WK 4 LAB ASSIGNMENT: DIFFERENTIAL DIAGNOSIS FOR SKIN CONDITIONS

Chapter JO I Nail Removal 41

Chapter

Nail Removal Margaret R. Colyar

. r C.ode 11730-32 Nail removal, partial or complete 11750 Permanent nail removal, partial or complete

No code for cotton wick insertion-Use l 1730-32 if part of the nail was removed.

An ingrown toenail occurs when the na il edge grows into the soft tissues, causing i111lammation, erythema, pain, and, possibly, abscess formation (Fig. 10.1). Many 1imes rhere is an offending nail spicule (small needle-shaped body) that must be

l'l'l110Ved.

OVERVIEW • C;1uses

• C urved nails Congeni tal malformation of the great toenail, an autosomal dominant trait

Nails cut roo short Nail trimmed round edges Poorly fitting or too-tight shoes

High-heeled shoes Accumulation of debris under nail

Poorly ventilated shoes Chronically wet feet

HEALTH PROMOTION/PREVENTION • Cut nails straight across. • Notch center of nail with a V. • Wt:ar absorbem socks. • Wl:;1r shoes that allow proper ventilation.

• Wt:ar shoes thar flt properly. • !\void high-heeled shoes. • \ J~t: good foot hygiene.

42 Section One I Dermatological Procedures

__,,.,~--:::::?" Dorsal cutaneous nerves

-+-+--Dorsal deep nerves

Hyponychium

Sulcus

Eponychium (cuticle)

Figure 10.1 Toenail anatomy.

OPTIONS

• Method 1-Cotton wick insertion • A noninvasive technique to be used as the initial treatment. Six trearments

may be required. • Method 2- Partial avulsion with phenolizat:ion

For lesions lasting more than 2 months with significant infection and development of granulomatous tissue

RATIONALE • 'Ii> di111ini.~ l1 pain • ·I( , p1·t·vrn1 m rdicvc . 1h.~n·~~ l(1rn1.11 ln11

Chapter 10 I Nail Removal 43

• To promote healing • To prevent toenail regrowth

INDICATIONS • Ingrown toenail without complicating medical history (onychocryptosis) • Chronic, rec urrent inflammation of the nail fo ld (paronychia)

CONTRAINDICATIONS • Diaberes mellitus • Peripheral vascular disease • Peripheral neuropathy • Anticoagulant therapy • l31ccding abnormalities • lmmunocompromised state • Pregnancy because of need to use phenol • Allergy to local anesthetics

l)ROCEDURE

Nail Removal Equipment • Mcrhod 1 only

Antiseptic skin cleanser Nail file or emery board Cotton: 3 mm (Vs-inch) thick by 2.5 cm (1 inch) long ( ;lovcs-nonsterile Splinter forceps-sterile T inctu re of iodine Silv..:r nitrate stick Ii x 4 gauze- sterile ·1:1 pc

• Mcd10cl 2 only-Digiral nerve block 'i -m L syringe .~ )- to 27-gauge, Yi- to I-inch needle I 1X1 liclocaine without epinephrine

• tvkd10<l 2-Avulsion ' li>11rniqlll:t l :lovt:.~-srcrile

I )rape - src.:rilc I lcmostat- stcrilc Su rgid .~cissors-ster i lc

S11l:ll l s1 r:1igh1 hcmostar- stcl'lk• • ( :011 on .~w:1hs-s1crilc

Sll w·1 11i1 r;11r stlc:i< Hll11,i 111 HH'to plw1wl

--

44 Section One IDermatological Procedures

• Alcohol swabs • Alcohol • Antibiotic ointment (Bactroban, Bacitracin, or Polysporin) • Nonadherent dressing-Telfa or Adaptic • Bandage roll (tube gauze)

Procedure METHOD I - COTTON WICK INSERTION

• Have the client lie supine with knees flexed and feet flat. • Cleanse affected toe with antiseptic cleanser. • File middle thi rd of nail on the affected side with a nail file or emery board as

illustrated (Fig. 10.2). • Roll cotton to form a wick. • Gently push the cotron wick under the distal portion of d1e lateral nail groove

on me affected side using splinrer forceps (Fig. 10.3) . • Identify me offending spicule and remove it. • Continue to insert cotton wick to separate the nail from the nai l groove (1 cm

of cotron wick should remain free). • Apply tincture of iodine to the cotton wick. • Cauterize granulomarous tissue with silver nitrate stick. • Bandage the toe.

Client Instructions • Change bandage daily, and apply tincture of iodine every omer day. • Return to th e office weekly for cotton wick replacement.

