Lesson 29 — Surgical Procedure Assisting

1. Sanitize your hands. Collect and assemble already inspected, sanitized instruments to be wrapped. Gloves may be worn.
2. Place the double-ply autoclave paper on a clean, flat surface.
3. Place the instruments diagonally at the approximate center of the double-ply autoclave paper. Make sure the size of the square is large enough for the items.

   Purpose

   Each of the four corners must fold over and completely cover the instruments, with a few extra inches of overlap for folding.

4. Open any hinged instruments. If the instrument is sharp, its teeth or tip should be shielded with cotton or gauze.

   Purpose

   To prevent puncture of the package or injury to the operator.

5. Depending on clinic policy, a biologic sterilization indicator or sterilization strip should be placed in the center of the pack to check for sterilization standards.

   Purpose

   To ensure that the autoclave is reaching effective levels of heat and pressure to destroy all microorganisms.

6. Bring up the bottom corner of the wrap and fold back a portion of it.

   Purpose

   This folded-back flap is the only part of each wrapper corner that can be touched when a sterile package is opened.

7. Repeat the previous step with each corner, making sure to turn back a portion each time.
8. Fold the last flap over.
9. Secure with autoclave tape and label the package with the date, including the year, contents, and your initials.

   Purpose

   So that staff members will know what is in the pack, when it was autoclaved, and who performed the task.

10. Check the water level in the reservoir and add distilled water as necessary.

    Purpose

    Too much or too little water may alter the effectiveness of the equipment. Tap water leaves lime deposits in the chamber.

11. Turn the control to "Fill" to allow water to flow into the chamber. The water flows until you turn the control to its next position. Do not let the water overflow.
12. Load the chamber with wrapped items, spacing them for maximum circulation and penetration.

    Purpose

    To ensure sterilization of all items.

13. Close and seal the door.

    Purpose

    The door must be closed, or the heated water in the chamber evaporates.

14. Turn the control setting to "On" or "Autoclave" to start the cycle.
15. Watch the gauges until the temperature gauge reaches at least 121° C (250° F) and the pressure gauge reaches 15 lbs. of pressure.

    Purpose

    The proper temperature and pressure must be reached before sterilization can begin.

16. Set the timer for the desired time.
17. At the end of the timed cycle, turn the control setting to "Vent."

    Purpose

    This releases the steam and pressure. The water at the bottom of the chamber drains back into the reservoir. Newer autoclaves automatically perform this step.

18. Wait for the pressure gauge to reach zero.
19. Standing behind the autoclave door, carefully open the chamber door.

    Purpose

    To allow steam to escape faster. Be careful to prevent accidental burns.

20. Leave the autoclave control at "Vent" to continue releasing heat.

    Purpose

    To dry the items faster.

21. Allow complete drying of all articles.
22. Using heat-resistant gloves, remove the items from the chamber and place the sterilized packages on dry, covered shelves or open the autoclave door and allow the items to cool completely before removal and storage.
23. Turn the control knob to "Off" and keep the door slightly ajar.

    Purpose

    To allow the inside of the autoclave to dry completely.

1. Confirm the patient's identity.
2. Explain the procedure and answer follow-up questions as directed by the physician.
3. Instruct the patient to remove any clothing that may interfere with the procedure.
4. Provide a gown if needed.
5. Once the patient is ready, place an absorbent drape under the prep site.
6. With gloved hands, apply antiseptic soap to the gauze sponge.
7. In a circular motion, gently scrub, working from the center out to the edges of the surgical site.
8. Discard used gauze, and repeat the step with a piece of fresh gauze.
9. Scrub the site for a minimum of five minutes. Follow office protocol regarding site scrub times.
10. Rinse the skin with sterile saline solution to limit the introduction of new contaminants.
11. Place a basin under the surgical site, and rinse well.
12. Using the same circular motion, dry the site with fresh gauze. A sterile towel can also be used to blot the site dry.
13. Using the same circular motion and working from the center out, paint the site with the antiseptic agent using a cotton-tipped applicator.
14. Do not return to an area where antiseptic has already been applied.
15. If necessary, shave the surgical site with electric clippers.

    Purpose

    This helps limit the risk of infection.

16. Place a sterile drape over the site.
17. Instruct the patient not to remove the drape or touch the site.
18. Document the procedure in the patient's medical record.

1. Check that the Mayo stand or countertop is dust free and clean. If it is not, clean with 70% alcohol or another disinfectant and allow to air dry.

   Purpose

   Although some areas cannot be sterile, steps must be taken to keep contamination to a minimum; moisture on a tray contaminates the pack.

2. Sanitize your hands and make sure they are completely dry. If you will be assisting with a surgical procedure immediately after opening the sterile pack, perform surgical hand scrub.

   Purpose

   To reduce the number of transient flora on your hands and forearms; moisture on your hands contaminates the pack.

