Posted in Procedures

Cryotherapy

Consent Form

Equipment List

  1. Nitrile exam gloves (1 pair)
  2. Liquid nitrogen (1)
  3. Ear speculums (1 each size)

Procedure Note

CRYOTHERAPY

Procedure was discussed with the patient including indications, risks, benefits, and alternatives. Local post-procedure care discussed. Side effects of treatment discussed. All questions answered. The patient opted to go forward with procedure. Timeout performed. The lesion was treated with light cryotherapy using cryo-cautery. The nozzle of the spray gun was positioned 1.0 to 1.5 cm above the skin surface and aimed at the center of the target lesion. Liquid nitrogen applied until an ice field encompassed the lesion and the desired margin of _ mm. Freeze thaw freeze technique was performed with complete thawing between cycles. A total of _ lesions treated. Patient tolerated procedure well.

Reference

https://www.aafp.org/afp/2020/0401/p399.html

Posted in Procedures

Nexplanon Replacement

Consent

Equipment List

  1. Nitrile exam gloves (1 pair)
  2. Sterile gloves (1 pair)
  3. Nexplanon
  4. 1% lidocaine with epinephrine (1 vial)
  5. Mosquito curved ridged hemostat (1)
  6. 11 Blade disposable scalpel (1)
  7. Chux pads (2)
  8. Alcohol swabs (6)
  9. 18 gauge 1.5 inch needle (1)
  10. 27 gauge 1.5 inch needle (1)
  11. 5 ml syringe (1)
  12. ChloraPrep 3mL stick (1)
  13. Steri strips (1)
  14. Sterile 2×2 gauze (6)
  15. Coban roll (1)

Procedure Note

NEXPLANON REPLACEMENT

The Nexplanon rod in place was palpated in the patient’s _ arm in the appropriate position. After informed consent was obtained, and time-out completed, the patient’s left arm was prepped in a sterile fashion with a ChloraPrep swab. Approximately 5 cc of 1% lidocaine with epinephrine was infused along the planned incision site, and below and along the palpated rod. An incision was made, the device brought to the level of the incision. The rod was removed intact and verified by patient and physician. Patient tolerated procedure well. Minimal bleeding throughout procedure. Steri-Strips were placed over incision, and covered by sterile gauze and pressure dressing. Minimal (<1 ml) blood loss during procedure. Post procedure instructions & precautions were given, including: keep top compression dressing in place for 24 hours, then dressing can be removed but allow Steri-strips to remain in place for 3-5 days. Keep the area clean and dry until fully healed. Return or call the clinic if there is bleeding, pus, or increasing redness, or pain at insertion site, or fever or chills. Patient informed that effective immediately she must use another form of birth control if pregnancy is not desired.

The needle of the Nexplanon insertion device was inserted into the skin through the newly created incision site. Upon insertion the needle was brought horizontal and using a tenting – advance motion the needle was advanced to its entire length. The applicator button was depressed and Nexplanon rod remained in place after the device was removed. The rod was palpated in place subdermally by both the physician and the patient. Minimal bleeding. The patient tolerated the procedure well. A Steri-strip and gauze dressing was applied over the insertion site and a pressure dressing was applied over the area. Post procedure instructions & precautions were given, including: keep compression dressing in place for 24 hours, then keep area clean and covered (with Band-Aid or gauze dressing) until healed, usually 3-5 days. Return or call the clinic if there is bleeding, pus, or increasing redness, or pain at insertion site, or fever or chills, the implant comes out or you have concerns about its location, or you have a positive pregnancy test or suspect you might be pregnant. Wallet card given.

Patient informed replacement date: _.

Posted in Procedures

Abscess Incision and Drainage

Consent Form

Equipment List

  1. Nitrile exam gloves (1 pair)
  2. 11 Blade disposable scalpel (1)
  3. Culture swab (1 swab)
  4. 1 Liter normal saline or sterile water (1)
  5. 60 ml (or largest available) syringe (1)
  6. Splash guard (1) if available
  7. Wash basin (1)
  8. Kidney basin (1)
  9. Forceps, curved (1 pair)
  10. Forceps, straight (1 pair)
  11. Sterile 4×4 gauze (10)
  12. Iodoform gauze (1 new bottle)
  13. Iodine swab sticks (3)
  14. Alcohol swabs (10)
  15. 1% or 2% lidocaine: If fingers, toes, penis, or nose – then without epinephrine. Otherwise with epinephrine. (1 vial)
  16. 10 ml syringe (1)
  17. 18 gauge 1.5 inch needle (1)
  18. 27 gauge 1.5 inch needle (1)
  19. Exam-room sheet (1 sheet)
  20. Chux pads (10)

Procedure Note

ABSCESS INCISION AND DRAINAGE

Risks and benefits of the procedure were discussed, including the risk of bleeding, pain, the need for repeat procedure. Patient indicated understanding and wished to proceed. Timeout performed.

