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Delwin B. Jacoby, DNP, APRN

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Presentation on theme: "Delwin B. Jacoby, DNP, APRN"— Presentation transcript:

1 Delwin B. Jacoby, DNP, APRN
Common Office Procedures Baby Health Service Lexington, KY Spalding University Louisville, KY Delwin B. Jacoby, DNP, APRN

2 Delwin B. Jacoby, MSN, APRN has no financial interest or affiliations with any entities regarding this content – April 17, 2013

3 Objectives for Common Office Procedures
Review AHA recommendations for antibiotic prophylaxis for common office procedures. Demonstrate removal procedures for veruccae and acrochordons. Discuss management of subungual hematomas. Develop a plan for the management of ingrown toenails. Demonstrate correct procedure for a digital nerve block in both hands and feet. Perform incision and drainage of an uncomplicated abscess and paronychia. Demonstrate procedures to biopsy suspicious lesions– shave biopsy, punch biopsy, and elliptical excision.

4 Overview of Simple Office Procedures
Can be performed in most any office Requires the following: good light source exam table mayo stand/table basic instruments and equipment protective gear anesthesia suture material

5 Basic Instruments & Equipment
Scalpels, scissors, punches Forceps Undermining scissors Hemostats Needle holders Syringes and needles Cotton swabs Liquid nitrogen/cryo Gauze pads Suture material English Nail Anvil *

6 Universal Precautions & Sterile Technique

7 Antibiotic Prophylaxis
April New AHA guidelines for antibiotic prophylaxis Prosthetic cardiac valve Previous infective endocarditis Congenital heart disease only in the following categories: Unrepaired cyanotic congenital heart disease, including those with palliative shunts and conduits Completely repaired congenital heart disease with prosthetic material or device, whether placed by surgery or catheter intervention, during the first six months after the procedure*  Repaired congenital heart disease with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (which inhibit endothelialization) Cardiac transplantation recipients with cardiac valvular disease

8 Acrochordons (Skin Tags)
Commonly found on neck, axilla, bra-line, groin Topical Anesthesia +/- EMLA Cetacaine spray Grasp tag with forceps and snip base with sharp scissors Apply pressure for hemostasis and dress Review S & S of infection No follow-up needed Few complications

9 Acrochordons (Skin Tags)
CPT Removal any method of up to 15 tags any area CPT – – Removal of each additional 10 lesions.

10 Warts Common, generally benign condition of viral etiology
Challenging!!!! Commonly spread by auto-inoculation Cosmetically unappealing Often resolve spontaneously Tend to be recurrent no matter the treatment option Occur most commonly in children

11 Types of Warts (Verrucae)
Verruca vulgaris – common warts Periungual warts – occur around nails Verruca planus – flat warts Verruca plantaris – plantar warts Condylomata acuminata

12 Warts Epidermal overgrowths caused by HPV. Spread by direct contact.
HPV type 1,2,4 – Assoc with Plantar Warts (verruca plantaris) HPV type 3 &10 – assoc with Flat Warts (verruca planus) HPV type 16,18,31 assoc with genital warts –assoc with genital cancers (condylomata accuminata). HPV 2,4,7,27,29 – Assoc with common warts (verruca vulgaris)

13 Verrucae

14 Common Treatments for Warts
Chemical Destruction Salicylic Acid Podophyllin/Podophylloxin Trichloracetic acid Bichloracetic acid Others Immune system modulator – Imiquimod (Aldara) Cryotherapy Liquid nitrogen Duct Tape?!?!

15 Cryotherapy Application of extreme cold to destroy lesions Easy to use
Quick Generally good results with little scarring No local anesthesia needed/pain tolerable Multiple lesions can be treated

16 Cryotherapy - Disadvantages
Initial cost and set-up Postoperative pain Lesion recurrence Hypopigmentation may occur Repeat visits common Occasional scarring

17 Cryotherapy - Precautions
Previous Rx to cryotherapy Do not use on suspected cancerous lesions Caution around nails and nailbed Do not use on eyelids, elbow, digits - relative contraindication Nose, ears, lips, ant. tibial area - caution Dark skin Vascular compromise Immunocompromised patients

18 Cryosurgical Systems Liquid nitrogen - 196 degrees C
Verruca-Freeze (chemical refrigerant) - 70 degrees C Histofreezer (chemical refrigerant) - 55 degrees C

19 Cryosurgery

20 Cryosurgical Products

21 Cryosurgery Techniques CPT – Destruction benign or premalignant lesion by any method, first lesion. CPT – Destruction benign or premalignant lesion by any method, 2nd – 14th lesion.

