Download Station: Punch Biopsy

Dermatology Laboratory
Biopsy, Cryosurgery, Toe Nail Removal, and I & D
Medical Procedures
Laboratory
Name: ____________________________
Pre-Lab Questions
Must complete prior to participation in lab
All answers are easily obtained from text book
Due start of lab
A patient presents with a lesion for removal. Based on clinical presentation you believe
that the lesion is melanoma. Based on clinical assessment, which biopsy method should
be utilized to remove this lesion?
What is the importance of skin tension lines?
Cosmetically it is more appealing to perform an excisional biopsy rather than a punch
biopsy on a lesion that is _______ or larger. Why?
Explain the procedure for performing a punch biopsy.
If a lesion is 1 cm x 0.5 cm, draw the intended incision lines for an excisional biopsy—
including angles, width, and length of intended lines.
List 4 contraindications of cryosurgery.
Explain the procedure of a cotton tipped Applicator/Swab Method for cryosurgery
How much freeze time is required for hypertrophic lesions during cryosurgery?
If permanently removing a nail, what must the provider do to the nail bed?
Biopsy
At the conclusion of this laboratory, the student shall
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Describe and label essential anatomy and physiology associated with layers of the
skin
Describe the indications, contraindications, and rationale for performing excision,
punch, and shave biopsies
List two types of partial-thickness skin biopsies.
List two types of full-thickness skin biopsies.
Describe the technique for a shave biopsy, and list lesions that would be
appropriate for this type of biopsy.
Describe the technique for a punch biopsy, and list lesions that would be
appropriate for this type of biopsy.
List areas of the body that are NOT suitable for a punch biopsy.
Identify common complications associated with performing biopsies
Identify the materials necessary for performing biopsies and their proper use
Perform an excisional, punch, and shave biopsy
Identify the important aspects of care after biopsies
NAME: __________________________
Station: Shave Biopsy
Grading Rubric for Shave Biopsy:
CHARACTERISTIC
Validate Order. Explains need and procedure to
patient
Uses universal precautions
Cleanses site with 70% ETOH. Lets air dry or
wipes dry using sterile dressing
If lesion has the potential to blanche with an
injection of lidocaine with epinephrine, mark the
margins of the lesion with a surgical marker
before anesthetic
Inject with anesthetic so that a wheal is raised
Hold No.15 blade flat and parallel with skin
surface
The lesion may be elevated with the use of
forceps
Use a gentle sawing motion to shave through the
lesion
Place lesion in specimen jar
Control light bleeding with pressure or 20%
aluminum chloride on a cotton tipped applicator
Place an antibiotic ointment on an adhesive
bandage to dress the wound
Provide patient instructions for wound care
RANGE OF
ACCEPTABILITY
S
Modify explanation according to
patient’s physical and emotional
status
No deviation
No deviation unless cautery use is
anticipated
No deviation
No deviation
No deviation
May not be necessary
No deviation
May not be necessary
Hand held cautery should be used if
bleeding not controlled
No deviation
No deviation
STUDENT NAME: _______________________________ Evaluator: _________
PASS: ________ FAIL: _______ ATTEMPT # _________
US
NAME: __________________________
Station: Punch Biopsy
Grading Rubric for Punch Biopsy:
CHARACTERISTIC
Explains need and procedure to patient
Uses universal precautions
Cleanses site with 70% ETOH. Lets air dry or
wipes dry using sterile dressing
Drape biopsy site if < 1 cm; If > 1 cm first scrub
area with povidone iodine or chlorhexidine for 3
minutes and then drape
If area has the potential to blanche, mark with
sterile surgical pen
Inject the lesion with anesthetic
Select appropriate size punch to completely
excise the lesion with minimal surrounding
normal tissue
Hold the skin taut perpendicular to the lines of
tension, wrinkle or skin fold
Hold the punch perpendicular to the skin and
place it so that the lesion is centered within the
punch area
Apply downward pressure while rotating the
punch
Extend punch into subcutaneous fat
Remove punch and cut specimen at the base with
a pair of scissors (or cut with a blade)
Place in a specimen container
Suture the wound, placing half as many sutures as
the size of the punch
Apply an antibiotic ointment on the adhesive
bandage to dress the wound
Provide patient follow up instructions (suture
removal) and inform of pathologic examination
when available
RANGE OF
ACCEPTABILITY
S
Modify explanation according to
patient’s physical and emotional
status
No deviation
No deviation unless cautery use is
anticipated
No deviation
No deviation
No deviation
No deviation
No deviation
No deviation
No deviation
No deviation
No deviation
No deviation
No deviation
No deviation
No deviation
STUDENT NAME: _______________________________ Evaluator: _________
PASS: ________ FAIL: _______ ATTEMPT # _________
US
NAME: __________________________
Station: Excisional Biopsy
Grading Rubric for Excisional Biopsy:
CHARACTERISTIC
Explains need and procedure to patient
Uses universal precautions
Anesthetize by using direct infiltration, digital
block, or a field block as necessary
Cleanses site with chlorhexidine or povidone
iodine for 5 minutes. Lets air dry or wipes dry
using sterile dressing
Drape biopsy site
If lesion has the potential to blanche, mark with
sterile surgical pen
Use a sterile surgical pen to mark the intended
incision line
Hold No. 15 blade like a pencil, perpendicular to
the skin
Use the tip of the blade to incise the corner of the
ellipse, but the belly is used for the rest of the
incision
Continue the incision through the dermis to the
subcutaneous fat
Use forceps to lift the specimen gently
Use the No. 15 blade to cut the specimen at the
base or subcutaneous fat
Tag lesion if malignancy suspected
Place in a specimen container
Determine if wound is under tension/undermine
as needed
Suture the wound closed
Apply an antibiotic ointment on the adhesive
bandage to dress the wound
Provide patient follow up instructions (suture
removal) and inform of pathologic examination
when available
RANGE OF
ACCEPTABILITY
S
Modify explanation according to
patient’s physical and emotional
status
No deviation
No deviation
No deviation unless cautery use is
anticipated
No deviation
No deviation
No deviation
No deviation
No deviation
No deviation
No deviation
No deviation
May not be necessary
No deviation
No deviation/may not be necessary
No deviation
No deviation
No deviation
STUDENT NAME: _______________________________ Evaluator: _________
PASS: ________ FAIL: _______ ATTEMPT # _________
US
Cryosurgery
At the conclusion of this laboratory, the student shall be able to
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Describe the indications, contraindications and rationale for performing cryosurgery
Identify and describe common complications associated with the use of cryosurgery
on small skin lesions
Describe the essential anatomy and physiology of the skin associated with the
performance of cryosurgery on small lesions
Identify the materials and tools necessary for performing cryosurgery on skin lesions
and their proper use for cotton tipped applicator or spray method
Identify the important aspects of care after cryosurgery on small skin lesions
Define the term, cryosurgery.
