Throbbing pain, or tenderness in the wound area
r
Pus or watery discharge collecting under the
r
skin or draining from the wound
Drainage that is yellow, green, or foul smelling
r
A foul odor from the wound
r
Redness, red streaks, or excessive swelling
r
around the area
Tender lumps or swelling in the armpit, groin,
r
or neck
Chills or fever
r
Patients also should be on the lookout for
abnormal ushing of the skin, general pain or tenderness, heat in the area of the wound, and any
loss of function or mobility.
Tell the patient to call the medical ofce if these
symptoms occur. Also teach patients about how
to stop any excessive bleeding by applying direct
pressure or elevating the body area.
Patients who require follow-up care will need
additional information about several things.
Dressing and bandage changes. Tell the patient,
r
per the physician’s instructions, when to return
to the ofce to have dressings or bandages
changed, or how and when to change the dress-
ings and bandages at home.
Follow-up visits. Remind the patient to sched-
r
ule follow-up appointments before leaving and
provide a reminder card for each appointment.
Showering or bathing. After consulting with the
r
physician, tell the patient when she can take a
shower or bath. Advise the patient on whether
the surgical wound can get wet. This depends
on the location and depth of the wound and the
physician’s preference.
Laboratory results. If a specimen was taken for
r
analysis, tell the patient when the results will be
available and how he will be informed.
Patient concerns. Answer any questions about
r
postoperative experiences. Encourage the patient
to call the ofce at any time if there’s a problem.
It may be necessary to ask permission to bring
r
a caregiver into the room to hear these instruc-
tions, too. Some patients may not understand all
of the directions immediately after the procedure.
402 Section IV Clinical Medical Assistant Skills
Procedure 18-1 Performing a Surgical Scrub
P
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Y
Equipment: Sink, nail brush or orange stick, surgical
soap, and sterile towel.
1. Remove any rings, watches, or bracelets. Jewelry
provides hiding places for microbes. Don’t let your
clothing touch the sink.
2. Adjust the water to a comfortable temperature. If
it’s too hot, it can dry the skin, causing cracks and
breaks. If it’s too cold, the soap won’t lather properly.
3. Hold your arms at or higher than waist level.
(During surgical procedures, all areas below the
waist are considered contaminated.) Keep your
hands higher than your elbows. Otherwise, water
may run down from unscrubbed areas of your arms
and contaminate your hands.
4. Use an orange stick or nail brush to clean under
each nail. Then discard the orange stick taking care
not to touch the insides of the sink or the faucet.
5. Apply surgical soap and wash your hands thoroughly. Use a rm circular motion. Hold your ngers up and rub each side of each nger, between the
ngers, and the back and front of each hand. This
process should take about 5 minutes for each hand.
6. Keeping your hands higher than your elbows, wash
your wrists and forearms thoroughly with soap.
Rinse your arms and hands under running water
without touching the sides of the sink or faucet.
7. Using more surgical soap and a sterile brush, scrub
all the surfaces you just washed. As before, follow a
systematic approach. Begin with your ngers, then
scrub your hands, and nally your arms. Don’t
scrub too hard, as that could scratch your skin.
8. Discard the sterile brush and rinse your hands and
arms by passing them through the running water in
one direction—from the hand to the elbow. Remember
to keep your hands higher than your elbows.
9. Turn off the faucet using the foot or arm mechanism.
10. Dry your hands using a sterile towel. Using one end
of the towel, dry one hand, then the arm, then the
forearm. Use the other clean end of the towel to dry
the other hand, arm, and forearm. Avoid touching
your clean hands with the part of the towel that
comes into contact with your arms.
Procedure 18-2 Applying Sterile Gloves
To move sterile items or place them on the sterile eld,
you must use sterile gloves. Be sure to choose gloves that
are the right size for your hands. Follow these steps to
apply them.
Equipment: Sterile gloves.
1. Before you put on the gloves, remove any rings or
other jewelry. Rings may pierce the gloves and contaminate the procedure.
2. Wash your hands before applying gloves. Wearing
gloves isn’t a substitute for handwashing.
3. Place the glove package on a clean, dry, at surface.
The cuffed end of the glove should be facing you.
4. Pull the outer wrapping apart to expose the sterile,
inner wrap.
(Reprinted from Kronenberger J, Ledbetter J. Lippincott
Williams & Wilkins’ Comprehensive Medical Assisting.
5th ed. Philadelphia, PA: Wolters Kluwer; 2016.)
P
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Chapter 18 Assisting with Minor Ofce Surgery 403
Procedure 18-2 Applying Sterile Gloves (continued )
5. With the cuffs toward you, fold back the inner
wrap to expose the gloves.
