I&D: How to perform an Incision & Drainage

I&D: How to perform an Incision & Drainage

William J. Kelly, MSN, FNP-C
William J. Kelly, MSN, FNP-C

Author | Nurse Practitioner

      

An I&D or Incision and Drainage is a procedure that is done to treat infections that have turned into abscesses.

Knowing how to perform an I&D is important for a nurse practitioner in most settings, but especially in the ER or Urgent Care.

Learn how to do an I&D (Incision and drainage) including step-by-step instructions how to drain an abscess, antibiotic selection, whether or not to pack the abscess, and discharge instructions

What is an I&D?

An I&D or Incision and Drainage is performed when there is an accumulation of fluid within the body that needs to be drained.

This is usually from a skin abscess.

An I&D is performed in urgent cares, emergency departments, or in outpatient clinics like general surgery.

Patients with an abscess will usually complain of pain, welling, and redness of the affected area.

Abscesses can occur anywhere on the body, but commonly occur:

  • In the axillae (armpits)
  • On the upper legs and buttock
  • Pilonidal region (above the buttcrack)
  • On fingertips next to nail (termed paronychia)

While anyone can get an abscess, these are more common in those with poor hygiene, as well as those who are immunocompromised.

Diabetics and patients who are obese are also at risk for abscess formation.

When To Do an I&D?

An I&D is performed to drain purulent fluid (pus) from the body.

These collections of pus are termed “abscesses”, and draining them is the best way to treat the infection, as well as preventing the abscess from getting bigger and causing a more serious infection.

If there is no fluctuance palpated (fluid felt underneath the skin), then a trial of PO antibiotics can likely be used without having to do an I&D.

Most cases of obvious abscesses will benefit from an I&D.

There are certain abscesses that require the expertise of a surgeon to drain. These include:

  • Perirectal or perianal abscesses
  • Anterior and lateral neck abscesses
  • Hand abscesses (except paronychia)
  • Abscesses adjacent to vital nerves or blood vessels
  • Abscesses in the center of the face
  • Breast abscesses near the areola and nipple

It is also best for abscesses >5cm to be drained and managed by a surgeon.

I&D and ANTBIOTICS

While antibiotics can help for skin infections like cellulitis, they often won’t be able to fully treat an infection if an abscess is there.

This is why an I&D is necessary.

Young, healthy patients who are not immunocompromised do not need antibiotics if an I&D is performed on a small abscess < 2cm.

Most others will require systemic antibiotics including:

  • Deep abscesses like in the abdomen
  • Multiple abscesses
  • Significant surrounding cellulitis
  • >2cm in size

However, these antibiotics likely won’t work without also performing an I&D!

Which Antibiotics?

Like skin infections, most abscesses are caused by staphylococcus aureus and other gram-positive bacteria.

However, MRSA is very common, especially with abscess formation. This means that standard antibiotics for cellulitis like Keflex may not work.

Antibiotic selection should cover MRSA

MRSA-covering PO agents include:

  • Bactrim 1-2 tabs BID x 10 days
  • Doxycycline 100mg BID x 10 days
  • Minocycline 100mg BID x 10 days
  • Clindamycin 300mg q6-8h x 10 days
  • Linezolid 600mg BID x 10 days (expensive)

Perirectal abscesses that are drained will need additional coverage for gram-negative bacilli and anaerobes, so options include:

  • Add Augmentin to the MRSA-covering agents above
  • Add Levaquin AND Flagyl to the MRSA-covering agents above
  • Add Cipro to Clindamycin

Severe infections and abscesses that require inpatient admission would be started on IV Vancomycin +/- Cipro/Flagyl or Zosyn.

Aerobic and anaerobic cultures should be obtained and sent to the lab to guide antibiotic use.

Patients at risk of bacterial endocarditis should be started on antibiotic prophylaxis. These should be given 1 hour prior to the I&D.

Bacterial Endocarditis Prophylaxis

Antibiotic prophylaxis is given to certain people at risk for developing bacterial endocarditis. These oral antibiotics should be given 1 hour prior to the I&D.

Antibiotic prophylaxis should be given for patients with:

  • Prosthetic heart valves
  • Rheumatic heart disease
  • Unrepaired congenital heart disease
  • H/o infective endocarditis
  • Central lines

Antibiotic prophylaxis for bacterial endocarditis include:

  • Bactrim
  • Doxycycline and amoxicillin
  • Minocycline and amoxicillin
  • Clindamycin

HOW TO PERFORM AN I&D

1. Collect your Equipment

An I&D is an invasive procedure and will require some equipment.

An I&D is also considered a clean procedure, so you do not need sterile gloves or a sterile field, although some do still utilize sterile technique.

Your facilities may have kits put together which contain much of what you need for the I&D.

I&D Equipment

I&D Kit PPE
  • Scalpel (#11)
  • Betadine or CHG
  • 4×4 Gauze
  • Curved hemostats
  • Scissors
  • Clean or Sterile Gloves
  • Gown
  • Face shield (trust me)
ANESTHETIC IRRIGATION
  • 1-2% Lidocaine
  • 3-5 cc syringe
  • Blunt needle
  • 25-30g needle
  • 1-2% Lidocaine
  • 3-5 cc syringe
  • Blunt needle
  • 25-30g needle
PACKING & DRESSING Culture Swabs
  • Iodoform or plain gauze packing tape
  • ABD pad and gauze
  • Tape
  • Aerobic swab
  • Anaerobic swab

3. Anesthetize

Before you make the incision, you should anesthetize the area you are going to cut.

Abscesses are already irritated and will be very painful.

Unfortunately, lidocaine doesn’t work as well as usual because abscesses are an acidic environment.

Draw up your 1-2% lidocaine into your 3cc syringe with a blunt needle.

Switch out to the smaller gauge needle (25-30g) and prime the lidocaine. You are now ready to infiltrate.

You have a few options when it comes to HOW you are going to anesthetize the area.

Linear Block

For smaller abscesses <5cm, locally infiltrate the lidocaine in a line where the incision will be, across the entire length of the abscess. This will be painful for the patient.

Incisions should be made along the lines of the body that have decreased tension to reduce scarring.

Local infiltration involves sticking the needle just underneath the epidermis, and injecting a small amount of lidocaine while you gently pull the needle back out.

You are infiltrating the subcutaneous tissue, but not deep enough to actually inject into the abscess itself.

This is done multiple times until the projected line where you will cut is fully infiltrated.

After 3-5 minutes, you can begin the incision.

Field Block

For larger abscesses >5cm, the linear approach above should be used, IN ADDITION to a ring or field block.

A field block is achieved by injecting a ring of subcutaneous 1% lidocaine around the abscess, approximately 1cm peripheral to the erythematous border.

Remember the max dose of lidocaine is 4.5mg/kg
(max 300mg)

This means for lidocaine 1% (10mg/mL) the max dose would be 30mL in most adults over 65kg – you hopefully should not be using anywhere near this amount.

Lidocaine should start working in 45-90 seconds, but you should give it 3-7 minutes to fully kick with an abscess.