METHOD 2-PARTIAL AVUI.SION WITH PHENOLIZATION

t lnjimned cowmt req11 ired • Have the diem lie supine with knees flexed and feet flat. • For digital nerve block, prepare 3 to 5 mL of lidocaine without epinephrine to

anesmetize the affected area.

illl I_.. ­

naur~ 10.2 Fiie· tlw 111lddl1• tlilul 11f d11 tHll

Chapter JO INail Removal 45

-­ Figure I 0.3 Gently push a conon wick under d1e lateral nail groove.

• ' fo anesrl1etize th e nerves innervating the proximal phalanx on th e extensor surface, insert the needle toward the planrar surface on the affected side.

• Injection sites are below the nail on me outer edges of the toe (Fig. 10.4). Be

c:m:Ful not to pierce the plantar skin surface. • Inject I 10 2 mL oflidocaine while withdrawing the needle. Do not withdraw

1li e needle from the skin. • Redirect rhe needle across the extensor surface, and insert me needle further.

lnjecr 1 mL of lidocaine while wimdrawing needle. • Repeat procedure on opposite side of the d igit. • Allow 5 minutes for lidocaine to take effect before beginning procedure. • Sl't'u b rhc toe with antiseptic, rinse, dry, and drape with sterile drapes. • Place the tourniquet around the base of the toe. Perform procedure in 15

111i11111cs or less to avoid ischemia. • Inscl'I a single blade of a small hemostat between the nailbed and the toe tO

op\'n a tract (Fig. 10.5). Remove hemostat. • l'l:in: thc blade of the scissors in the tract, and cut the nail plate from disr;i l

1·dgc 10 1he proximal nail base (Fig. 10.6). • llt·111ovc 1he nai l with a small hemostat, using genrle rotation row:ird rhc

1 lfl i:~· 1 l·d nail (Pig. 10.7). • l J,,lng a hcmos1a1, i11spccr rhe nail g1•onvt1 1111' ~p lc11lcs.

• 1)1 )' di ~ 11nvly c.~ posd n:illhcd.

46 Section O ne I Dermatological Procedures

Figure I 0.4 Anesthetize the nerve innervating the proximal phalanx. Inject the roe on the outer edges just below the nail.

Figure I O.S Insen a single blade of a hemostat between the nailbed and the toe to open a tracr.

• Rub cotron swab saturated wi th phenol on germinal matrix beneath the c111 il:k· for 2 m inutes.

• Cauterize granulomas with silver nitrate stick. • Remove ro11rniq11cl and cleva1 c font for 15 111i11u1 c~. • Pl:11:e :1 dress I11g In ii1c Ille.

Chapter JO I Nail. Removal 47

Figure I 0.6 Cm the nail plate from distal edge co proximal nail base.

Figure 10.7 Remove the nail using gen tle ou1ward rotation toward the affected nail.

Client lnstrua ions • Avoid bchc111 ia or !CW hy l1Jtl~l'lll 11 11 ili l h.111d,1nl' :i 11d hangi ng roOI down. • Nn1 Hy 11 1<· prar1l1lo1w1 ll' p,11 11 111\Wdll11~11111r,1 '>l'~ nr gn:en 01· y(·llmv di~~'h.uw;

I'< j lrl'Sl' ll I.

48 Section One I Dermatological Procedures

• If roes become cold and pale Elevate foot above heart level

• Flex the roes Check circulation by pressing on the roe and watching for return of redness when pressure is released Call the practitioner if symptoms do not subside within 2 hours

• Use pain medications as ordered. Take Tylenol No. 3 every 4 to 6 hours for the first 24 hours; then take an NSAID such as ibuprofen.

• Take ordered antibiotics for 5 days (cephalexin, tetracycl ine, trimethoprim· sulfamethoxawle, amoxicillin).

• Return to the office for follow-up visit in 2 days.

81 BLIOGRAPHY c:::;;:;=;;;;;;;;;;;;;::;;:;:;;;:;;.:::;;.:;::;...

Heidelbaugh JJ, Lee H. Management of rhe ingrown toenail. Am Fam Physician. 2009;79(4):303-308.

Pfenninger JL, Fowler GC. Procedures for Primmy Care Physicians. Sr. Louis, MO: Mosby; 2011.

Zuber TJ. Ingrown toenail removal. Am Fam Physician. 2002;65(12):2547-2550.

Chapter

Ring Removal Cynthia R. Ehrhardt

( r C.o :le 20670 Superficial removal of constricting metal band 20680 Deep removal of constricting metal band

Occasionally, a ring must be removed from a digit. Whenever possible, a nondesrruc­ cive method is preferred. Only when conservative methods have been exhausted should a ring cutter be used.

OVERVIEW • Complicating factors

• Swelling or edema ro the digit • Increased pain and sensitivity to area • Embedding of metal filings into digit

General Principles • Minimize 1hc amoun1 of pain. • S11H>o1h 1ccl111iquc min imizes fo rt ht·r 1r:i 111ll:1 to :11nt,