Area of concern was cleaned and draped. Alcohol used to clean skin over area of injection. Injected _ ml of _% lidocaine with epinephrine. Area further swabbed with iodine swab sticks and allowed to dry. Using scalpel performed linear incision over lateral aspect of of induration. Drained _ ml of purulent fluid. Probed wound for loculations and broke them down using gentle opening motion of forceps. Irrigated wound with copious clean water. Wound packed with _. Covered with sterile dressing.

Patient tolerated the procedure well with approximately _ ml of bleeding.

Instructed patient to follow-up in _ days for removal of packing. Return immediately for fever, significantly worsening pain, spreading redness around the area, or other concerning symptom.

Posted in Procedures

Nexplanon Removal

Consent

Equipment List

  1. Nitrile exam gloves (1 pair)
  2. Sterile gloves (1 pair)
  3. 1% lidocaine with epinephrine (1 vial)
  4. Mosquito curved ridged hemostat (1)
  5. 11 Blade disposable scalpel (1)
  6. Chux Pads (2)
  7. Alcohol swabs (6)
  8. 18 gauge 1.5 inch needle (1)
  9. 27 gauge 1.5 inch needle (1)
  10. 5 ml syringe (1)
  11. ChloraPrep 3mL stick (1)
  12. Steri strips (1)
  13. Sterile 2×2 gauze (6)
  14. Coban roll (1)

Procedure Note

NEXPLANON REMOVAL

The Nexplanon rod in place was palpated in the patient’s _ arm in the appropriate position. After informed consent was obtained, and time-out completed, the patient’s left arm was prepped in a sterile fashion with a ChloraPrep swab. Approximately 3 cc of 1% lidocaine with epinephrine was infused along the planned incision site, and below the palpated rod. An incision was made, the device brought to the level of the incision. The rod was removed intact and verified by patient and physician. Patient tolerated procedure well. Minimal bleeding throughout procedure. Steri-Strips were placed over incision, and covered by sterile gauze and pressure dressing. Minimal (<1 ml) blood loss during procedure. Post procedure instructions & precautions were given, including: keep top compression dressing in place for 24 hours, then dressing can be removed but allow Steri-strips to remain in place for 3-5 days. Keep the area clean and dry until fully healed. Return or call the clinic if there is bleeding, pus, or increasing redness, or pain at insertion site, or fever or chills. Patient informed that effective immediately she must use another form of birth control if pregnancy is not desired.

Posted in Patient Information

Sleeping Difficulties in Infants

Adapted verbatim from:
Am Fam Physician. 2009Jul15;80(2):139-142.

Guidance for Parents

Newborns usually wake up every two to three hours. Each baby will have different sleep habits. Babies will sleep longer as they get older. Most babies sleep through the night by one year of age, but some babies start sleeping through the night by four to six months of age.

If your baby is not sleeping through the night by the end of the first year, you can try some things to help him or her sleep longer. Responding less often to your baby’s cries may help. For example, at first go to your baby within five minutes of crying, then wait for 10 minutes the next time, and then a little longer each time. After awhile, your baby will learn to calm down and go back to sleep.

Having your baby wake up at the same time each morning and go to sleep at the same time each night can help. Waking up your baby before expected middle-of-the-night awakening times also might help. For example, if your baby usually wakes up at 1:00 a.m., 4:00 a.m., and 7:00 a.m., wake him or her 15 minutes earlier each time. Your baby may eventually sleep through his or her predicted times.

More Info: Development of Normal Sleep Pattern

An important part of the childhood development process is gaining independence, and one way in which an infant works toward this goal is by sleeping through the night. Approximately 80 percent of children sleep through the night by six months of age, and 90 percent by one year of age. The definition of “sleeping through the night” is variable, because sleep schedules for each family and person are unique. Some children sleep through the night at an early age, but temporarily revert to nighttime awakenings. These awakenings are usual in the nine- to 18-month age group, when separation anxiety is common.

American Academy of Sleep Medicine 2006 Recommended Methods for Prolonging Sleep in Infants (5 years and younger):

The Parental Guidance above is from on these recommendations. These recommendations were based on a review of 52 articles on sleep in children. There is insufficient evidence to favor one method of sleep intervention over another. There is also insufficient evidence to support a combination of methods as more favorable than one sleep intervention alone.