Tips to Decrease pain with lidocaine

  • Buffer the lidocaine with 9:1 ratio (lidocaine to 8.4% bicarb)
  • Use a smaller needle
  • Inject slowly
  • Use room temperature lidocaine
  • Stimulate adjacent skin
  • Ring block/field block technique as above

4. Make the Incision

Once you have given enough time for the lidocaine to work (3-5 minutes), make a linear incision with the scalpel.

This needs to be deep enough to penetrate the abscess wall, but not too deep to cause injury.

It helps if you have 4×4 gauze in the other hand, as purulent fluid will usually immediately start gushing out.

Cut the entire length of the abscess, as not making a wide enough incision is one of the main causes of a recurrent abscess.

5. Obtain Cultures

Young healthy patients with small abscesses <2cm who won’t get antibiotics don’t need cultures obtained.

Patients started on antibiotics should have cultures obtained if:

  • Significant cellulitis
  • Systemic symptoms like fevers
  • History of recurrent abscesses
  • Failure of initial antibiotics
  • Very young or old
  • Immunocompromised

Make sure to obtain swabs for both aerobic and anaerobic gram stain and culture.

6. Loculations & Irrigation

Abscesses have a tendency to become loculated. This means there can be individual pockets of pus within the abscess itself.

To “break these up”, insert a hemostat into the incision and open it up in all directions in order to break up any possible loculations. This is often painful.

Draw up sterile saline with the 20-60cc syringe, attach the splash guard or IV catheter, and irrigate the incision to effectively clean out the abscess.

This is best practice although not always performed, especially for smaller abscesses.

7. Pack wound (optional)

I&D incisions are almost never closed with sutures but are left open to heal by “secondary intention”, meaning naturally.

Sometimes packing should be used.

Packing is when you insert special gauze into the wound that promotes drainage.

Packing is generally recommended for:

  • Abscesses >5cm
  • Pilonidal abscesses
  • Immunocompromised / diabetics

If you decide to pack the wound, do not over-pack the wound too tightly. This increased pressure can cause tissue damage.

Gently insert the iodoform ribbon into the wound with a blunt object such as a cutip swab. This does not have to “stuff” the wound. Leave a 1cm tail outside of the wound.

Cover the packing with an absorbable dressing.

Patients with packing will need to return for a wound check-in 2 days. If there is still significant drainage, more packing can be placed.

Discharge Instructions

Before discharge, make sure their tetanus is uptodate.

I&D without packing should soak in warm soapy water 2-3 times per day, and f/u in 7-10 days or sooner if systemic signs of infection present.

I&D with packing should return in 24-48 hours. Once packing is removed and the drainage stops, warm soapy soaks can be started.

REFERENCES

Approach to management of drainable abscess or skin infection with purulent drainage in adults. (2021). UpToDate. Retrieved September 7, 2021, from https://www.uptodate.com/contents/image?imageKey=ID%2F114919&topicKey=ID%2F110530
Graphic 114919 Version 10.0

Buttaravoli, P. M., & Leffler, S. M. (2012). Cutaneous Abscess or Pustule. In Minor emergencies (3rd ed., pp. 655-659). Saunders.

Downey, K. A., & Becker, T. (2021). Techniques for skin abscess drainage. In T. W. Post (Ed.), UpToDate. https://www.uptodate.com/contents/techniques-for-skin-abscess-drainage

Sexton, D. J., & Chu, V. H. (2021). Antimicrobial prophylaxis for the prevention of bacterial endocarditis. In T. W. Post (Ed.), UpToDatehttps://www.uptodate.com/contents/antimicrobial-prophylaxis-for-the-prevention-of-bacterial-endocarditis

 

How to Become an Emergency Nurse Practitioner (ENP)

How to Become an Emergency Nurse Practitioner (ENP)

If you find yourself wondering how to become an ENP, you’ve found the right resource!

In this article, we’ll not only talk about HOW to become an ENP (Emergency Nurse Practitioner), but we’ll also talk about their job role, and how much money they can expect to make.

If you prefer to watch instead of read, then watch the video below!

What is an ENP?

An Emergency Nurse Practitioner (ENP) is a nurse practitioner who is certified to see patients of all ages in the emergency departments and ambulatory care centers.

An ENP is specialized to see patients in the following clinical settings:

  • EDs (fast-track & Main ER)
  • Trauma Centers
  • Urgent Care Clinics
  • Retail health Clinics
  • Jails and Prisons
  • Mobile units (Flight team, EMS, etc)

What do ENPs do?

At work, an ENP evaluates and treats patients who present to the Emergency Department or urgent care settings.

They may work in fast-track which sees lower-acuity patients (like extremity injuries and coughs/colds), or they may be on the main side seeing chest pains, abdominal pains, headaches, sepsis, strokes, etc.

An ENP will also perform routine ER procedures like:

  • Incision & Drainage of abscesses
  • Suturing & laceration repairs
  • Shoulder & Joint reductions
  • Administering local anesthesia blocks
  • Splinting extremity injuries

They will also be trained for critical and life-saving procedures like:

  • Rapid Sequence Intubation (RSI)
  • Central line placement
  • Chest tube insertion (tube thoracostomy)

They will usually be working in conjunction with an attending physician, especially within emergency departments. These physicians will serve as a resource for help, guidance, or if escalation of care is needed.

How much does an ENP make?

As with most nurse practitioner salaries, an ENP can definitely expect to make at least 6 figures.

According to Zip Recruiter, an Emergeny Medicine Nurse Practitioner (ENP) can expect to make 133K on average or $64/hr, whereas a general nurse practitioner is: 110K per year (53$/hr).

The emergency setting is higher risk and tends to be more stressful with higher risk and less desirable hours, so the increased pay makes sense.

But of course, the pay will fluctuate depending on multiple different factors such as location, the specific company you work for, and how much experience you have.

Many ERs and urgent cares will utilize an RVU pay system, so the busier you are, the higher the acuity of the patients, and the more procedures you do – the more your hourly rate will be.

WHAT IS an RVU?

RVU stands for Relative Value Unit. This is a means to measure the productivity of Physicians or NPs/PAs.

The more patients you see, the higher acuity they are, and the more procedures you perform will all increase your RVUs.

Each facility pays out RVUs differently. They might give you your RVUs monthly, quarterly, or added onto your hourly rate.

HOW TO BECOME AN ENP

So now that we know what an ENP is, what an ENP does, and how much money an ENP makes – how does someone actually become an ENP?

1 BECOME AN RN

So as with any NP specialty, the first step is to become a registered nurse.

This deserves its own article itself (coming next week), and there are a few different methods you can do, but I’m going to briefly overview the main recommended way.

Long story short, you’re going to need to attend a program that grants you a BSN or a Bachelor of Science in Nursing.

After graduation, you will take the board certification exam called the NCLEX-RN.

Once you pass the NCLEX-RN, you can apply for your state licensure in your specific state, and get a job working as an RN.

2 ER RN EXPERIENCE

So once you get your RN, you can start working as a nurse.

