Presentation on theme: "Delwin B. Jacoby, DNP, APRN"— Presentation transcript:
1Delwin B. Jacoby, DNP, APRN Common Office Procedures Baby Health Service Lexington, KY Spalding University Louisville, KYDelwin B. Jacoby, DNP, APRN
2Delwin B. Jacoby, MSN, APRN has no financial interest or affiliations with any entities regarding this content – April 17, 2013
3Objectives 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.
4Overview of Simple Office Procedures Can be performed in most any officeRequires the following:good light sourceexam tablemayo stand/tablebasic instruments and equipmentprotective gearanesthesiasuture material
5Basic Instruments & Equipment Scalpels, scissors, punchesForcepsUndermining scissorsHemostatsNeedle holdersSyringes and needlesCotton swabsLiquid nitrogen/cryoGauze padsSuture materialEnglish Nail Anvil *
7Antibiotic 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
8Acrochordons (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
9Acrochordons (Skin Tags) CPT Removal any method of up to 15 tags any areaCPT – – Removal of each additional 10 lesions.
10Warts 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
11Types of Warts (Verrucae) Verruca vulgaris – common wartsPeriungual warts – occur around nailsVerruca planus – flat wartsVerruca plantaris – plantar wartsCondylomata acuminata
12Warts 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)
14Common Treatments for Warts Chemical DestructionSalicylic AcidPodophyllin/PodophylloxinTrichloracetic acidBichloracetic acidOthersImmune system modulator – Imiquimod (Aldara)CryotherapyLiquid nitrogenDuct Tape?!?!
15Cryotherapy 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
16Cryotherapy - Disadvantages Initial cost and set-upPostoperative painLesion recurrenceHypopigmentation may occurRepeat visits commonOccasional scarring
17Cryotherapy - 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
18Cryosurgical Systems Liquid nitrogen - 196 degrees C Verruca-Freeze (chemical refrigerant) - 70 degrees CHistofreezer (chemical refrigerant) - 55 degrees C
24Subungual 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
25Subungual Hematoma Evacuation CPT – –Evacuation of subungual hematoma
26Ingrown Toenail (Onychocryptosis) CommonLeads to pain/ disabilityEtiology - ill-fitting shoes, improper toenail cutting, trauma.Ingrown toenail spicule leads to inflammatory response
27Stages of Ingrown Toenails Stage 1 - erythema, pain, swellingStage II – erythema, pain, swelling, suppurationStage III – granulation tissue, hypertrophy along with stage II characteristics
30Partial 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
31Partial 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
32Ingrown Toenail - Partial Nail Removal English Nail Anvil
33Ingrown Toenail - Partial Nail Removal CPT – – Avulsion of nail plate, partial or complete, simple; single
37Incision 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 !!
39Indications 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
40Contraindications/Caution Facial abscess - CN VIICaution in area around vital structures such as the eye and neckCaution in areas overlying nerves and blood vessels
43I & 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
44I&D ProcedureCPT – I & D of singleor simple abscess
45I & 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
46Fingernail/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
47Draining ParonychiaCPT – – I & D of single or simple abscess
48Punch 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
49Indications for Punch Biopsy DiagnosisInflammatoryskin diseaseSkin cancerRemovalSmall neviDermatofibromas - challenging/often better to not remove
50Contraindications 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
51Equipment 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
52Punch 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
53Punch Biopsy CPT – 11100 – Biopsy of skin, subcutaneous CPT – – Biopsy of each separate or additional lesion.
54Shave Biopsy Indicated for raised lesion removal Advantages – minimal time, simple, no suturing, generally good cosmetic results
55Shave Biopsy Consider for Not indicated for suspected melanoma!! skin tagsseborrheic keratosisneviactinic keratosisNot indicated for suspected melanoma!!
56Shave 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
58Shave 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.
59Elliptical Excision Used when lesion is too large for punch Removes full thickness lesionMajor stepsPlanningAnesthesiaIncisionUnderminingHemostasisClosure
60Planning 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
62Elliptical ExcisionHemostasis – pressure, electrocautery, local anesthesia with epinephrine if indicated!!!!Wound closure – vertical mattress, 2 layer closure, single layer closure.Send specimen for pathology
65Elliptical Excision CPT – 11400 – Benign excision, TAL. < 0.6 cm Additional CPT depending onsize and location.
66Common 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