Cutaneous Abscess I&D: Procedure Preparation

00:01 Hello, my name is Glenna Lashley and I'm a family nurse practitioner.

00:06 I work with students all the time and they always want more opportunity to see and hear from experienced providers how to perform advanced skills.

00:15 In this video today, I'm going to talk you through evaluating an abscess and an incision and drainage. We will also talk about when packing is I&Dicated and what patients need to know about their post-care procedures.

00:30 Because the skill involves multiple steps and things to think about, I want to reassure you I will explain what I'm thinking as we go along.

00:39 As I do this, I am going to explain the terminology that you need and how to document the procedure for your records, as well as for billing and coding.

00:48 We will also talk about which situations this is appropriate for and what patient variables you will need to consider. I will give you some ideas on how to talk to patients, as well as what equipment you need and any aftercare instructions you need to give your patient. Before we get started, let's talk about how abscesses present and why you might need to consider an incision and drainage as an advanced practice provider.

01:14 Most patients present to a provider because they have developed a cutaneous or skin abscess.

01:21 The areas these usually occur are around hair follicles.

01:24 So you think about this in the axilla area , the groin or the buttocks.

01:29 There's also sites of trauma or injection sites, as well as areas prone to friction or moisture.

01:37 The rationale to perform an incision and drainage is when the abscess demonstrates the following.

01:43 You want to make sure that it's fluctuant.

01:45 What this means is that there's fluid movement when you palpate.

01:49 You want the size greater than one centimeter.

01:52 You want to see signs of localized infection that will include erythema, warmth, and tenderness. And you also want a clear point of maximal fluency or spontaneous drainage point. Here is an example of what maximal fluency or spontaneous drainage point means.

02:11 And it's basically a fancy way of saying where the head is created.

02:16 Do not perform an I&D when you encounter the following deep tissue abscesses or those near vital structures. I would not perform an I&D on a chest wall or abdominal wall.

02:30 Facial abscesses in the danger triangle, which are going to be around the corners of the mouth and the bridge of the nose, as well as abscesses near large blood vessels or nerves, perirectal or polygonal abscesses.

02:45 This is going to be an abscess between the buttocks.

02:49 Immediate referral for patients is with deep tissue abscesses requiring imaging guidance, breast abscesses and lactating women, peritonsillar abscesses, hand abscesses where it's risk of a tendon involvement, large carbuncles with multiple drainage points, abscesses, and immune compromised patients, as well as any abscesses with systemic symptoms indicating sepsis. Before the procedure, let's make sure we have all the right equipment.

03:21 So over here you can see on my tray this is not sterile yet, but you would need a pair of sterile gloves.

03:27 You're going to need some antiseptic.

03:29 You want to use 1% lidocaine with epi.

03:32 Unless you're doing areas you need to be cautious with using epi.

03:36 You're going to use a 10 or 11 blade scalpel.

03:41 You're going to use a culture swab.

03:44 You also want to have your hemostats for exploration as well as irrigation supplies, gauze for packing if needed, and dressing supplies.

03:56 Step one, patient consent.

03:58 Before the procedure starts, you want to gain consent.

04:01 You want to explain to the patient what the goal is, which is to relieve pain and pressure, as well as reduce the risk of infection.

04:09 Some situations may require you to obtain a sample so that you can prescribe the right antibiotic therapy. Because splashing is possible, you want to make sure you will be wearing your goggles or glasses in my circumstances.

04:23 A face mask is also recommended and of course you will be wearing gloves.

04:28 You'll need a sterile field for both your supplies as well as the patient and a clean area with.

04:35 And you want to clean the area with an antiseptic solution.

04:39 You also want to palpate the abscess for density and potential for tunneling tenderness, heat, and spontaneous drainage.

04:48 Consider pain management options such as a digital field block.

04:52 And what this means is you're going to anesthetize the area around the abscess.

04:57 Check for numbness with a pricking sensation.

05:00 You want to let the patient know that they should feel pressure, but they should not feel any pain.

05:06 You want to make a linear incision over the point of maximal fluctuates.

05:11 Remember, that's where it's going to be coming to a head.

05:14 Incisions should be large enough to allow adequate drainage, but not too large. You want to cut parallel to the skin tension lines when it's possible.

05:25 You want to express the contents gently, but you want to obtain a culture first.

05:31 Explore the cavity with the hemostats or with the end of the Q-Tip to break up the flocculation.

05:38 Now we're going to talk about wound packing.

05:41 You're going to assess the need for packing based on the cavity size and location.

05:45 This is going to vary, but these are some of the circumstances in which you would want to do this.

05:50 If the cavity depth is greater than 1 to 2cm the presence of significant dead space, What that means is there's just a lot of tunneling in there, and you need to fill that space to create the healing process.

06:03 High risk areas prone to premature closure and large abscess cavities requiring healing by secondary intention. You also want to select the appropriate packing material.

06:17 You can use plain or iodoform gauze strips.

06:20 If you use Iodoform golf strips, you want some with antiseptic.

06:26 Use sterile technique. You want to gently insert the packing using your cotton tip, or you can also use your forceps.

06:36 You want to pack loosely at about 25% of the volume.

06:40 The reason for this is you're wanting the wound to heal and actually start to close up.

06:45 You want to leave a tail of the packing, and you want to tape it to the outside area of the skin, and you want to apply an outer absorbent dressing.