If your goal is to be an ENP, you should prioritize working as an ER Nurse.

This will be huge in developing your assessment skills, getting comfortable with what kind of patients present to the ER and with what symptoms, as well as familiarize yourself with treatments and medications.

It also will give you a chance to change your mind before actually knowing that an ENP certification is what you want.

The amount of time you need to work as an RN before going back is debated to say the least. Some nurses immediately go into their NP program, but this isn’t the norm and is more for FNP.

When it comes to ENP programs, all ENP programs are going to require you to have at least 1 year of work experience as an ER RN. 

While working as an ER nurse, you’ll have between 4-8 patients at a time(closer to 4 if you’re lucky like I was). You will learn SO MUCH as an ER nurse that will benefit you as a future ENP.

The next step is where we have some options because there are 4 different ways to become an ENP once you are an RN and working as a nurse.

3 BECOME ELIGIBLE FOR ENP EXAM

This step is where we have some flexibility in becoming an ENP. We have the option of attending a specific ENP program or post-masters certification, applying by portfolio as an FNP, or by completing an ER fellowship.

a. ATTEND AN ENP PROGRAM

The ENP certification just officially came out in 2017, so it is still relatively new, and only offered by the AANP.

This means that there aren’t many ENP programs out there, but there are at least 10 as of now.

Some top ENP schools are Emory University and Vanderbilt.

When you attend an ENP program, the content is specific to emergency medicine.

Almost all of your clinical rotations will be in the ER and urgent care settings (aside from FNP curriculum), so you will get great training specific to your area of focus.

All of the ENP programs that I’ve seen are actually dual FNP-ENP, so you will be obtaining your FNP as well.

This means the program may be a bit more expensive and longer than a single specialty program, and require more clinical hours. I am not aware of any stand-alone programs, other than post-masters certificates.

ENP programs will take you on average 3 years to complete, with 600-1000+ hours of clinical in both emergency medicine settings, as well as family practice, women’s health, and pediatrics.

Many nurses will continue to work on a per-diem or part-time basis at the bedside as an RN, which from personal experience, really does help you put into practice what you’re learning, in addition to your formal clinical hours.

b. POST-MASTERS ENP CERTIFICATION

A family nurse practitioner (FNP) can go back and obtain a post-masters certificate from an ENP program, where they complete only the ENP portion fo the curriculum. This takes about a year to complete. 

c. APPLY BY PORTFOLIO

If you don’t attend an ER program you can choose to apply by portfolio. This is for those who are already practicing as an FNP.

A Family Nurse practitioner can apply by portfolio to become an ENP if they meet the following requirements within the last 5 years:

  • Over 2,000 hours in an ER setting
  • Over 100 hours of continuing education hours in emergency medicine, with over 30 being related to emergency procedures

d. ER FELLOWSHIP

Additionally, an FNP can complete an ER fellowship or residency, which then makes them eligible to sit for the ENP certification exam.

These fellowships typically take 1-2 years to complete, and you will be paid less during the training, but gain great training within the ER.

4 Take the ENP Exam

The last step of becoming an ENP is to take the ENP certification exam once you are eligible to do so.

The ENP certification exam is currently only provided by AANP, and consists of 150 multiple choice questions, 135 of which are scored.

The exam will consist of questions related to medical screening, medical decision making and differential, patient management, patient disposition, and professional, legal, and ethical practices.

Once you pass this test, you are certified as an ENP and can apply for your specific state’s nurse practitioner license, and get a job working in the ER setting as an ENP.

And that’s how you become an ENP, as well as what you will be doing, where you will be working, and what pay you can expect to make as an ENP.

REFERENCES

Choosing the right nurse practitioner specialty is important in planning your future as an NP. #NP #Nursepractitioner #nursing

Nurse Practitioner Specialties: What are the Differences?

Nurse Practitioner Specialties: What are the Differences?

Nurse practitioner specialties will dictate which patient population you can treat once you are a practicing nurse practitioner.

There are many different nurse practitioner specialties that you can obtain, and we will outline the differences between them here!

If you prefer video content instead, you can check out my youtube video below!

Why are Nurse Practitioner Specialties Important?

Nurse practitioners are registered nurses (RNs) who attend additional schooling and training to become an advanced practice registered nurse or APRN.

APRN is the umbrella term for various advanced practice nurses, which includes:

  • Nurse Practitioners
  • Certified Registered Nurse Anesthetists
  • Certified Nurse-Midwives
  • Clinical Nurse Specialists

We are going to be outlining the different nurse practitioner specialties that an NP must choose before entering their advanced nurse practitioner program.

When a nurse wants to become a nurse practitioner, they have to attend an advanced nursing program that grants them either a Master’s of Science in Nursing (MSN), or a Doctorate of Nursing Practice (DNP).

These programs are specific to various patient populations – so basically what demographic of patients you will be treating. These are known as nurse practitioner specialties.

It is important to pick the right nurse practitioner specialty before actually going through a program, because this may limit your job opportunities depending on what you want to do in the future, so knowing the difference between these specialties is important.

For example, if you complete an acute care program, you will not be able to sit for a family nurse practitioner certification.

The main nurse practitioner specialties include:

  • Family Nurse Practitioner or FNP
  • Adult-Geriatric Primary Care Nurse Practitioner or AGPCNP
  • Adult-Geriatric Acute Care Nurse Practitioner AGACNP or ACNP for short
  • Emergency Nurse Practitioner
  • Women’s Health Nurse Practitioner (WHNP)
  • Psychiatric and Mental Health Nurse Practitioner (PMHNP)
  • Pediatric Nurse practitioner or PNP
  • Neonatal Nurse Practitioner (NNP)

I want to briefly discuss the differences between these, and some general guidance when choosing a specialty.

Nurse practitioner programs will all have similar base classes such as advanced pharmacology and advanced pathophysiology, but each specific program will branch into classes that are specific to each specialty and patient population.

NURSE PRACTITIONER SPECIALTIES

Family Nurse Practitioner

Family Nurse Practitioner or FNP is the most common Nurse Practitioner specialty, accounting for about half of all NPs – and there’s good reasons for that, because FNPs are the most versatile NP certification that there is.

FNP programs focus on family medicine, spanning from birth to death, ages 0-100+. FNP programs focus on primary care, but specialty clinicals can be completed in the ER, hospitals, and various outpatient specialties depending on the NP program.

Due to the lack of age requirements and general primary care training, FNPs are able to work in many different settings.

While most FNPs will work in outpatient primary care offices, many work outside of primary care like:

  • Specialty Offices (cardiology, orthopedics, etc)
  • Emergency dept and Urgent Cares
  • Inpatient (non-critical care areas)

The benefit of an FNP working in the ER is that they are certified to see patients of all ages. Many ERs have combined pediatric and adult emergency departments, and providers are often expected to see both.

Some states and facilities will hire FNPs to work inpatient in non-critical care areas. This will be state and facility-dependent.