(Reprinted from Kronenberger J, Ledbetter J.
Lippincott Williams & Wilkins’ Comprehensive
Medical Assisting. 5th ed. Philadelphia, PA: Wolters
(Reprinted from Kronenberger J, Ledbetter J.
Lippincott Williams & Wilkins’ Comprehensive
Medical Assisting. 5th ed. Philadelphia, PA: Wolters
Kluwer; 2016.)
6. Grasping the edges of the outer paper, open the
package out to its fullest. Remember that the inner
surface of the package is a sterile eld.
Kluwer; 2016.)
8. Curl your ngers and thumb together and insert
them into the glove. This prevents you from accidentally touching the outside surface of the glove.
Straighten your ngers and pull the glove on with
your nondominant hand still grasping the cuff.
9. Unfold the cuff by pinching the inside surface that
will be against your wrist and pulling it toward
your wrist. Only the unsterile portions of the glove
will be touched by your hands.
(Reprinted from Kronenberger J, Ledbetter J.
Lippincott Williams & Wilkins’ Comprehensive
Medical Assisting. 5th ed. Philadelphia, PA: Wolters
Kluwer; 2016.)
7. Using your nondominant hand, pick up the dominant hand glove by grasping the folded edge of the
cuff. Lift it up and away from the paper to avoid
brushing an unsterile surface. (The folded edge of
the cuff is contaminated as soon as it is touched
with the ungloved hand.) Be very careful not to
touch the outside surface of the sterile glove with
your ungloved hand.
10. Place the ngers of your gloved hand under the cuff of
the remaining glove. Lift the glove up and away from
the wrapper to prevent it from touching an unsterile
surface. Slide your ungloved hand carefully into the
glove with your ngers and thumb curled together.
(Reprinted from Kronenberger J, Ledbetter J.
Lippincott Williams & Wilkins’ Comprehensive
Medical Assisting. 5th ed. Philadelphia, PA: Wolters
Kluwer; 2016.)
404 Section IV Clinical Medical Assistant Skills
Procedure 18-2 Applying Sterile Gloves (continued )
11. Straighten your ngers and pull the glove up and
over your wrist by carefully unfolding the glove.
Folding the cuffs out to their fullest allows the
greatest area of sterility.
(Reprinted from Kronenberger J, Ledbetter J.
Lippincott Williams & Wilkins’ Comprehensive
Medical Assisting. 5th ed. Philadelphia, PA: Wolters
Kluwer; 2016.)
Procedure 18-3
Wrapping Instruments for
Sterilization in an Autoclave
12. Settle the gloves comfortably onto your ngers by
lacing your ngers together and adjusting the tension over your hands. The gloves should t snugly
without wrinkles or areas that bind the ngers.
(Reprinted from Kronenberger J, Ledbetter J.
Lippincott Williams & Wilkins’ Comprehensive
Medical Assisting. 5th ed. Philadelphia, PA: Wolters
Kluwer; 2016.)
P
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Y
Equipment: Gloves, autoclave wrapping material, autoclave tape, sterilization indicators, black or blue ink pen,
and instruments for autoclave.
1. First, wash your hands and put on nonsterile gloves.
2. Check the instruments being wrapped to be sure
they’ve been sanitized and disinfected and are
dry. Also check that they’re in working order.
Instruments that are defective, broken, or in need
of repair, sanitization, or disinfection shouldn’t be
wrapped or autoclaved.
3. Autoclave wrap may be double layers of cotton
muslin, special paper, or appropriately sized instrument pouches. The wrapping material needs to
have these properties:
Permeable to steam but not contaminants
r
Resists tearing and puncturing during normal
r
handling
Allows for easy opening to prevent contamina-
r
tion of the contents
Maintains the sterility of the contents during
r
storage
4. Tear off one piece of autoclave tape. Write the date,
your initials, and the contents of the pack or the
name of the instrument that will be wrapped. (After
the item is wrapped, you cannot see what is inside.)
The date is necessary so it can be determined later
if the contents are still considered sterile.
5. Lay the wrapping material diagonally on a at,
clean, dry surface. Place the instrument in the center of the wrapping material.
Ratchets or handles should be open to allow
r
steam to penetrate all surfaces.
Include a sterilization indicator.
r
(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 405
Procedure 18-3
Wrapping Instruments for Sterilization
in an Autoclave
6. Fold the ap at the bottom of the diagonal wrap
up. Fold back the corner to make a tab. The tab
allows the pack to be opened easily without contaminating the contents.