Unmodified extinction

Lay the infant down to sleep at a designated time and do not respond to any crying until morning

Graduated extinction

Gradually respond less frequently to the infant’s cries (e.g., initially respond within five minutes of crying, then space out the response to every 10 minutes, then longer)

Bedtime routines

Maintain the same sleep and wake schedule daily

Scheduled awakenings before expected awakening time

If the predicted awakening times for the infant are, for example, 1:00 a.m., 4:00 a.m., and 7:00 a.m., awaken the infant 15 minutes earlier than the predicted time; the infant will eventually sleep through the predicted times

Note: Some methods listed may not be feasible for some families; for example, a family that lives in a thin-walled apartment complex may have complaints from neighbors if they attempt to let their infant cry through the night. Parents can try a method that fits with their values, culture, and living arrangement.

Avoid Medications

Trial of Infant Response to Diphenhydramine (TIRED)
The TIRED study showed that diphenhydramine (Benadryl) was no more effective than placebo in reducing nighttime awakenings in infants. Medication should not be used to treat this normal developmental stage. Parents can be reassured that regardless of the method used, there is no difference in family functioning between children who have and do not have sleep issues.

Resources

Childhood Sleep Information from UM Pediatrics

Posted in Procedures

Nexplanon Insertion

Consent

Ensure Patient is Not Pregnant

Equipment List

  1. Nitrile exam gloves (1 pair)
  2. Nexplanon device (1 package)
  3. 1% Lidocaine with epinephrine (1 vial)
  4. Chux pads (2)
  5. Alcohol swabs (6)
  6. 18 Gauge 1.5 inch needle (1)
  7. 27 Gauge 1.5 inch needle (1)
  8. 5 ml Syringe (1)
  9. ChloraPrep 3 ml stick (1)
  10. Steri strips (1)
  11. Sterile 2×2 gauze (6)
  12. Coban roll (1)

Procedure Note

NEXPLANON INSERTION

After informed consent was obtained and pregnancy reasonably excluded, a time-out was completed. The patient’s _ arm was then prepped in a sterile fashion with a ChloraPrep swab. A subdermal wheal was created at the entry point, then approximately 5 cc of 1% lidocaine with epinephrine was infused along the planned insertion path. The needle of the Nexplanon insertion device was inserted into the skin. Upon insertion the needle was brought horizontal and using a tenting – advance motion the needle was advanced to its entire length. The applicator button was depressed and Nexplanon rod remained in place after the device was removed. The rod was palpated in place subdermally by both the physician and the patient. Minimal bleeding. The patient tolerated the procedure well. A Steri-strip and gauze dressing was applied over the insertion site and a pressure dressing was applied over the area. Post procedure instructions & precautions were given, including: keep compression dressing in place for 24 hours, then keep area clean and covered (with Band-Aid or gauze dressing) until healed, usually 3-5 days. Return or call the clinic if there is bleeding, pus, or increasing redness, or pain at insertion site, or fever or chills, the implant comes out or you have concerns about its location, or you have a positive pregnancy test or suspect you might be pregnant. Patient instructed to use a back-up form of birth control for 7 days past insertion date. Wallet card given.

Patient informed replacement date is three years from today.

Posted in Procedures

Pilonidal Cyst Incision and Drainage

Consent Form

Equipment List

  1. Nitrile exam gloves (1 pair)
  2. Disposable scalpel – 11 blade (1)
  3. Forceps, curved (1 pair)
  4. Forceps, straight (1 pair)
  5. Sterile 4×4 gauze (10)
  6. Iodine swab sticks (3)
  7. Alcohol swabs (10)
  8. 1% lidocaine with epinephrine (1 vial)
  9. 10 ml syringe (1)
  10. 18 gauge 1.5 inch needle (1)
  11. 27 gauge 1.5 inch needle (1)
  12. Exam-room sheet (1 sheet)
  13. Chux pads (10)

Procedure Note

PILONIDAL CYST INCISION AND DRAINAGE

Risks and benefits of the procedure were discussed, including the risk of bleeding, pain, the need for repeat procedure. Patient indicated understanding and wished to proceed. Timeout performed.

Area cleaned. _ ml of 1% lidocaine with epinephrine injected through the thinnest area of the pilonidal cyst to form a bleb approximately 1 cm off of midline. Using scalpel a linear incision over lidocaine bleb was created, deep enough for pus to exude. Drained _ ml of purulent fluid. Area gently widened with forceps, and gauze applied. Covered with gauze dressing.

Patient tolerated the procedure well with approximately _ ml of bleeding.

Patient instructed to continue home dressing changes, and return once

Return immediately for fever, significantly worsening pain, spreading redness around the area, or other concerning symptom.

References

Posted in Procedures

Wound Suture

Background

When done properly wound irrigation and repair can help prevent infection and speed recovery. Remember that large volumes of low pressure water should be used for irrigation. The water does not have to be sterile! The wound is already dirty, so clean water is enough! The best option is allowing the patient to wash it out in a sink with constantly running water. Repair can help to reduce the time it takes for the wound to heal, but may increase infection risk. Healing by secondary intent is ok when you have significant concerns about infection from a dirty wound. Finally, remember to check if a tetanus shot is needed!