The downside is that while your FNP program will give you the base knowledge you need for these various specialties, most of the hands-on clinical experience will be in primary care, and this can leave you somewhat unprepared for certain specialties such as the ER.

This can lead to a big learning curve outside of primary care areas, and it makes it especially important to get a job with a thorough orientation process and great ongoing support by your supervising and collaborating physicians as well as the nursing staff.

Quick Note

I personally am an FNP and I have worked as an inpatient hospitalist, as well as within the ER. 

Adult-Gerontology Primary Care Nurse Practitioner

Adult-Gerontology Primary Care Nurse Practitioners or AG-PCNP is similar to FNP, but they are limited to evaluating and treating patients who are over the age of 13.

AGPCNPs often work in:

  • Adult internal medicine offices (outpatient primary care)
  • Outpatient specialty offices (cardiology, nephrology, etc)
  • ER and Urgent cares *but needs to be adult-only which can lead to difficulty finding a job*

Adult-Gerontology Acute Care Nurse Practitioner

Adult-Gerontology Acute Care Nurse Practitioners or AG-ACNP (or just ACNP) are those who are specialized to treat adults and geriatric patients within acute and critical care areas. This means primarily within the hospital, both ICU and general floor admissions. They are also limited to seeing patients 13 years or older.

AGACNPs can work in:

  • Inpatient hospitalist positions
  • Inpatient ICU
  • Outpatient specialty offices (Cardiology, nephrology, etc)
  • Nursing Homes and LTAC facilities

Specialty clinics often have on-call and rounding privileges within the hospital, which an ACNP is specifically trained for so this can be a great option for them.

ACNPs can also work in the ER, but will be limited to patients 13 years or older, and this can significantly limit the ability to get a job in this setting. However, the their training in the acute care setting will likely benefit them in seeing emergent patients within the ER.

Some programs offer dual FNP-ACNP certifications, which is the most ideal and the most flexible nurse practitioner specialty certification. However, it will require additional schooling and clinical hours, because you are doing the work for and paying for 2 separate certifications. You will also have to test for both.

Emergency Nurse Practitioner

A newer certification is the Emergency Nurse Practitioner or ENP. There are a few ENP programs now throughout the US, and they allow an NP to specialize in emergency medicine. These NPs will be certified to see patients of all ages within emergency and ambulatory departments (i.e. urgent cares, retail clinics, etc).

The education and training will be specific to ER and ER procedures. So while you’ll get great training, you will be significantly limited on where else you can work other than ER or urgent care facilities.

An FNP with a minimum of 2000 hours of work experience that meets certain requirements is able to apply by portfolio to become an ENP and then has to sit for the ENP certification exam (read the requirements here).

Otherwise, they have to attend an ENP program, or they can complete a fellowship program in emergency medicine.

Women’s Health Nurse Practitioner

Women’s Health Nurse Practitioner is a certification that focuses on women’s primary care needs including:

  • Well-woman exams
  • Reproductive health
  • Breast and cancer screenings
  • Vaginal and urinary complaints
  • and more

Depending on the program, this may be offered in conjunction with a family or adult-geriatric certification as well.

Again, this offers great training specific to women’s health needs. However, it will limit you to this patient population unless you obtain a dual-certificate in something else, or later choose to get a post-masters certification.

But if women’s health is 100% where you want to work forever, then it is a great choice and will give you great experience and training.

This certification exam is not offered by the AANP or ANCC, but rather another organization called the NCC (National Certification Corporation).

Psychiatric Mental Health Nurse Practitioner

Psychiatric Mental health Nurse Practitioner or PMHNP is gaining definitely gaining popularity.

The PMHNP certifies nurse practitioners to treat patients with psychiatric and mental health disorders across the lifespan. This includes treating conditions such as:

  • ADHD
  • Anxiety & Depression
  • Bipolar disorder
  • Schizophrenia
  • and more

Again, this specialty is very specific, and you will not be able to work outside the realm of psychiatric mental health. However, you can work inpatient psych, outpatient psych, or even telehealth which is definitely gaining popularity as well.

Pediatric Nurse Practitioner

Pediatric Nurse Practitioner or PNP certifies a nruse practitioner to see patients from birth to 21 years old. Training and education will be specific to the pediatric population, but you won’t be able to leave that patient population without additional education.

Neonatal Nurse Practitioner

Neonatal Nurse Practitioner or NNP, works with neonates, infants, and toddlers up to the age of 2. Neonates include those who were born prematurely.

And those are the main NP specialties that you will run into. As you can see, sometimes it is straightforward, and other times it can be a little more difficult to choose between programs.

Which NP Specialty Should you Choose?

FNP offers the most flexibility with different specialties and populations but may leave you with a big learning curve if you start working in a non-primary care setting.

This is a good choice if you’re not really sure where you want to work, or if you think you may want to work in multiple different settings in the future. This is also an excellent choice if you want to work in primary care.

AG-PCNP is great if you want to work with only adults in primary care or outpatient specialty offices.

AG-ACNP is a great choice if you love inpatient medicine and want to work within the hospital or long-term care facility, and sometimes outpatient specialty offices.

The other specialties are a bit more straightforward and will give you great education and training and leave you feeling well prepared.

If you want ER or urgent care – do an ENP program.

If you want to work in Women’s health – do a WHNP program.

If you want to work in Psych – do a PMHNP program.

If you want to work with kids – do a PNP program.

If you want to work with neonates – do an NNP program.

However, keep in mind that many of those specialties except for neonatal will also hire FNPs or AG-NPs depending on the states and facilities. Don’t forget though that jobs that require you to see kids won’t hire an AGNP.

While they used to hire FNPs for some psych work, the PMHNP is becoming the standard for psych jobs. Of note though, treating basic anxiety and depression is within the scope of a primary care NP.

All of these different nurse practitioner specialties have similar lengths, costs, and clinical requirements. They will just differ in some of the material that is taught, and the clinical experiences that are offered to their students.

And that is a complete overview of the main nurse practitioner specialties that you can obtain.

Leave a comment down below to let us know what you think about nurse practitioner specialties and which one you think is best!

Choosing the right nurse practitioner specialty is important in planning your future as an NP. #NP #Nursepractitioner #nursing
Nurse Practitioner Specialties: AGPCNP
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How to Suture: Simple Laceration Repair

How to Suture: Simple Laceration Repair

This post may contain affiliate links, which means I get a commission if you decide to purchase through my links, at no cost to you. Please read affiliate disclosure for more information

Knowing how to suture is imperative for a nurse practitioner or any other provider, especially within Emergency, Urgent Care, and family practice settings. Your experience suturing during clinical will vary depending on your rotations, but unfortunately many NP students graduate without solid suture experience. Many job interviews will ask if you are comfortable suturing, and your answer could literally make or break the interview.

Hopefully this full breakdown of how to suture will help you be able to confidently know how to suture

How to suture: Thumbnail

As a heads up, this article is long and full of helpful infographics, so to please feel free to use the Table of Contents to navigate this page if it helps!

 When to Suture?

