Summary Advanced Practice Nursing Procedures- Detailed Copy

Advanced Practice Nursing Procedures Dermatological Procedures Chapter 1 Punch Biopsy Margaret R. Colyar CPT Code 21550 Biopsy of soft tissue of neck or thorax 21920 Biopsy of soft tissue of back or flank, superficial 23066 Biopsy of soft tissue of shoulder, superficial 24065 Biopsy of upper arm and elbow area 23066 Biopsy of soft tissue of forearm or wrist, superficial 27040 Biopsy of soft tissue of pelvis and hip area 27323 Biopsy of soft tissue of pelvis and hip area 27613 Biopsy of soft tissue of leg and ankle area 11100 Skin lesion—Depends on the site, technique, and if benign or malignant lesions Biopsy is the removal of a small piece of tissue from the skin for microscopic examination. Partial or full thickness of skin over the lesion is removed for evaluation. OVERVIEW Punch biopsy is used for full and partial dermal lesions such as ● Basal cell carcinoma ● Squamous cell carcinoma ● Actinic keratoses ● Seborrheic keratoses ● Lentigo (freckles) ● Lipomas ● Melanomas ● Nevi ● Warts—verruca vulgaris RATIONALE ● To confirm etiology of lesion for treatment ● To establish or confirm a diagnosis for treatment and/or intervention 2 Section One | Dermatological Procedures INDICATIONS ● Partial- or full-dermal-thickness lesion not on the face, eye, lip, or penis CONTRAINDICATIONS ● Lesion on eyelid, lip, or penis, REFER to a physician. ● Infection at the site of the biopsy ● Bleeding disorder ● Lesions that are deep or on the face, REFER to a physician. ◗ Informed consent required PROCEDURE Punch Biopsy Equipment ● Antiseptic skin cleanser ● Drape—sterile ● Gloves—sterile ● Disposable biopsy punch (Fig. 1.1) ● Pickups—sterile ● Scissors—sharp for the fine tissue—sterile ● 3-mL syringe ● 27- to 30-gauge, ½-inch needle ● 1% lidocaine ● Container with 10% formalin ● 4 × 4 gauze Figure 1.1 Disposable biopsy punches. Chapter 1 | Punch Biopsy 3 ● Nonstick dressing (Adaptic or Telfa) ● Kling ● Tape ● Steri-Strips (if biopsy will be greater than 4 mm) or one suture Procedure ● Position the client so that the area to be biopsied is easily accessible. ● Cleanse the skin with antiseptic skin cleanser. ● Put on gloves. ● Drape the area to be biopsied. ● Anesthetize with 1% lidocaine. ● With the thumb and index finger, spread the skin to apply tension opposite natural skin tension lines. This allows a more elliptical-shaped wound for easy closure. ● Apply biopsy punch to skin, rotate per manufacturer’s directions, and remove the punch (Fig. 1.2). ● With pickups, pull up loosened skin. ● Cut with scissors, and place tissue in tissue container of 10% formalin (Fig. 1.3). ● If less than 2 to 3 mm, apply nonstick dressing and pressure dressing. ● If greater than 4 mm, apply Steri-Strips and cover with 4 × 4 gauze. ● Apply Kling and secure with tape. Client Instructions ● Keep dressing clean, dry, and in place for 48 hours to decrease the chance of bleeding and oozing. ● Avoid touching or contaminating the area biopsied. ● To prevent the chance of infection, take cephalexin (Keflex) 500 mg three times per day or amoxicillin (Amoxil) 500 mg twice a day for 5 days. Figure 1.2 Apply biopsy punch to skin and rotate. 4 Section One | Dermatological Procedures ● Some redness, swelling, and heat are normal. Return to the office if symptoms of infection occur, such as ● Yellow or green drainage ● Red streaks ● Pain ● Elevated temperature ● Take acetaminophen (Tylenol) or ibuprofen (Motrin) every 4 to 6 hours as needed for pain. BIBLIOGRAPHY De Vries HJ, Zeegelaar JE, Middelkoop E, et al. Reduced wound contraction and scar formation in punch biopsy wounds. Native collagen dermal substitutes. A clinical study. Br J Dermatol. 1995;132(5):690–697. Zuber TJ. Ingrown toenail removal. Am Fam Physician. 2002;65(12):2547–2550. Figure 1.3 Cut with scissors. Chapter 2 | Skin Biopsy 5 Chapter 2 Skin Biopsy Margaret R. Colyar CPT Code 11300–03 Shaving of epidermal or dermal lesion; single lesion— trunk, arms, or legs 11305–08 Shaving of epidermal or dermal lesion; single lesion— scalp, neck, hands, feet, or genitalia 11400–06 Excision benign lesions—trunk, arms, or legs 11420–26 Excision benign lesions—scalp, neck, hands, feet, or genitalia 11600–06 Excision malignant lesions—trunk, arms, or legs 11620–26 Excision malignant lesions—scalp, neck, hands, feet, or genitalia Skin biopsy is the excision of a small piece of living tissue for microscopic examination. The two major categories of skin biopsy are ● Partial dermal thickness—shave and curettage ● Full dermal thickness—punch and elliptical excision HEALTH PROMOTION/PREVENTION ● Inspect the skin periodically for lesions. ● Note lesions that change size or color, are irregular, or are painful. OPTIONS ● Method 1—Shave biopsy ● Use for elevated skin lesions such as • Skin tags • Benign nevi (interdermal) • Epithelial tags • Small basal cell carcinomas • Condyloma acuminatum • Cherry angiomas • Actinic keratoses • Seborrheic keratoses