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, KYDelwin 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 officeRequires the following:good light sourceexam tablemayo stand/tablebasic instruments and equipmentprotective gearanesthesiasuture material
5 Basic Instruments & Equipment Scalpels, scissors, punchesForcepsUndermining scissorsHemostatsNeedle holdersSyringes and needlesCotton swabsLiquid nitrogen/cryoGauze padsSuture materialEnglish Nail Anvil *
7 Antibiotic Prophylaxis April New AHA guidelines for antibiotic prophylaxisProsthetic cardiac valvePrevious infective endocarditisCongenital heart disease only in the following categories:Unrepaired cyanotic congenital heart disease, including those with palliative shunts and conduitsCompletely 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, groinTopical Anesthesia +/-EMLACetacaine sprayGrasp tag with forceps and snip base with sharp scissorsApply pressure for hemostasis and dressReview S & S of infectionNo follow-up neededFew complications
9 Acrochordons (Skin Tags) CPT Removal any method of up to 15 tags any areaCPT – – Removal of each additional 10 lesions.
10 Warts Common, generally benign condition of viral etiology Challenging!!!!Commonly spread by auto-inoculationCosmetically unappealingOften resolve spontaneouslyTend to be recurrent no matter the treatment optionOccur most commonly in children
11 Types of Warts (Verrucae) Verruca vulgaris – common wartsPeriungual warts – occur around nailsVerruca planus – flat wartsVerruca plantaris – plantar wartsCondylomata 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)
14 Common Treatments for Warts Chemical DestructionSalicylic AcidPodophyllin/PodophylloxinTrichloracetic acidBichloracetic acidOthersImmune system modulator – Imiquimod (Aldara)CryotherapyLiquid nitrogenDuct Tape?!?!
15 Cryotherapy Application of extreme cold to destroy lesions Easy to use QuickGenerally good results with little scarringNo local anesthesia needed/pain tolerableMultiple lesions can be treated
16 Cryotherapy - Disadvantages Initial cost and set-upPostoperative painLesion recurrenceHypopigmentation may occurRepeat visits commonOccasional scarring
17 Cryotherapy - Precautions Previous Rx to cryotherapyDo not use on suspected cancerous lesionsCaution around nails and nailbedDo not use on eyelids, elbow, digits - relative contraindicationNose, ears, lips, ant. tibial area - cautionDark skinVascular compromiseImmunocompromised patients
18 Cryosurgical Systems Liquid nitrogen - 196 degrees C Verruca-Freeze (chemical refrigerant) - 70 degrees CHistofreezer (chemical refrigerant) - 55 degrees C
24 Subungual HematomaPainful accumulation of blood under the nail secondary to traumaEvacuation relieves pain> 50% of nail bed involvement suggests sig. laceration and possible fracture.Assess neurovascular function prior to procedurePatient education and expectations are very important
25 Subungual Hematoma Evacuation CPT – –Evacuation of subungual hematoma
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 betadineElevate the nail edge with hemostats or nail elevatorPartial 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 nailApply phenol solution (88%) to the nail matrixApply topical antibiotic and dressingDispense wound care instructionsRecheck as needed, observe for signs of infectionPrevention 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
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 glandCarbuncle – furuncle extends to subcutaneous tissueAcute paronychia – abscess around nailBacteria involved – Mostly S. aureus and other gram+ organisms, MRSA common !!
39 Indications for I & D of Abscess An abscess must be drained in order to healSystemic antibiotics cannot penetrate the abscessCheck 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 VIICaution in area around vital structures such as the eye and neckCaution in areas overlying nerves and blood vessels
43 I & D Procedure Determine skin tension lines to minimize scarring Prep skin with antibacterial agentInject local anesthesiaMake a 90 degree stab incision with #11 scalpel bladeApply pressure to expel purulent materialIf no purulent material, reassess and try againBreak up loculations with swab, hemostat or curette+/- Pack with nu-gauze *Apply dressing
44 I&D ProcedureCPT – I & D of singleor simple abscess
45 I & D Follow-up/Patient Education Quick shower and change outer dressingExpect additional drainageReturn visit 1-2 daysManagement options at revisitRemove packing and repackRemove packing completelyPartially remove packingFollow-up as needed for resolutionWarm 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 anesthesiaInsert #11 blade into area of fluctuanceApply pressure and drainWarm H20 soaks until resolved
47 Draining ParonychiaCPT – – I & D of single or simple abscess
48 Punch BiopsyFast 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 resultsUseful to diagnose inflammatory disease
49 Indications for Punch Biopsy DiagnosisInflammatoryskin diseaseSkin cancerRemovalSmall neviDermatofibromas - challenging/often better to not remove
50 Contraindications of Punch Biopsy Less than optimal biopsy technique for SCC and BCCMust Know Anatomy!!!!!!!!!!!!!!Facial nerveTrigeminal nerveEyelidDigitsAreas 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 scissorsForcepsNeedle holderSuture materialLocal anesthesia
52 Punch Biopsy Procedure Sterile TechniqueChoose a punch to remove entire lesionLocal anesthesia 1% lidocaineApply 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 pathologyUndermine if neededClose with simple interrupted suturesDress 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 tagsseborrheic keratosisneviactinic keratosisNot indicated for suspected melanoma!!
56 Shave Biopsy Prep skin Local anesthesia to elevate lesion Use #15 blade or DermaBladeExcise the lesion level or minimally depressed in relation to the surrounding skin.Achieve hemostasisPressureElectrodessicationTopical agentsAluminum chlorideMonsel’s solutionSilver nitrateSubmit for pathology
58 Shave Biopsy - DermaBlade CPT – Depends on site and size.11300 – Trunk, arm, leg < 0.6 cmTrunk, arm, leg 0.6 – 1.0 cmMany others, see CPT code book.
59 Elliptical Excision Used when lesion is too large for punch Removes full thickness lesionMajor stepsPlanningAnesthesiaIncisionUnderminingHemostasisClosure
60 Planning the Elliptical Excision Avoid vital structures! Know anatomy!Know Kraissel’s lines and plan accordinglyIncisional margin 3x diameter of lesionAnesthesiaIncision with # 15 blade perpendicular to the skin surface through epidermis and dermisUndermine to allow closure of the incised area
62 Elliptical ExcisionHemostasis – pressure, electrocautery, local anesthesia with epinephrine if indicated!!!!Wound closure – vertical mattress, 2 layer closure, single layer closure.Send specimen for pathology
65 Elliptical Excision CPT – 11400 – Benign excision, TAL. < 0.6 cm Additional CPT depending onsize 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. MosbyBlair, RE (2007, March) “Surgical Management of Soft Tissue MRSA Abscesses”, Family Physician NewsMayeaux, EJ (2009)The Essential Guide to Primary Care Procedures. Wolters/Lippincott/Williams &WilkinsPfenninger, JL (2011) Procedures for Primary Care, 3rd Edition: MosbyTrott, AT (2012) Wounds and Lacerations, 4th Edit. Mosby