Even if you know how to suture, don’t forget to recognize when to suture. Suturing is not always indicated. Sometimes there are other alternative wound closure options, and sometimes it is best to let the wound heal by itself (termed secondary intention).

Where is the Laceration?

The location of the laceration will help determine the need for sutures, as well as the size of sutures needed and when they should be removed. Sutures are commonly used for simple lacerations of the hands, feet, extremities, and face. Lacerations of the scalp are often better suited for closure with staples. Staples can also be used in areas where cosmetic results are not necessary, especially when the laceration is >5cm.

Depth of the Laceration

Superficial lacerations that do not extend through the epidermis often do not need to be sutured closed and will heal without difficulty with good cosmetic results. Additionally, some well-approximated lacerations that aren’t under areas of tension can be better closed with steri-strips or dermabond. Deeper gaping lacerations may need to have the subcutaneous tissue approximated with internal absorbable sutures first, then closed with non-absorbable sutures at the surface.

How Old is the Laceration?

The age of the laceration will have a major impact on your decision to suture. Clean, uninfected lacerations can be closed up to 18 hours following an injury. Facial wounds can be closed after the incident up to 24 hours, or even 48-72 hours in some cases with no risk factors for infection.

Mechanism of Injury

How the laceration occurred is also a very important part of the history in a patient with a laceration. This can cue you in on the need for X-rays to determine a foreign body or to rule out a possible fracture. A fracture with overlying open skin is considered an open fracture, and these should not be closed and are usually treated with at least one dose of IV antibiotics and Ortho consultation.

The mechanism of injury can also give you a better indication of the degree of contamination, although proper assessment of the wound should too. Seriously contaminated wounds require extensive irrigation and often prophylactic antibiotics with delayed closure.

Animal Bites

Animal bites (including human bites), especially in non-cosmetic areas such as the hands or feet, should NOT be closed as these are at high risk for infection. However, in some instances, primary wound closure can be done such as with certain dog bites. If the patient has diabetes or venous stasis, delayed closure is even more highly recommended. Be sure to give rabies immunoglobulin and vaccine when bitten by strays or unvaccinated animals that cannot be quarantined.

Cat Bites

Cat bites should be left open and treated with prophylactic antibiotics (usually Augmentin), and can be referred for delayed closure in 3 days if needed. However, cat bites on the face can be closed if within 24 hours prior to closure. Puncture wounds should not be closed.

Dog Bites

Dog bites have also traditionally been recommended to treat with prophylactic antibiotics and refer for delayed closure. However, recent literature seems to support primary closure of many of these wounds as a reasonable alternative. Most dog bites on the face, trunk, and extremities can be sutured, as long as <12 hours old, or <24 hours for the face. Bites on the hands or feet should not be closed, but rather referred in 3 days for potential delayed closure and of course treated with antibiotics as above.

Human Bites

Similar to cat bites, human bites should never be initially closed unless on the face that is less than 24 hours old. These wounds also warrant prophylactic antibiotics.

Make Sure Tetanus is Up To Date

Updating tetanus shots is necessary to prevent the patient from developing tetanus disease. Tetanus is a disease that can occur after contamination of a wound which causes painful muscle stiffness and spasms. In order to make sure the patient’s tetanus is up to date, you need to ask the patient when their last tetanus vaccination was. Many patients will not know.

Update Tetanus Vaccination if: 

  • Received < 3 doses in their lifetime
  • Last dose > 10 years in clean and minor lacerations/ wounds
  • Last dose > 5 years in contaminated/complex* wounds (see below)

Give tetanus immune globulin if:

  • Less than 3 Tetanus vaccinations in past (or unknown) AND contaminated/complex* wounds
  • HIV positive patients or those with severe immunocompetence

*Contaminated wounds are those contaminated with feces, soil, dirt, or saliva. Complex wounds include puncture wounds, avulsions, crush injuries, or burns.

Clean Wound Dirty** Wound
<3 Tdap* or unknown Tdap Tdap + TIg
>3 Tdap but LKD >10y Tdap Tdap
>3 Tdap but LKD >5y None Tdap
Tetanus UTD None None

 *Tdap or Td (tetanus containing vaccination)
TIg = Tetanus Immune Globulin | LKD = Last Known Dose | UTD = Up To Date
**Dirty wounds are those contaminated with feces, soil, dirt, or saliva; puncture wounds, avulsions, crush injuries, or burns.

How to suture - tetanus ppx
How to suture: Animal bites

Perform Appropriate Wound Assessment

A good assessment of the laceration is also necessary. Be sure to assess their distal neurovascular status. Assess the tendon function in hand lacerations – make sure full ROM is maintained distal to the injury. Make sure no visible tendons are lacerated. Assure the wound does not appear infected or grossly contaminated. Observe for any signs of foreign bodies and ensure that bleeding is controlled. Measure the laceration’s length, width, and depth. These are all part of a good wound/laceration assessment and necessary for adequate documentation.

Laceration Documentation Example: “4x1x1 cm laceration noted to the right posterior proximal forearm. Wound appears clean with smooth edges and scant bleeding. There are no foreign bodies or debris noted. No tendons are visualized. Distal neurovascular status intact including pulse, cap refill, color, temperature, sensation, and ROM.”

How to Suture

So now we know it is appropriate to suture, we’ve updated the patient’s tetanus if needed, and we have done a proper assessment of the patient’s laceration. We can finally learn how to suture a laceration. In this article, I will be overviewing the most common suturing method, which is the simple interrupted suture, which is appropriate for most simple lacerations.

1. Collect your Equipment

Before you’re able to suture, you will need to collect all of your equipment to irrigate, clean, anesthetize, suture, and dress the wound.

Irrigation Equipment:

  • Bottle of NS (50-100cc per cm) or an equivalent volume of tap water (One 250ml NS bottle usually sufficient)
  • 30-60cc syringe
  • 18g IV catheter (remove the needle)
  • Absorbable pads or towels
  • Kidney basin
  • Splash guard

Suture Kit: (Often already collected and packaged)

  • Sterile drapes / field
  • Gauze (4×4)
  • Needle Driver
  • Tweezers or small toothed forceps
  • Scissors

Gloves:

  • 1 pair of clean gloves (for cleaning, irrigation, and anesthetizing)
  • 1 pair of sterile gloves (for suturing)

Sutures: See below

Anesthetic Material:

  • Lidocaine with or without Epinephrine
  • 3-10cc syringe
  • 25-30g needle
  • Blunt needle

Choosing the Suture Type

There are many different suture types, those that are either absorbable or nonabsorbable. Each suture type will change the suture’s properties including tensile strength, knot strength, elasticity, and whether or not they will absorb on their own.

Nonabsorbable Sutures

Nonabsorbable sutures have been the standard for simple laceration repairs, and they are what I almost always use. These can be used anywhere and have good tensile strength, knot security, are easy to work with, and have minimal tissue reactivity (aside from silk). Nonabsorbable sutures include:

Nylon: High tensile strength, elastic, minimal tissue reactivity, low cost, requires 3-4 knot throws.

