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 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.

Posted in Procedures

IUD Insertion

Consent Form:

Patient Handouts

Ensure Patient is Not Pregnant

Equipment List

  1. IUD device
  2. Sterile gloves (2 pair)
  3. Chux Pads (3)
  4. Exam-room sheet (1 sheet)
  5. Sanitary Pad (1)
  6. Pipelle (1)
  7. Os Finder (1)
  8. Speculum (1 each size)
  9. Speculum Light (1)
  10. Sponge Forceps (1)
  11. Curved Scissors (1)
  12. Tenaculum (1)
  13. Iodine swabs (5)
  14. Foxtail Swabs (10)
  15. Surgical Lubricant (2)

Procedure Note

IUD INSERTION

Before the procedure the risks and benefits were discussed, including the risk of bleeding, expulsion or migration of IUD, uterine perforation or embedding in the uterine wall, and infection. Patient voiced understanding and desire to proceed. Timeout performed (time documented on paper timeout form).

The speculum was inserted and the cervix was identified. Betadine was applied to the cervix and cervical os. Tenaculum was applied to anterior/superior cervix. Os Finder was inserted to gently dilate the cervix, and pipelle was used to sound the depth of the uterus. Depth measured at _ centimeters. The intrauterine device was inserted and deployed per manufacturer instructions. The string was cut to 3 centimeters length and a sample of the remaining string was given to the patient for later comparison. The patient tolerated the procedure well, without significant signs or symptoms of vasovagal responses. EBL less than _ ml. Standby present throughout the procedure including any pre-procedure examinations: _.

The patient was given the patient handout and card for the specific device and lot number of inserted device. The patient agrees to return for fever, severe lower abdominal cramping, heavy bleeding, or purulent discharge. The patient was counseled on how to check the strings herself to ensure the IUD has not been displaced, ind instructed to return for a post-placement exam if desired.

Posted in Procedures

Reasonable certainty a woman is not pregnant

For the purpose of starting birth control

  1. No symptoms or signs of pregnancy, and
  2. Any one of the following:
    1. ≤7 days after the start of normal menses.
    2. No had sexual intercourse since the start of last normal menses.
    3. Been correctly and consistently using a reliable method of contraception.
    4. ≤7 days after spontaneous or induced abortion
    5. Within 4 weeks postpartum.
    6. Fully or nearly fully breastfeeding (exclusively breastfeeding or the vast majority ≥85% of feeds are breastfeeds), amenorrheic, and <6 months postpartum.

Should you wait to start birth control?

In situations in which the health-care provider is uncertain whether the woman might be pregnant, the benefits of starting the implant, depot medroxyprogesterone acetate (DMPA), combined hormonal contraceptives and progestin-only pills likely exceed any risk; therefore, starting the method should be considered at any time, with a follow-up pregnancy test in 2-4 weeks. For IUD insertion, in situations in which the health-care provider is not reasonably certain that the woman is not pregnant, the woman should be provided with another contraceptive method to use until the health-care provider can be reasonably certain that she is not pregnant and can insert the IUD.

When starting a new form of birth control, if >5 days after menses started, use back-up method or abstain for 7 days. Exception: Copper-containing IUDs are immediately effective.

Documentation

Pregnancy was reasonably excluded based on the patient having no symptoms or signs of pregnancy and:

  • [_] ≤7 days after the start of normal menses.
  • [_] no sexual intercourse since the start of last normal menses.
  • [_] been correctly and consistently using a reliable method of contraception.
  • [_] ≤7 days after spontaneous or induced abortion
  • [_] within 4 weeks postpartum.
  • [_] fully or nearly fully breastfeeding (exclusively breastfeeding or the vast majority ≥85% of feeds are breastfeeds), amenorrheic, and <6 months postpartum.

Reference:

Posted in Procedures

Subacromial Shoulder Injection

Consent Form

Equipment List

  1. Nitrile Exam Gloves (1 pair)
  2. Kenolog (Triamcinolone Acetonide) 40mg/mL (1 vial)
  3. 1% lidocaine (without epinephrine) (1 vial with minimum 10mL remaining)
  4. 10 mL syringe (1)
  5. 18 gauge 1.5 inch needle (1)
  6. 25 gauge 1.5 inch needle (1)
  7. Iodine swabs (2)
  8. Sterile 4×4 gauze (2)
  9. Alcohol Swabs (4)
  10. Band-Aid (1)

Procedure Note

SUBACROMIAL SHOULDER INJECTION

Risks and benefits were discussed, including treatment failure (no relief from this injection), new pain, swelling, and infection. Specifically, the patient was counseled that in the first 72 hours it is common to have rebound worsening of pain symptoms, before improvement is noted. Patient verbalized understanding and wished to go forward with procedure. Verbal timeout performed, pausing to verify patient and procedure.

Patient remained in a seated position, posterior approach without ultrasound guidance. Posterior acromion palpated. The skin was prepped with iodine swabs. 40 mg of triamcinolone acetonide (1 ml of 40mg/ml) was drawn into a syringe with 9 ml of 1% lidocaine without epinephrine. A 25 gauge 1.5″ needle was used to inject all 10 ml into the subacromial space. The patient tolerated the procedure well.