(Reprinted from Kronenberger J, Ledbetter J. Lippincott
Williams & Wilkins’ Comprehensive Medical Assisting.
5th ed. Philadelphia, PA: Wolters Kluwer; 2016.)
7. Fold the left corner of the wrap in to the center.
Again, fold back the corner to make a tab. Do the
same for the right corner of the wrap.
(continued )
8. Fold the top corner down, tucking the tab under
the material.
9. Secure the wrapped instrument package with the
labeled autoclave tape.
(Reprinted from Kronenberger J, Ledbetter J.
Lippincott Williams & Wilkins’ Comprehensive
Medical Assisting. 5thed. Philadelphia, PA: Wolters
Kluwer; 2016.)
(Reprinted from Kronenberger J, Ledbetter J.
Lippincott Williams & Wilkins’ Comprehensive
Medical Assisting. 5th ed. Philadelphia, PA: Wolters
Kluwer; 2016.)
Procedure 18-4 Operating an Autoclave
Equipment: Autoclave, distilled water, autoclave operating manual, and items wrapped for autoclaving.
1. Gather equipment and supplies.
Some medical ofces will want you to include
r
a separate, wrapped sterilization indicator with
the autoclave load.
This allows you to check that the procedure was
r
performed properly without opening a sterilized
pack.
2. Check the water level in the autoclave reservoir.
Add more distilled water if necessary.
3. Add water to the internal chamber of the autoclave.
Make sure the water level is at the ll line.
Too little water means not enough steam will be
r
produced.
Too much water can cause saturated steam,
r
which extends drying time.
P
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406 Section IV Clinical Medical Assistant Skills
Procedure 18-4 Operating an Autoclave (continued )
4. Load the autoclave, following these guidelines:
Place trays and packs on their sides, 1 to 3 inches
r
apart. Air cannot circulate if items are too tightly
packed. Placing them vertically stops air from
pooling in containers.
Put containers on their sides with lids off.
r
Removing lids and placing containers on their
sides improve air circulation.
In mixed loads, place hard objects on the bot-
r
tom shelf and softer packs on the top racks.
Otherwise, hard objects may form condensation,
which can drip onto softer items.
(Reprinted from Kronenberger J, Ledbetter J.
Lippincott Williams & Wilkins’ Comprehensive
Medical Assisting. 5th ed. Philadelphia, PA: Wolters
Kluwer; 2016.)
5. Read the instructions for closing and operating
the machine. Most machines require similar procedures, such as in the list below.
Close the door and secure or lock it.
r
Turn on the machine.
r
When the temperature gauge reaches the required
r
level (usually 250°F), set the timer. Many autoclaves can be programmed for the required time.
When the timer indicates the cycle is over, vent
r
the chamber.
After releasing the pressure to a safe level, crack
r
the door of the autoclave slightly to allow additional drying. Most loads dry in 5 to 20 minutes.
Hard items dry faster than soft ones.
6. When the load has cooled, remove the items. Check
the sterilization indicator, if one was included in the
autoclave or in each pack.
If the indicator registers that the load or pack
r
was properly processed, the items are considered
sterile.
If not, the items are considered unsterile. They
r
must be rewrapped and processed again.
7. Store the items in a clean, dry, dust-free area for 30
days. After 30 days, reprocessing is necessary. The
pack must be rewrapped, taped with new tape with
the current date, and autoclaved again.
8. Clean the autoclave according to the manufacturer’s directions.
Typically, cleaning involves scrubbing the interior chamber with a soft brush and mild detergent.
Pay attention to the exhaust valve. It can become
r
blocked with lint accumulation.
Rinse the machine thoroughly and allow it to
r
dry.
Record your maintenance procedures and the
r
date they were performed in the maintenance
and quality control logs.
Procedure 18-5 Performing Chemical Sterilization
Equipment: The sterilization chemical, the safety data
sheet (SDS) for the sterilization chemical, personal protective equipment (PPE), heavy-duty utility gloves, a
stainless steel or glass container with airtight cover, sterile water, a sterile basin, sterile transfer forceps, sterile
towels, and the items to be sterilized.
1. Gather equipment and materials.
2. Put on disposable gloves, goggles, and other PPE.
You need to protect your eyes, clothing, and
exposed skin from possible harmful chemicals.
3. Scrub and sanitize the items to be sterilized to
remove debris and body uids.
4. Rinse and dry the items. They must be dry when
placed in the chemical sterilization solution in
order to avoid diluting the solution.
5. Check the expiration date on the container of the
sterilization chemical. If the chemical is used past
its expiration date, it may not be as effective.