Polypropylene (Prolene): High tensile strength, low tissue reactivity, requires 4-5 knots. Can come in blue color which is helpful in the scalp or dark-skinned individuals

Polybutester (Novafil): Similar to above, but has greater elasticity so can be helpful if significant wound edema is expected

Silk: Not as strong, higher tissue reactivity, but still used for central lines, chest tubes, etc

Absorbable Sutures

Absorbable sutures used to only be used for deep sutures, and are still used for internal sutures with very deep lacerations. However, some advocate for its use in primary closure of percutaneous lacerations in adults and children using fast-absorbing gut sutures. This is especially useful in children who will fight against suture removal. Some common absorbable sutures are:

Chromic gut: retains tensile strength for 10-14 days, often used for oral mucosa, but has increased tissue reactivity for subcutaneous internal sutures.

Vicryl: Retains tensile strength 3-4 weeks, complete absorption in 60-90 days. Ideal choice for subcutaneous sutures.

Vicryl Rapide: Retains tensile strength 10-14 days, “falls off” in 7-10 days. Useful for under casts, can be used as an alternative to nonabsorbable sutures , but possible risk of infection and tracking vs nonabsorbable although was NOT statistically significant in research.

Absorbable vs Nonabsorbable?

While nonabsorbable are generally recommended for wound closure, a meta-analysis found equivalent cosmetic outcomes and no significant difference in wound infection or dehiscence, although follow-up was insufficient in several studies. Department culture will often dictate what you use. You will not gro wrong with nonabsorbable nylon interrupted sutures of the appropriate size.

How to suture absorbable vs nonabsorbable sutures

Choosing the Suture Size

The size of the sutures will determine how big the needle and thread are. Depending on the location, certain sizes are recommended. The larger the number, the smaller the size and lower the strength. 1-0 are the largest, and 10-0 are the smallest, but most simple laceration repairs will use anywhere between 3-0 to 6-0.

To choose your size, simply assess where the laceration is. See the table below for more information.

Location Suture Size When to Remove
Face 6-0 preferred,
5-0 acceptable
5 days
Scalp 4-0 or 5-0
staples preferred
7 days
Eyelid 6-0 or 7-0 5-7 days
Eyebrow 5-0 or 6-0 5-7 days
Oral Mucosa 5-0 (chromic gut) NA
Arm 5-0, 4-0 near joint 7-10 days
Hand 5-0 7-10 days
Leg 4-0 7-10 days
Foot 4-0 12-14 days
Chest/Abdomen 4-0 or 5-0 12-14 days
Back 4-0 or 5-0 7-10 days

 

How to suture - suture size and removal

Choosing the Anesthetic

To suture, you will need to numb the surrounding area as you will be sticking a needle in their skin multiple times. Your main decision will be whether or not to use the lidocaine with or without epinephrine.

Lidocaine 1-2%

Lidocaine is the go-to anesthetic for laceration repair. Max dose is 5mg/kg (max 300mg), which you won’t come close to with smaller basic lacerations. The 1% comes in at 10mg/mL, and the 2% is 20mg/mL. Lidocaine will begin working in 45-90 seconds, and will last for 30-90 minutes.

Lidocaine is usually injected via local infiltration. Enter the subcutaneous space from the inside of the wound, slowly making your way around the entire laceration circumference. Most basic lacerations will only require between 1-3cc of lidocaine.

Local infiltration will give the patient a “pinch and a burn” while injecting. One way to decrease pain is to mix 1cc of bicarb with 10cc of lidocaine. However, in adults the lidocaine injections are usually tolerable, so this may be more wasteful than helpful. Alternatively, frequent pinching of the skin has been found to decrease discomfort.

Lidocaine 1-2% with Epinephrine 1:100,000

Lidocaine with Epi is great for wounds that are bleeding or are more likely to bleed while suturing. These include highly vascular areas like the face. This is because the epinephrine causes local vasoconstriction. It also blanches the skin, which makes it easy to see where you’ve numbed after a few minutes. The addition of epinephrine also causes decreased systemic absorption, causing a longer duration of action of the lidocaine (~3 hours).

Traditionally Lido w/ Epi was avoided in areas like the fingers, nose, or ears as the worry is causing vasoconstriction and risking skin necrosis. However, the evidence is lacking so Uptodate basically says you can. However, it is still recommended to avoid injecting the digits with epinephrine-containing lidocaine in those with peripheral vascular disease.

How to suture: LIdocaine with vs without epinephrine infographic

2. Anesthetize the Area

Prepare the area with 1 or 2 absorbable pads and have clean gauze ready, as local infiltration will often cause mild bleeding of the wound as well as leakage of the anesthetic agent.

Clean the wound surface with an alcohol wipe (which will sting) or diluted betadine (1:10 iodine to NS solution). This is to briefly clean the area before injecting, as you likely have not irrigated the wound yet. Do not use betadine surgical scrub as this can be toxic to the wound.

Use a blunt needle to draw up your anesthetic into a 3cc or 5cc syringe. Replace the needle with a fresh 25-30g needle. Inject the dermal area just inside the edge of the wound, locally infiltrating the anesthetic. You should be able to see the surrounding skin “swell” up. Note that sometimes the anesthetic has a tendency to leak out the wound – catch this with your clean gauze. Remove the needle and inject it again, slowly making your way around the wound. Be sure to use the previously numbed tissue that you just injected. It won’t be fully numb yet, but it will be less painful for the patient with subsequent pokes.

For lacerations on the distal digits, a digital block will likely be the best choice, as there is usually not much space to infiltrate in these areas. These are also very sensitive, and local infiltration can be very uncomfortable for the patient.

3. Irrigate the Laceration

Irrigation of a laceration is essential to prevent infection and clear any foreign bodies or debris. Cleaner wounds will need less irrigation, whereas more contaminated wounds will need more irrigation. Generally, it is acceptable to irrigate 50-100cc per cm of the laceration.

To irrigate, make sure your absorbable pads are in place as this can get the patient pretty wet.

Open a sterile NS bottle or alternatively use tap water, and fill a 30-60cc syringe. Attach an 18g catheter to the end of the syringe – this is to increase the pressure of the irrigation. Inject the water or saline into the wound with high pressure, catching any water with a kidney basin if possible. The use of a splash guard is helpful to prevent splashback.

Once cleaned, it is often easier to measure the dimensions of the wound.

4. Set up Sterile Field

Once the laceration has been anesthetized and irrigated, you can begin setting up your sterile field.

Maintaining a sterile environment is another important factor in preventing infection. However, it might not be as necessary as once thought when suturing a simple laceration. Multiple randomized control trials (RCTs) have found clean gloves did not have higher infection rates than sterile gloves. Nonetheless – sterile technique is still often recommended and is considered the “standard”.

Most suture kits will have sterile drapes within them. Open your suture kits in a sterile fashion. Drop your open sutures onto the kit or field in a sterile manner. Drop any other necessary equipment (gauze) if needed.

Clinical Tip: You can pour some sterile NS into small containers or the sterile kit itself onto the gauze. This is optional but I find it personally useful to have wet gauze when wiping away scant bleeding during the procedure.

