Completing surgery and postoperative care

Completing the surgical procedure

At the conclusion of the procedure, the provider begins wound closure. The techniques and methods of tissue closure vary; all of them cannot be described or illustrated here. The two basic methods of suturing are the continuous running suture and the interrupted suture, where each knot is placed and tied one at a time, so that if one breaks, the others keep the wound closure intact. The interrupted technique is used for most skin closures in a medical office.

The provider may prefer that the medical assistant place the needle in a needle holder and pass it, handle first. When the wound is closed, you may assist by cutting the suture and sponging the site. If an interrupted suture method is used, the first suture is placed at the midpoint of the incision. Then each side of the first suture is mentally divided in half again, and the next two sutures are placed at each of these midpoints. The rest of the sutures are placed using the same technique until the wound edges have been completely approximated. The provider may also choose to close a wound with surgical staples.

After the skin closure, the blood and iodine should be gently removed and the area blotted dry using sterile dry sponges. Care must be taken not to disturb the wound edges or sutures. Next, a sterile dressing is placed over the incision, and a bandage is applied to support the dressing.

Postoperative responsibilities

After caring for the patient, the medical assistant clears the sterile field, following Standard Precautions. Wear gloves until all contaminated materials have been properly removed and handled. Place disposable equipment and supplies in biohazard waste containers or sharps containers. The room should be checked for any blood spills or other contamination and disinfected appropriately. After completing this process, remove the contaminated gloves and sanitize your hands.

Single-assistant preparation for minor surgery

1. Sanitize your hands and gather all supplies:
   • Sterile side (Mayo tray): Two towel packs, skin prep pack, patient drape pack, instrument pack, miscellaneous pack or packs, three glove packs, face shields, impermeable gowns
   • Non Sterile side (side counter): Syringes, suture material, anesthetic solutions, additional sponges, sterile dressings, bandages, transfer forceps, waste basin, sharps and biohazard waste containers, nonsterile gloves, face shields, and impermeable gowns
2. Verify that the informed consent has been signed and is in the patient’s health record.
3. Identify the patient, and escort him or her into the room.
4. Greet and converse with the patient.
5. Position the patient on the table.
6. Sanitize your hands.
7. Open the first towel pack.
8. Open the skin prep pack.
9. Pour the soap and antiseptic solutions.
10. Expose the site to be prepped.
11. Put on gloves and arrange prep items within the sterile field.
12. Place sterile towels at skin scrub boundaries using sterile technique.
13. Prep the patient’s skin.
14. Discard skin prep materials in appropriate sharps/biohazard containers.
15. Discard gloves: sanitize your hands, following the guidelines for a surgical hand scrub if this procedure is part of the policy of the provider or the facility.
16. Open the table drape pack on the Mayo stand to create a sterile field.
17. Open the instrument pack or packs and transfer the instruments to the sterile field. Add the sterile syringe unit.
18. Add sterile items as requested. The provider joins you and converses with the patient.
19. Open the provider’s glove pack (the provider now puts on gloves).
20. Open the patient drape pack (the provider now drapes the surgical site).
21. Cleanse and hold up the anesthetic vial for the provider to withdraw the anesthetic with the sterile syringe (the provider now administers the anesthetic).
22. Repeat the surgical hand wash; reglove with a new glove pack.
23. Arrange the sterile field instruments and other materials for safety and in sequence; check the condition of each instrument.
24. Open the suture/needle pack per the provider’s choice; load the first suture into the needle holder, grasping the needle in the third of the needle closest to where it joins the suture.
25. Place two gauze squares at the site.
26. Assist with the procedure:
    • For the provider: Pass the instruments, maintain the field, anticipate his or her needs, and cut sutures.
    • For the patient: Retract tissue, sponge blood from the wound, apply the sterile bandage, and care for the specimen.
27. Help the patient sit up and dress if needed, and monitor vital signs as instructed.
28. Record and prepare specimens.
29. Sanitize and disinfect the room; clear materials and discard in biohazard waste containers.
30. Document the procedure in the patient’s health record.
31. Help the patient prepare to leave the office.
32. Sanitize, disinfect, and sterilize the equipment at the first available time.

Wear gloves while disinfecting the room, including the table, Mayo stand, side and back tables, any other equipment in the room, and the floor. Used instruments must be sanitized, disinfected, and resterilized for future use.
The provider and the medical assistant both document the surgical procedure in the patient’s health record.

Postoperative instructions and care

The patient should be given time to rest after the surgery. If a sedative was administered, make sure the patient has recovered sufficiently to avoid injury after the surgery or during the trip home. If the patient was given a topical or local anesthetic, explain to him or her that the anesthesia effect will wear off and that some discomfort may be felt at the operative site. Check with the provider to determine if pain medication needs to be prescribed. If medication has been prescribed, review the purpose of the medication and the directions for its use with the patient and his or her companion. Make a follow-up appointment before the patient leaves the office.

Postoperative care extends for the total recovery period, not just for the time of immediate care before the patient leaves the office. Most medical assistants are responsible for teaching patients to care for themselves at home after surgery. A postoperative patient may have trouble comprehending or remembering instructions. All instructions should be given to the patient in writing. They should be simple and easily understood by both the patient and caregivers. These instructions can be preprinted forms for each type of surgery or a general form with checkboxes for particular post operative instructions that apply specifically to the individual patient.

Warning signs

Explain to the patient the importance of calling the office if any questions come up or changes occur that cause the person concern. If the patient does not call within the next 24 hours, you should call the patient. Many patients tend to “ride it out” or say they did not want to disturb you. Never allow the postoperative patient to leave the office without the provider’s knowledge and approval. Tell patients to call the office immediately if they note redness around the operative site, bleeding from the wound, fever, swelling, or increasing or severe pain. The wound should be kept clean and dry, and the patient should be taught how to change the dressing if needed.

Follow-up

If the healing process is long or the wound becomes infected, the patient may return for follow-up care. If the wound requires a new dressing, follow Standard Precautions; wear gloves and other protective barriers as appropriate. If at any time you determine that the wound may be infected, stop and have the provider examine it. Generally, no bandaging material should be reused, including elastic bandage wraps.

Tape applied directly to a patient’s skin is not a good dressing immobilizer. If tape is used, always keep it to a minimum. If tape is holding a dressing in place, always remove it by pulling toward the wound. If it is adhering to a hairy area of the body, lift the outer tape edge with one hand and slowly and gently separate the underlying hair and skin from the tape with the thumb of your other hand. Peel the skin from the bandage, not the bandage from the skin. Never rapidly rip tape from the body because this may injure the skin. If the tape is not irritating to the patient, it may be advisable to leave the tape in place until total healing has taken place.

When the wound has healed, the provider may ask the medical assistant to remove the patient’s sutures or staples. The patient must return to the facility to have the sutures/staples removed. When removing sutures or staples, it is important for medical assistants to alert the provider to any concerns they have with the wound healing and to document the procedure.