P
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Chapter 18 Assisting with Minor Ofce Surgery 407
Procedure 18-5
Performing Chemical Sterilization
(continued )
6. Read the manufacturer’s instructions on the container of the sterilization chemical and review the
SDS for the chemical being used. This step minimizes the risk of injury from mishandling of the
chemical and provides rst-aid information should
an accident occur.
7. Put on the heavy-duty utility gloves over the disposable PPE gloves. These gloves will protect your
disposable gloves from punctures by sharp instruments and exposure to harsh chemicals that might
damage your skin.
8. Mix or prepare the solution according to the manufacturer’s directions on the label. This will ensure
that the solution used is the correct strength.
9. Pour the solution into a glass or stainless steel
container with an airtight lid. The solution should
be left covered in order to avoid loss of potency
through evaporation or injury from splashes or
inhalation of fumes.
10. Carefully place the dry sanitized items into the container in order to avoid splashing, making sure they
are completely covered by the solution. Replace the
container’s airtight lid.
12. Leave the items in the solution for the required
time. This may be from 20 minutes to 3 hours or
more, depending on the chemical being used. Do
not open the container or add more items during
this time.
13. After the recommended processing time has
expired, open the container and remove each item
from the solution using sterile transfer forceps.
With the sterile forceps, hold the item over a sterile
basin and pour large amounts of sterile water over
and through it. This will remove all traces of the
chemical solution from the item.
14. Continue to hold the item over the sterile basin for
a moment to allow the excess water to drain off.
Then place the item on a sterile towel.
15. After all the items have been removed from the
container, rinsed, and transferred onto sterile towels, dry them with another sterile towel. Take care
to avoid touching the instruments or the side of the
towel being used to dry them.
16. Use the sterile transfer forceps to place the items
in storage for future use according to your ofce
procedures.
11. Label the lid with the name of the chemical, the
date and time, and the length of time required for
sterilization.
Note: Change the solution in the sterilization container every day or according to the manufacturer’s
instructions.
Procedure 18-6 Opening Sterile Packs
Equipment: Sterile surgical pack, Mayo or surgical
stand, and sterile drape.
1. Verify the procedure to be performed and remove
the appropriate surgical pack (tray or item) from
the storage area. Check the label for the contents
and expiration date. Packs that are past the expiration date should not be used.
2. Check the package for tears, stains, and moisture,
which would suggest contamination.
3. Place the package, with the label facing up, on a
clean, dry, at surface, such as a Mayo or surgical
stand. Although the eld will be protected by the
barrier below it, using a clean surface keeps microorganisms to a minimum. The surgical stand makes
it easy to move the eld as needed.
4. Wash your hands. Carefully remove the sealing
tape. Take care not to tear the wrapper. For commercial packages, carefully remove the outer wrapper. Many disposable packages are wrapped in
clear plastic lm that will become the sterile eld
when properly opened.
P
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408 Section IV Clinical Medical Assistant Skills
Procedure 18-6 Opening Sterile Packs (continued )
5. Loosen the rst ap of the folded wrapper by pulling it up, out, and away from you. Let it fall over
the far side of the table or stand. Then you will not
need to reach across the sterile eld again.
(Reprinted from Kronenberger J, Ledbetter J.
Lippincott Williams & Wilkins’ Comprehensive
Medical Assisting. 5th ed. Philadelphia, PA: Wolters
Kluwer; 2016.)
6. Open the side aps in a similar manner to minimize your movements over the sterile eld. Use
your left hand for the left ap and your right
hand for the right ap. Touch only the outer surface (which is not sterile). Do not touch the sterile
inner surface.
7. Grasp the outer surface of the remaining ap. Pull it
down and toward you. The outer surface of the wrapper should now be against the surgical stand. The
sterile inside of the wrapper forms the sterile eld.
(Reprinted from Kronenberger J, Ledbetter J.
Lippincott Williams & Wilkins’ Comprehensive
Medical Assisting. 5th ed. Philadelphia, PA: Wolters
Kluwer; 2016.)
8. Some packages have a second inside wrapper.
Repeat steps 5 to 7 to open the second wrapper. It
also will provide a sterile eld.
9. If you need to leave the area after opening the sterile eld, cover the tray and its contents with a sterile drape. Here is how.
Without leaving or turning your back on the
r
sterile area, open the sterile drape.
Carefully lift it out of the package by the edges.
r
Take care not to touch the drape to any surfaces.
Place the drape over the sterile eld working
r
from your body outward so that your arms do
not cross the uncovered sterile eld. Your arms
can cross the drape that is covering the tray.