Remove your clean gloves, wash your hands, and apply sterile gloves. Set up your sterile drapes – have the patient lift their arm or leg to assist you if needed. Some kits will have a sterile perforated drape to help focus your sterile field, which is optional. Once you are all set up, you can finally start suturing.

5. How to Suture the Wound

To begin suturing, you first need to decide which type of suture technique you are going to use. Most simple lacerations can be repaired with simple interrupted sutures. This is what I use 99% of the time in the Emergency Department.

Before placing sutures, make sure the bleeding has stopped, as continued bleeding after closure can lead to hematoma formation.

To perform the simple interrupted stitch, insert the needle at a 90° angle (side A). You should start about 5mm (0.5cm) from the edge of the laceration, 5mm deep, and come out 5mm on the other side of the wound. Facial lacerations require a finer touch and are recommended to be 2.5mm from edge, 2.5mm deep, and 2.5mm apart.

I usually place the first suture in the center of the laceration. You will often need 2 bites for the first stitch – one for each side of the wound, as the edges of the wounds are usually not well approximated. However, I find that often after the first stitch the other sutures can usually be achieved within one bite.

Clinical Tip: You can use toothed or untoothed forceps in your suture kit to help manipulate the skin – but I find this is usually unnecessary and leads to more local trauma to the wound.

Once you pull your needle through the other side (side B), pull the thread through until you leave a short tail on the original side. Place your needle driver in the middle, parallel to the wound. Wrap the long-tail side B around the needle driver with two loops for the first throw. Grab onto the short tail of Side A with the needle driver, pulling toward side B while simultaneously pulling the long-tail side B toward side A. Pull tight enough to approximate the skin but not too tight. This creates a square knot. Be sure to pull the knot to one side of the wound so that it is not overlying the laceration. Perform this same knot throw about 3-4 more times, except you only need to loop around the needle driver once instead of twice for subsequent throws in the same knot.

Clinical Tip: When tying the knots, be sure to do most of the pulling with the long-tail and your hand, as pulling too hard on the short-tail with the needle driver can elongate the tail and lead to wasted suture material. As far as number of knots, a good rule of thumb is to use the same amount of knot throws as the size of the sutures (3 knots for 3-0, 4 knots for 4-0, 5 knots for 5-0, etc).

When you have thrown the appropriate number of knots, use the scissors in your kit to cut both ends at approximately 5mm length.

For your next stitch, you can start working in either direction about 5mm away from the first (2.5mm on the face), or you can bisect each remaining side until the wound is closed.

6. Dress the Wound

Once the laceration is closed, the last step is to dress the wound. Apply bacitracin or Neosporin directly to the wound, and then apply a nonadherent dressing. I use a Telfa dressing covered by dry gauze, then wrapped with Kerlix. Other nonadherent dressings can be used as well (nonadherent sterile gauze), and even a simple bandaid can be used for small lacerations (works well for the face).

Suture Discharge instructions?

Wound instructions

Providing excellent discharge instructions is imperative, as there is usually a good amount of necessary follow-up that needs to occur.

Tell the patient to leave the dressing in place for 24-48 hours, and can then be opened to air. The wound should be covered if possible contamination is expected (such as while at work). Nonabsorbable stitches can be cleaned gently with soap and water twice a day. Half-strength hydrogen peroxide can be used twice daily to prevent crusting over sutures, especially on the face. The patient can use an OTC antibiotic ointment or white petroleum ointment twice a day as well if desired, which can help prevent scar formation and promote healing. It is generally recommended to avoid submerging the wound in water until it is healed.

My Patient Discharge Instructions: Keep the wound clean and dry for 24-48 hours, then you can wash it gently twice a day with soap and water, but otherwise do not submerge wound in water. You may use Neosporin if desired to help prevent infection and scab formation. Please return for a wound check in 2-3 days if red/swollen/or if there is discharge from the wound, otherwise your sutures will need removed in X days. This can be done at your doctor’s office, an urgent care, or back here in the ED.

Follow-up

Always recommend a wound check in 2-3 days if the patient has any noticed redness, swelling, or discharge of the wound. Otherwise – they will need to follow-up when the sutures will need to be removed (which will depend on the location as stated above).

If the patient is high-risk for infection (Diabetes, on chemo, renal disease, etc) or if the wound was highly contaminated, a wound check in 2-3 days should be recommended regardless.

Prophylactic PO antibiotics can be given for contaminated wounds, animal or human bites, patients with vascular insufficiency, or immunocompromise.

That concludes how to suture! There are other suture methods, and there isn’t always a “one size fits all”. If you are still confused, there are plenty of videos on youtube which you can check out as well! Let me know if you have any questions below and I’ll try to answer them. For more in-depth reading, check out the Uptodate articles listed in the references below!

How to suturer

Advanced Physical Exam Maneuvers

Advanced Physical Exam Maneuvers

When becoming a nurse, we are taught how to assess our patients and perform a physical exam. We talk with them and make sure they are alert and oriented, we listen to their lungs and heart, check for leg swelling or redness, and are making sure there are no significant changes every shift. However, there are many advanced physical exam maneuvers that are not taught to us in nursing school.

This may be because these advanced physical exam maneuvers tend to guide diagnosis and “nurses don’t diagnose”. However, performing advanced physical exam techniques can help you recognize serious conditions in your patient, which you can notify the Provider about and improve patient outcomes.

Physical Exam

1. Extraocular Muscles

Extraocular Muscles (EOMs) are responsible for eye movement and are largely innervated by the third cranial nerve – the oculomotor cranial nerve, as well as the 4th and 6th cranial nerves. Intact EOMs suggests that those three cranial nerves are intact, but also is important in ruling out a central lesion such as a stroke or a mass – although a more thorough cranial nerve assessment is required.

When looking at the extremes of vision, sometimes nystagmus can occur. Nystagmus is defined as a fine rhythmic oscillation of the eyes. A few beats at the lateral gaze extremes can be normal,  but any excessive nystagmus, especially when the eyes or more centered, can suggest vertigo, seizure activity, Chiari malformation, stroke, or a mass.

Additionally, testing EOMs in your physical exam can be useful to test when evaluating for orbital cellulitis. Orbital cellulitis is an infection of the orbital structures and muscles. As you might expect, when the extraocular muscles are infected, they are inflamed and painful. This means testing of the EOMs often is painful, especially when looking in a certain direction. Painful EOMs in association with swelling or redness of the eye or surrounding area should prompt a CT of the orbits with contrast to rule out any orbital cellulitis. Orbital cellulitis often requires IV antibiotics, whereas periorbital cellulitis can usually be discharged home with PO antibiotics and close ophthalmology follow-up.

EOMs should be tested whenever there is any neurologic complaint (possible strokes, vertigo, seizures), or when you suspect periorbital or orbital cellulitis.