3. Place the sterile pack on the Mayo stand or countertop and read the label.

   Purpose

   Take care to open the required pack. Most medical offices have a limited supply of autoclaved packs. Opening a wrong package could mean not having enough sterile supplies for a different procedure.

4. If using an autoclaved pack, check the indicator tape for a color change.

   Purpose

   Autoclave indicator tape changes color after the sterile processing cycle.

5. Open the outside cover. Position the package so that the outer envelope flap is at the top and facing you.

   Purpose

   This positions the pack for correct opening so that you do not have to cross over the sterile pack to open it.

6. Open the outermost flap. Next, open the first flap away from you. Do not cross over the pack.
7. Open the second corner, pulling to side.

   Purpose

   To prevent contamination of the sterile field.

8. Be careful to lift the flaps by touching only the small, folded-back tab and without touching or crossing over the inner surface of the pack or its contents.
9. Open the remaining two corners of the pack.
10. You now have a sterile drape as a sterile field from which to work and for the distribution of additional sterile supplies and instruments.
11. Perform the surgical hand scrub before putting on sterile gloves.
12. Open the glove pack, being careful not to cross over the open area in the middle of the pack. Remember, a 1" area around the perimeter of the glove wrapper is considered not sterile.

    Purpose

    The open glove pack is a sterile field.

13. Glove your dominant hand first.

    Purpose

    This sets up your dominant hand to do the more difficult step, which is to put on the second glove.

14. With your nondominant hand, pick up the glove for your dominant hand with your thumb and forefinger, grabbing the top of the folded cuff, which is the inside of the glove, being careful not to cross over the other sterile glove.

    Purpose

    The inside of the glove will be next to your skin and is considered not sterile.

15. Lift the glove up and away from the sterile package.

    Purpose

    To prevent accidental contamination from touching the glove on the 1" area around the perimeter of the glove wrapper.

16. Hold your hands up and away from your body and slide the dominant hand into the glove.
17. Leave the cuff folded.

    Purpose

    You will unfold the cuff later.

18. With your gloved dominant hand, pick up the second glove by slipping your gloved fingers under the cuff, extending the thumb up and away from the glove, so that your gloved fingers touch only the outside of the second glove.

    Purpose

    Sterile surfaces must always touch sterile surfaces.

19. Slide your nondominant hand into the glove without touching the exterior of the glove or any part of the gloved hand.
20. Still holding your hands away from you, unroll the cuff by slipping the fingers into the cuff and gently pulling up and out.
21. Do not touch your bare arm or the internal surface of the glove with any part of the sterile glove.
22. Now, slip your gloved fingers up under the first cuff and unroll it, using the same technique.

1. Prep the patient's skin with surgical soap and antiseptic solution. Explain the prep procedure to the patient.

   Purpose

   To ensure infection control and to demonstrate awareness of possible patient concerns.

2. Perform the surgical hand scrub.
3. Set up the sterile field with instruments and supplies in the sequence to be used. Put on sterile gloves. After the sterile field has been set up, cover it with a sterile drape.
4. Position the Mayo stand near the patient and the operative site, making sure the patient understands not to touch the sterile field.

   Purpose

   To prevent contamination of supplies and provide easy access for the physician.

5. Grasp the patient drape by holding one edge or corner in each hand.
6. Drape the surgical site without touching any part of the patient or the operating area with your gloved hands.
7. If the provider requests medication, such as a local anesthetic, a second circulating assistant holds the vial of local anesthetic so that the provider can read the label. The provider withdraws the desired amount using sterile technique.

   Purpose

   The vial of local anesthetic medication must be held by the second assistant away from the sterile field to prevent crossing over the field with a nonsterile item. The medication label must be checked before a medication is dispensed or administered.

8. The provider injects the local anesthetic and waits a few minutes for it to take effect.
9. Position yourself across from the practitioner. Arrange the sterile field. Check the placement location on the Mayo stand.
10. Keep all sharp equipment conspicuously placed on the sterile field.

    Purpose

    Sharp instruments that are not clearly visible may injure a team member.

11. Pass the scalpel, blade down and handle first, to the provider, or the provider will reach for it. The provider will take the scalpel with the thumb and forefinger in the position ready for use.

    Purpose

    To protect the practitioner and yourself from injury.