Consent Form

Equipment List

  1. Nitrile Exam Gloves (1 pair)
  2. Irrigation Fluid: Access to a sink, or 1 L Normal Saline or Sterile Water (1)
  3. 60 ml (or largest available) Syringe (1)
  4. Splash Guard (1) if available
  5. Wash Basin (1)
  6. Kidney Basin (1)
  7. Iris Scissors, Straight (1 pair)
  8. Needle Driver (1 pair)
  9. Toothed Pickup (1)
  10. Suture: Assorted (if specific suture not requested by provider)
    • 3-0 Vicryl (1)
    • 4-0 Ethilon (1)
  11. Iodine swabs (5)
  12. Alcohol Swabs (4)
  13. Sterile 4×4 gauze (10)
  14. Sterile 2×2 gauze (5)
  15. 1% or 2% lidocaine: If fingers, toes, penis, or nose – then without epinephrine. Otherwise with epinephrine. (1 vial)
  16. 10 ml syringe (1)
  17. 18 gauge 1.5 inch needle (1)
  18. 27 gauge 1.5 inch needle (1)
  19. Exam-room sheet (1 sheet) when necessary due to location of area to be sutured.
  20. Chux pads (5)
  21. Petroleum jelly (1 tube)
  22. Dermabond (1 tube)
  23. Steri Strips (3)
  24. Paper medical tape (1 roll)
  25. Coban roll (1)
  26. Band-Aid (1) if area is small enough to be covered by Band-Aid

Procedure Note

Wound examined to ensure no foreign bodies. Wound irrigated with large volume of clean water prior to repair. Risks and benefits of wound closure discussed with the patient including risk of infection and potential need to remove repair in the future. Patient indicated understanding and wished to proceed with closure. Anesthesia achieved with subcutaneous injection of _ ml of _% lidocaine with_ epinephrine. Wound then closed with _. Good tissue approximation and hemostasis achieved. Return precautions discussed. Patient instructed to return in _ days for removal of suture.

Tips

Posted in Procedures

Suture Tips

Suture Removal Time Period

  • Face: 5 days
  • Ear: 5 days
  • Neck: 7 days
  • Scalp: 7 days
  • Arm: 10 days
  • Hand: 10 days
  • Leg: 10 days
  • Chest: 10 days
  • Abdomen: 10 days
  • Back: 14 days
  • Foot: 14 days

Sutures in wounds under greater tension may have to be left in place slightly longer. For joint extensor surfaces, add 3 days.

Needle Types

  • Taper Point: This is a standard sewing needle type needle- it just gets bigger as you go along. It dilates the skin rather than cuts it. Best suited for soft tissue and stuff that stretches.
  • Reverse Cutting: Very sharp, and ideal for the skin. This cuts rather than dilates.
  • Conventional Cutting: Very sharp, cuts rather than dilates. However this needle has the cutting surface on the inside of the curve of the needle – so it creates weaknesses that allow the suture to tear out.
  • Taper Cutting: This is mainly used in cardiac or vascular procedures, because it works well on touch or calcified tissues.
Posted in Procedures

Shave Biopsy

Consent

Equipment List

  1. Nitrile exam gloves (1 pair)
  2. Toothed pickup (1)
  3. DermaBlade (1)
  4. ChloraPrep 3 ml stick (1)
  5. Sterile 4×4 gauze (10)
  6. Sterile 2×2 gauze (about as many as expected biopsies)
  7. Medical paper tape (1 roll)
  8. 1% or 2% lidocaine (with epinephrine) (1 vial with minimum 20 ml remaining)
  9. 10 ml syringe (1)
  10. 18 gauge 1.5 inch needle (1)
  11. 27 gauge 1.25 inch needle (1)
  12. Exam-room sheet (1 sheet, when necessary due to location of area to be excised)
  13. Chux pads (1)
  14. Formalin cups (as many cups as biopsy specimens)
  15. DrySol (Aluminum chloride) (1)
  16. Sterile cotton tipped applicators (CTA) (10)
  17. Petroleum ointment (1 packet)

Procedure Note

SHAVE BIOPSY

The procedure was explained in detail and informed consent was obtained from the patient. The area was prepped in a sterile fashion, and infiltrated with _ ml of _% lidocaine with_ epinephrine for local anesthesia. Forceps were used to elevate the lesion and a shave biopsy was performed with DermaBlade. The specimen was placed in a specimen jar and sent for analysis. DrySol solution was used for hemostasis. Petroleum ointment and a bandage were applied. EBL was less than 1 ml. Good hemostasis. There were no complications. Wound care and post-procedure warning signs were discussed. Patient voiced understanding.