22 Cryotherapy - Veruccae

23 Nail Anatomy

24 Subungual Hematoma Painful accumulation of blood under the nail secondary to trauma Evacuation relieves pain > 50% of nail bed involvement suggests sig. laceration and possible fracture. Assess neurovascular function prior to procedure Patient education and expectations are very important

25 Subungual Hematoma Evacuation
CPT – –Evacuation of subungual hematoma

26 Ingrown Toenail (Onychocryptosis)
Common Leads to pain/ disability Etiology - ill-fitting shoes, improper toenail cutting, trauma. Ingrown toenail spicule leads to inflammatory response

27 Stages of Ingrown Toenails
Stage 1 - erythema, pain, swelling Stage II – erythema, pain, swelling, suppuration Stage III – granulation tissue, hypertrophy along with stage II characteristics

28 Ingrown Toenail (Onychocryptosis)

29 Ingrown Toenail Management
Stage 1 – Conservative management Stage 2 – Partial toenail removal Stage 3 – Partial toenail removal; Consider referral to Podiatrist

30 Partial Nail Removal Soak in warm H20 prior to procedure
Digital nerve block bilaterally with plain 2% xylocaine or bupivacaine (marcaine) 0.25% Prep area with betadine Elevate the nail edge with hemostats or nail elevator Partial nail removal 2-3 mm with nail splitter or sharp scissors

31 Partial Nail Removal (Cont.)
Remove the wedged section by rotating the separated portion toward the healthy nail Apply phenol solution (88%) to the nail matrix Apply topical antibiotic and dressing Dispense wound care instructions Recheck as needed, observe for signs of infection Prevention instructions

32 Ingrown Toenail - Partial Nail Removal
English Nail Anvil

33 Ingrown Toenail - Partial Nail Removal
CPT – – Avulsion of nail plate, partial or complete, simple; single

34 Digital Nerve Block

35 Digital Nerve Block ***No CPT exists for digital nerve block; Service included in procedure performed.

36 Abscess

37 Incision and Drainage of Abscess
Abscess – local collection of purulent materiel in a cavity surrounded by inflamed tissue. produces pain, pressure and tissue damage. Furuncle (boil) – Starts in hair follicle or sweat gland Carbuncle – furuncle extends to subcutaneous tissue Acute paronychia – abscess around nail Bacteria involved – Mostly S. aureus and other gram+ organisms, MRSA common !!

38 Skin Tension Lines

39 Indications for I & D of Abscess
An abscess must be drained in order to heal Systemic antibiotics cannot penetrate the abscess Check to see if the lesion is “fluctuant” All skin abscesses, furuncle/carbuncle, inflamed epithelial cysts, paronychia with abscess must have I & D for resolution

40 Contraindications/Caution
Facial abscess - CN VII Caution in area around vital structures such as the eye and neck Caution in areas overlying nerves and blood vessels

41 Instruments Needed

42 Surgical Blades

43 I & D Procedure Determine skin tension lines to minimize scarring
Prep skin with antibacterial agent Inject local anesthesia Make a 90 degree stab incision with #11 scalpel blade Apply pressure to expel purulent material If no purulent material, reassess and try again Break up loculations with swab, hemostat or curette +/- Pack with nu-gauze * Apply dressing

44 I&D Procedure CPT – I & D of single or simple abscess

45 I & D Follow-up/Patient Education
Quick shower and change outer dressing Expect additional drainage Return visit 1-2 days Management options at revisit Remove packing and repack Remove packing completely Partially remove packing Follow-up as needed for resolution Warm H2O soaks? Complete healing takes 7-21 days or longer

46 Fingernail/Toenail Paronychia
Infection of the nail fold. Usually S. aureus if acute; may be Candida albicans if chronic (>6 weeks). Toenail paronychia often associated with ingrown toenail and requires partial toenail removal. Usually no anesthetic needed. May use ethyl chloride as local anesthesia Insert #11 blade into area of fluctuance Apply pressure and drain Warm H20 soaks until resolved