(Reprinted from Kronenberger J, Ledbetter J.
Lippincott Williams & Wilkins’ Comprehensive
Medical Assisting. 5th ed. Philadelphia, PA: Wolters
Kluwer; 2016.)
(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 409
Procedure 18-7 Using Sterile Transfer Forceps
P
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Y
Equipment: Sterile transfer forceps, sterile tray set up,
items to be transferred to sterile tray.
1. Sterile forceps often are stored in a container with
sterilization solution. When you need to use them,
slowly lift the forceps straight up and out of the
container. Do not touch the outside of the container
or the inside of the container above the level of the
solution. These areas are not considered sterile.
2. Hold the forceps with the tips down at all times.
This prevents contamination by preventing the
solution from running up toward the unsterile
handles and then down to the grasping blades and
tips. Keep the forceps above waist level to avoid
accidental or unnoticed contamination.
3. Use the forceps to pick up items to be transferred
onto the sterile eld. Drop the items carefully onto
the eld.
Do not let the forceps contact the sterile eld.
r
They may be moist from the soaking solution.
Drops of solution on the sterile eld could wick
microorganisms from below.
Transfer forceps that have been wrapped and
r
autoclaved may be placed with their tips on the
sterile eld and their handles extending beyond
the 1-inch border that is considered contaminated. This allows you to move objects easily
around the sterile eld.
4. When nished moving items, carefully place the
forceps back into the sterilization solution. The
solution keeps the tips of the forceps sterile for
(Reprinted from Kronenberger J, Ledbetter J. Lippincott
Williams & Wilkins’ Comprehensive Medical Assisting.
5th ed. Philadelphia, PA: Wolters Kluwer; 2016.)
future use. The solution should be changed at least
daily, or according to ofce policy.
Procedure 18-8 Adding Sterile Solution
Equipment: Sterile tray set up on sterile eld, sterile
bowl or cup, solution to pour in bowl.
1. Place a sterile bowl or cup on the sterile eld using
sterile transfer forceps. Identify the correct solution
by carefully reading the label. The label should be
checked three times to prevent errors. Check the label:
When taking the container from the shelf
r
Before pouring the solution
r
When returning the container to the shelf
r
2. Check the expiration date on the solution label.
Don’t use the solution if:
The solution is out of date
r
The label can’t be read
r
The solution appears abnormal
r
Out-of-date solutions may have changed chemically or
deteriorated. They are not considered sterile.
Sterile water and saline bottles must be dated
r
when opened.
If not used within 48 hours, they should be
r
discarded.
3. If you’re adding medication, such as lidocaine, to
the solution, show the medication label to the physician. This allows the contents to be veried.
4. Remove the cap or stopper on the bottle. Hold the
cap with your ngertips, with the opening facing
down to prevent contamination.
P
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410 Section IV Clinical Medical Assistant Skills
Procedure 18-8 Adding Sterile Solution (continued )
If you must put the cap down, place it on a
r
side table (not the sterile eld) with the open
end up.
If you’ll be pouring the entire contents of the bot-
r
tle into the sterile bowl or cup, you can discard
the cap.
Keep the bottle so you can note the amount
r
added to the eld and for charting later.
(Reprinted from Kronenberger J, Ledbetter J.
Lippincott Williams & Wilkins’ Comprehensive
Medical Assisting. 5th ed. Philadelphia, PA: Wolters
Kluwer; 2016.)
5. Grasp the container with the label against the palm
of your hand (known as palming the label). That
way, if solution runs down the side of the bottle, it
won’t obscure the label.
6. Pour a small amount of the solution into a separate
container or waste receptacle. The lip of the bottle
is considered contaminated. Pouring off this small
amount cleanses the lip.
7. Without reaching across the sterile eld, carefully
and slowly pour the desired amount of solution
into the sterile container.
Pouring slowly reduces the chances of splashing
r
and overlling.
Hold the bottle no more than 6 inches and no
r
<4 inches above the container. The bottle of solution should never touch the sterile container or
tray.
Solution poured too quickly from an improper
r
height may splash. Spilled solution may lead to
wicking of contaminants from the eld below.
8. After pouring the solution, recheck the label for
the contents and expiration date. Replace the cap
carefully, without touching the bottle rim with any
unsterile surface of the cap. This ensures the contents will remain sterile.
9. Return the solution to its proper storage area
or discard the container after checking the label
again.
(Reprinted from Kronenberger J, Ledbetter J.
Lippincott Williams & Wilkins’ Comprehensive
Medical Assisting. 5th ed. Philadelphia, PA: Wolters
Kluwer; 2016.)