Wound Care Workshop Part II: Office Procedures Biopsies, I&D

1. Wound Care Workshop Part II: Office ProceduresBiopsies, I&D Patsy Thompson Leavitt, DNP(c), FNP Assistant Professor University of Southern Maine Executive Director Leavitt’s Mill Free Health Center

2. Disclosures and credits • Patsy Thompson Leavitt, DNP(c), FNP • No commercial disclosures • Reference for graphics: • Penninger (ed.) (2011) Procedures for primary care, 3rd ed. Mosby/Elsevier. Philadelphia • ISBN: 978-0-323-05267-2

3. Our Objectives • 1. Describe advanced skin lesion assessment and decision making processes. • 2. Demonstrate local anesthetic administration techniques for field block. • 3. Discuss anesthetic decision making for skin lesion removal and incision and drainage (I&D) • 4. Demonstrate beginning skills in performing incision and drainage of skin abscesses. • 5. Demonstrate beginning skills in performing a skin shave biopsy and punch biopsy.

4. Three Phases of Wound Healing (Box 22-1, p. 158) • Phase 1 (Initial Lag Phase, Days 0–5) No gain in wound strength • Phase 2 (Fibroplasia Phase, Days 5–14) Rapid increase in wound strength occurs   At 2 weeks, the wound has achieved only 7% of its final strength • Phase 3 (Final Maturation Phase, Day 14 until Healing Is Complete)    Further connective tissue remodeling   Up to 80% of normal skin strength

5. Cautions • Maximum doses commonly used local anesthetics • Sensitivity to lidocaine usually related to preservative in multidose vial, single dose vials available

6. What about epinephrine? • Benefits? • Risks? • Anatomical precautions • Co – morbidities

7. Field block Sterile Technique

8. Digit blocks

12. Decreasing pain • Room temp for injectables • Buffer with Na Bicarb 1.0 ml per 9 ml lidocaine • Topical preps • Intact skin EMLA • (Open wound LET/LAT) • Mucous membranes – viscous lido • Topical ethyl chloride or liquid nitrogen

13. Prep • Sterile technique • Povidone Iodine • Circular motion – concentric circles starting mid lesion • Apply X 3 separate swabs/soaked gauze, discard http://www.aafp.org/afp/2011/1101/p995.pdf accessed 4/19/14

14. Biopsy decision making

15. Biopsy type by location (skin)

16. Seven “D’s” of biopsy for pathologist

17. Shave biopsy

18. Shave biopsy

19. http://www.aafp.org/afp/2011/1101/p995.pdf Punch biopsy Langer Lines

20. Punch biopsy- use less than 5mm

24. Cauterize & protect • Silver Nitrate sticks • Monsel’s solution (ferrous substrate) • White petroleum jelly (as effective, less allergic reactions)(Pickett, 2011)

25. Lesion excision decisions • Lines of tension • Consider when planning excision

26. Make an elliptical incision

29. Undermine

30. Undermining

31. Close dead space with subcutaneous suture …close skin with simple interrupted or other technique

32. Abscess I&D Form a wheal with lido/epi

33. Eye protection a must!

34. Express sebaceous material and pus

35. Clean it, irrigate it, pack it

36. NO sutures

37. Paronychia

38. Thank you! My Dad, Dr. Bill Thompson, General Surgeon (ret.)… seated between his older siblings Circa 1923 (taught me how to tie a Surgeon’s knot)