47 Draining Paronychia CPT – – I & D of single or simple abscess

48 Punch Biopsy Fast and easy procedure to obtain a full thickness specimen for pathology. Indicated for unknown and malignant lesions. Great for diagnostic purposes for flat lesions. Useful to remove small, flat nevi. Usually good cosmetic results Useful to diagnose inflammatory disease

49 Indications for Punch Biopsy
Diagnosis Inflammatory skin disease Skin cancer Removal Small nevi Dermatofibromas - challenging/often better to not remove

50 Contraindications of Punch Biopsy
Less than optimal biopsy technique for SCC and BCC Must Know Anatomy!!!!!!!!!!!!!! Facial nerve Trigeminal nerve Eyelid Digits Areas with little soft tissue – tibia, digits, ulna, etc

51 Equipment for Punch Biopsy
Punch – 2-8mm. Choose the punch that can completely excise the lesion < 3mm may not need sutures > 6mm , best to use an elliptical excision. Fine, sharp-sharp scissors Forceps Needle holder Suture material Local anesthesia

52 Punch Biopsy Procedure
Sterile Technique Choose a punch to remove entire lesion Local anesthesia 1% lidocaine Apply tension perpendicular to Kraissel’s lines with hand not performing the punch. Apply punch completely over the lesion, apply pressure, and rotate through the dermis – expose the subq. Adipose tissue. Remove the plug, cut with sharp-sharp scissors and send for pathology Undermine if needed Close with simple interrupted sutures Dress and provide follow-up instructions

53 Punch Biopsy CPT – 11100 – Biopsy of skin, subcutaneous
CPT – – Biopsy of each separate or additional lesion.

54 Shave Biopsy Indicated for raised lesion removal
Advantages – minimal time, simple, no suturing, generally good cosmetic results

55 Shave Biopsy Consider for Not indicated for suspected melanoma!!
skin tags seborrheic keratosis nevi actinic keratosis Not indicated for suspected melanoma!!

56 Shave Biopsy Prep skin Local anesthesia to elevate lesion
Use #15 blade or DermaBlade Excise the lesion level or minimally depressed in relation to the surrounding skin. Achieve hemostasis Pressure Electrodessication Topical agents Aluminum chloride Monsel’s solution Silver nitrate Submit for pathology

57 Shave Biopsy

58 Shave Biopsy - DermaBlade
CPT – Depends on site and size. 11300 – Trunk, arm, leg < 0.6 cm Trunk, arm, leg 0.6 – 1.0 cm Many others, see CPT code book.

59 Elliptical Excision Used when lesion is too large for punch
Removes full thickness lesion Major steps Planning Anesthesia Incision Undermining Hemostasis Closure

60 Planning the Elliptical Excision
Avoid vital structures! Know anatomy! Know Kraissel’s lines and plan accordingly Incisional margin 3x diameter of lesion Anesthesia Incision with # 15 blade perpendicular to the skin surface through epidermis and dermis Undermine to allow closure of the incised area

61 Surgical Blades

62 Elliptical Excision Hemostasis – pressure, electrocautery, local anesthesia with epinephrine if indicated!!!! Wound closure – vertical mattress, 2 layer closure, single layer closure. Send specimen for pathology

63 Elliptical Excision Remember………… Skin tension lines!!!!

64 Elliptical Excision

65 Elliptical Excision CPT – 11400 – Benign excision, TAL. < 0.6 cm
Additional CPT depending on size and location.

66 Common Office Procedures References
American Heart Association (2007, April 19).  Prevention of Infective Endocarditis: Guidelines From the American Heart Association, by the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease. Circulation  Buttaravoli, P (2012) Minor Emergencies. Splinters to Fractures, 3rd Edit. Mosby Blair, RE (2007, March) “Surgical Management of Soft Tissue MRSA Abscesses”, Family Physician News Mayeaux, EJ (2009)The Essential Guide to Primary Care Procedures. Wolters/Lippincott/Williams &Wilkins Pfenninger, JL (2011) Procedures for Primary Care, 3rd Edition: Mosby Trott, AT (2012) Wounds and Lacerations, 4th Edit. Mosby

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