12. Pick up a tissue forceps by the tips and pass it to the provider to grasp a piece of the tissue to be excised.
13. Dispose of soiled sponges in the biohazardous waste receptacle, being careful to keep your hands above your waist and to avoid touching any nonsterile items.
14. Hold clean sponges in your hand to pat or sponge the wound as needed.
15. Safely position the specimen (if any) where it will not be disturbed in a sterile container on the sterile field.
16. If there is a bleeding vessel or if a hemostat is requested, pass the hemostat in the manner described previously.
17. Continue to sponge blood from the wound site.
18. Retract the wound edge, as needed, with a skin retractor.
19. Continue to monitor the sterile field and assist the provider as needed.
20. Pass the needle and suture material to close the wound and apply a sterile dressing as requested.
21. Monitor the patient and provide assistance as needed.
22. When the provider is finished, clean the surgical site using sterile technique.
23. Collect the specimen using Universal Standards, place it in a labeled specimen cup, and send it to the laboratory with the proper requisitions.
24. Sanitize your hands.
25. Document the procedure, wound condition, and patient education on wound care.

    Purpose

    To ensure infection control. Procedures are not complete until they are recorded.

26. After surgery is complete, lavage or rinse the sutured area with sterile saline.

    Purpose

    To cleanse the postsurgical site.

27. Before the sterile drape is removed and while you are still wearing sterile gloves, pick up the dressing from the sterile field, place it on the wound, and hold it there.

    Purpose

    To prevent the introduction of microorganisms into the wound area.

28. Then remove the drape, switching hands to hold the dressing in place.

    Purpose

    To keep the wound as clean as possible.

29. Secure the dressing with paper tape and/or an appropriate bandage.

    Purpose

    To keep the wound covered and protected.

30. Provide patient education as needed for wound care and document the procedure in the patient's health record.

    Purpose

    A procedure is not completed until it is recorded.

1. After surgery is complete, lavage or rinse the sutured area with sterile saline.

   Purpose

   To cleanse the postsurgical site.

2. Before the sterile drape is removed and while you are still wearing sterile gloves, pick up the dressing from the sterile field, place it on the wound, and hold it there.

   Purpose

   To prevent the introduction of microorganisms into the wound area.

3. Then remove the drape, switching hands to hold the dressing in place.

   Purpose

   To keep the wound as clean as possible.

4. Secure the dressing with paper tape and/or an appropriate bandage.

   Purpose

   To keep the wound covered and protected.

5. Provide patient education as needed for wound care and document the procedure in the patient's health record.

   Purpose

   A procedure is not completed until it is recorded.

6. Assemble the necessary supplies.
7. Sanitize your hands, following Standard Precautions.
8. Identify and greet the patient. Explain the procedure to the patient and instruct the person to lie or sit still during the procedure.

   Purpose

   To ensure cooperation during the procedure.

9. Position the patient comfortably and support the sutured area.
10. Place dry towels under the site.
11. Check the incision line to make sure the wound edges are approximated and there are no signs of infection, such as inflammation, edema, or drainage.

    Purpose

    Sutures or staples should not be removed unless the site is completely healed with the wound edges together; infection at the site will interfere with the healing process; removing sutures or staples before the site is completely healed may result in wound dehiscence.

12. Put on disposable gloves. Using antiseptic swabs, cleanse the wound to remove exudate and destroy microorganisms around the sutures or staples. Clean the site from the inside out, starting at the top of the wound and working your way down. Use a new swab if the step must be repeated.

    Purpose

    Dried exudate on sutures or staples may make removing them without traumatizing the wound more difficult. Cleansing the wound reduces the possibility of wound infection.

13. Open the suture or staple removal pack while maintaining the sterility of the contents.
14. Place a sterile gauze sponge next to the wound site.

    Purpose

    To receive the removed sutures or staples.

15. Put on sterile gloves.
16. Grasp the knot of the suture with the dressing forceps without pulling.
17. Cut the suture at skin level.
18. Lift, do not pull, the suture toward the incision and out with the dressing forceps.
19. Place the suture on the sterile gauze sponge and check that the entire suture strand has been removed.

    Purpose

    Suture fragments left in a wound may cause irritation and/or infection and may prolong the healing process.

20. If any bleeding occurs, blot the area with a sterile gauze sponge before continuing.
21. Continue in the same manner until all sutures have been removed.
22. Gently place the bottom jaw of the staple remover under the first staple.
23. Tightly squeeze the staple handles together.
24. Carefully tilt the staple remover upward until the staple lifts out of the wound.
25. Place the removed staple on a 4×4-inch gauze square.
26. Continue the process until all staples have been removed.
27. Remove the gauze sponge holding the sutures or staples and dispose of contaminated materials in the biohazardous waste container.
28. The surgeon may apply or may have you apply Steri-Strips or an adhesive bandage strip for added support, strength, and protection.
29. Instruct the patient to keep the wound edges clean and dry and not to place excessive strain on the area.
30. Document the procedure, wound condition, number of sutures or staples removed, whether a dressing or bandage was applied, and the instructions on wound care given to the patient.

    Purpose

    A procedure that is not documented was not done.

Knowledge-check items

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L29-01 · Autoclave Use

L29-02 · Surgical Skin Prep

L29-04 · Assist with Minor Surgery

L29-05 · Wound Care