Describe the sensation associated with a cryosurgery treatment to a patient.
Discuss advantages and disadvantages of cryosurgery
Explain why scarring is minimal with cryosurgery.
Identify the temperatures at which regular and malignant tissue destruction by
cryosurgery occur.
Identify the best way to estimate freeze depth and determine freeze time.
Describe the appearance of the skin over the first several days after effective freezing.
Explain how skin pigmentation or hair growth may change as a result of cryosurgery.
List some procedures that are amenable to cryosurgery.
Explain how and why the cryosurgery technique needs to be modified in patients with
disorders associated with high levels of circulating cryoglobulins.
Perform cryosurgery
NAME: __________________________
Station: Cryosurgery
Grading Rubric for Cryosurgery:
CHARACTERISTIC
Explains need and procedure to patient
Uses universal precautions
Consider pre-cryosurgery anesthesia with topical
agents
Ensure patient comfort in a sitting or supine
position as indicated
Consider marking the margins of the lesion with a
surgical marker
Obtain liquid nitrogen from container into
Styrofoam cup
With gloved fingertip, loosen tight weave of swab
Dip swab in liquid nitrogen and apply swab to
lesion
Repeat process until an ice ball extends 1 to 2 mm
beyond the clinical lesion, lasting from 10-20
seconds
Provides patient instruction
RANGE OF
ACCEPTABILITY
S
Modify explanation according to
patient’s physical and emotional
status
No deviation
May not be necessary
No deviation
May not be necessary
No deviation
No deviation
No deviation
No deviation
No deviation
STUDENT NAME: _______________________________ Evaluator: _________
PASS: ________ FAIL: _______ ATTEMPT # _________
US
I&D
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Define abscess
Define furuncle or boil
Define carbuncle
Define Paronychia
Describe the indications, contraindications, and rationale for performing incision
and drainage (I & D) of an abscess
Define the cardinal signs of infection
Define the borders of the triangular area on the face that should not be incised
Identify and describe common complications associated with incision and
drainage of an abscess
Describe the essential anatomy and physiology associated with the performance
of incision and drainage of an abscess
Identify the materials necessary for performing incision and drainage of an
abscess and their proper use
Discuss the procedure for performing incision and drainage of abscesses
Identify the appropriate anesthetic technique used to anesthetize an abscess
Identify the appropriate location for wound culture of an abscess
Define the purpose of iodoform gauze
Define the healing process used in I & D
Identify the important aspects of care after incision and drainage of an abscess
Identify patients who might need antibiotics post I & D procedure
Explain how to recognize when a palmar abscess has extended from superficial to
deep tissue, and how this problem needs to be treated.
NAME: __________________________
Station: Incise and Drain (I & D)
Grading Rubric for I & D:
CHARACTERISTIC
Explains need and procedure to patient
Uses universal precautions
Apply single layer of povidone iodine to the
abscess and allow to air dry
Use a regional field block anesthetic technique
around the perimeter of the abscess
Place drapes to ensure isolation of abscess
Make the incision parallel to Langer’s lines along
full dimension
If required obtain culture from purulent material
Explore the abscess cavity completely to break
septum and loculations
Irrigate cavity with saline
Insert iodoform gauze into the abscess cavity,
with 1 cm of gauze exiting from the cavity
Apply a sterile dressing over the abscess
Instruct on packing/dressing change and follow
up care
RANGE OF
ACCEPTABILITY
S
Modify explanation according to
patient’s physical and emotional
status
No deviation
May cleanse site with 70% ETOH.
Lets air dry or wipes dry using sterile
dressing
No deviation
No deviation
No deviation
No deviation
No deviation
No deviation
No deviation
No deviation
No deviation
STUDENT NAME: _______________________________ Evaluator: _________
PASS: ________ FAIL: _______ ATTEMPT # _________
US
Name: ____________________________________
Biopsies, Cryosurgery, and I & D
Station #1: Pre-Lab Preparation
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Read chapters 24, 25, 27, and 28
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Answer questions prior to start of lab
Station #2:
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Demonstrate proper technique in performing a shave biopsy
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Demonstrate proper technique in performing a punch biopsy
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Demonstrate proper technique in performing an excisional biopsy
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Demonstrate proper technique in performing cryosurgery
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Demonstrate proper technique in performing an I & D
Station #3:
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Self directed tutorial toenail removal