To test EOMs – hold out a finger or a pen approximately 2 feet away from the patient’s eyes. Ask them to follow your finger or object with their eyes only. Now move your finger/object in the six cardinal directions, making a large “H” in the air. To the right, upper right, lower right, then to the left, upper left, and lower left (see illustration).

An abnormal exam is when these movements are painful, when they cause dizziness, or when one or both eyes are unable to gaze in a specific direction. The latter can indicate a brain lesion such as a stroke, so this is a major physical exam finding that you don’t want to miss and is part of your NIH scale!

Be sure to check out my advanced cranial nerve assessment for more information on proper neurological assessments! Keep reading for more advanced physical assessments!

 

    2. Jugular Vein Distention

    Jugular vein distention, or JVD, is just that – when the jugular veins are bulging or distended. Pressure in the jugular veins indicates right atrial pressure, which can be helpful when evaluating patients with known or suspected heart failure, volume overload, or even pulmonary embolisms.

    Testing the Jugular venous pressure isn’t exactly easy, and sometimes a “gestalt” JVD is noted by healthcare providers. This can usually be noticed when the patients are in clear volume overload.

    JVD can be tested whenever you suspect a patient to have volume overload or increased right atrial pressures. This means whenever you suspect heart failure, volume overload in renal failure patients, or a pulmonary embolism.

    JVD can be “noticed” with a bulging external jugular vein when the patient is between 30 and 45 degrees semi-fowlers, with their head turned toward their left. You should be evaluating their right side as this is the most accurate indication of right atrial pressures. The higher they are sitting up while maintaining jugular venous distention, the higher the pressure is.

    If you want to get technical, you can also measure – but most of us don’t carry around a measuring device. I have never seen a non-specialty clinician actually perform this in real life. However, to officially test the jugular venous pressure, you want to elevate the head of the bed to approximately 30-45 degrees. Have the patient turn their head to the left. Identify the top of the venous pulsations of the external jugular vein, or preferably the internal jugular vein. You can not directly visualize the internal jugular vein, but should be able to see the pulsations. Use a pen to “draw” or visualize a horizontal line from the top of the pulsations to above the sternal angle. This is the notch where the sternum begins. Now measure how high this horizontal line is above the skin. Then add 5cm because the right atrium is approximately 5cm deep. The total is the patient’s estimated central venous pressure (CVP).

    Remember that normal CVP are 0-8 cm H2O. Anything higher is considered abnormal and could indicate the increased right atrial pressures.

    Hepatojugular Reflux

    The hepatojugular reflux (HJR) is an additional physical exam maneuver to help determine possible heart failure exacerbation or other conditions which could increase venous pressures. This is often performed if JVD is not obvious but clinical suspicion remains.

    To test the HJR, position the patient the same as JVD. Apply gentle pressure over the RUQ or mid-abdomen for 10-60 seconds, and watch for increased JVD. Normal patients should have a decrease in JVP (less distention) with this physical exam maneuver since it should decrease venous return. Those with fluid overload and heart failure will have an increase >3cm in measured JVP.

    Related article: “Interpreting Cardiac Labs”

     

      3. Murphy’s Sign

      Murphy’s sign is a physical maneuver to determine the possibility of cholecystitis or inflammation of the gallbladder. This can be a great physical exam test to aid in the clinical suspicion of acute cholecystitis (inflammation of the gallbladder).

      Murphy’s sign is tested when a patient presents with abdominal symptoms such as abdominal pain, nausea, or vomiting. You can also perform this physical exam maneuver if the patient has a fever of unknown etiology – especially in the elderly or those who may not be able to verbally express pain.

      To check for Murphy’s sign, place your fingers firmly in the patient’s right upper quadrant underneath the patient’s ribs, and ask the patient to take a deep breath. This is considered deep subcostal palpation, and on inspiration, the diaphragm pushes the gallbladder towards your palpating fingers, which should be painful if the gallbladder is inflamed.

      A positive’s Murphy sign is indicated when during inspiration, the patient has an acute increase in pain that will often cause them to stop inspiring mid-way through their breath. In true acute cholecystitis – this is often positive as Murphy’s sign as high sensitivity (97%) for acute cholecystitis, however, it is much less specific (48%) – this means that it could indicate other pathology within the liver or surrounding area.

       

        4. Costovertebral Angle Tenderness (CVAT)

        Costovertebral angle tenderess (CVAT or CVA tenderness) is a physical exam maneuver that is often used when evaluated potential kidney stones or other inflammatory renal pathology. The costovertebral angle is the angle “formed by the lower border of the 12th rib and the transverse process of the upper lumbar vertebrae.” Basically – On the back when the ribs end on each side – approximately where the kidneys lie. If there is a condition which has your kidney’s or surrounding structures inflamed and irritable, percussion over this area often causes acute worsening of pain.

        CVA tenderness should be checked whenever the clinician suspects a kidney stone or pyelonephritis. Often, this means the patient is presenting with flank pain, back pain, or some form of dysuria – whether painful urination, difficulty going, or even hematuria.

        To check for CVA tenderness – place one hand over their costovertebral angle on their back, and percuss with your other fist. You don’t want to be too forceful because if they do have a kidney stone – this can be very painful. However, you also want to make sure you are not percussing too lightly. Percuss a few times on each side.

        Positive CVA tenderness is when the patient reports pain with percussion. From my own experience – this is often very painful for those with acute kidney stones. However, I have also had plenty of patient’s with negative CVA tenderness who ended up having acute renal pathology including kidney stones.

         

          5. McBurney’s Sign

          Not to be confused with Murphy’s sign above, McBurney’s sign is an advanced physical exam maneuver to help raise suspicion for acute appendicitis.

          Mcburney’s point tenderness is when the patient’s most tender area is 1.5-2 inches from the anterior superior iliac spine in the direction of the umbilicus. Draw an imaginary line from the anterior superior iliac spine to the naval, and approximately 1/3 down the line closest to the the iliac spine is the “sweet spot”.

          If a patient has abdominal pain with this being their most tender spot, they should undergo further testing to rule out acute appendicitis. Mcburney’s sign is 50-94% sensitive, and 75-86% specific.

            McBurney's Sign for acute appendicitis

            As always, these advanced physical exam maneuvers should always be used with clinical judgment as part of a full history and physical exam. Hopefully these advanced physical maneuvers can help aid in your diagnosis. Nurses are constantly at the bedside, and knowing these physical exam maneuvers can help strengthen your physical assessment skills.

            Let me know if you found these helpful below in the comments!

            Be sure to also check out:

            How to Become a Nurse Practitioner

            How to Become a Nurse Practitioner

            How to become a nurse practitioner is not as complicated as you might think. Like most nursing specialties, it involves additional schooling beyond that of a nurse, but it is worth the hard work. It isn’t easy – but it is possible!

            Some people decide to become a nurse practitioner after they are already working as a bedside RN for years, but others have that goal from the very beginning. I fall into the latter, and I worked hard to achieve my end-goal and become a nurse practitioner fast!

            This article outlines the “traditional” method of becoming a nurse practitioner – this is the route that I personally took and the one that I know best. If you’re interested in nontraditional NP routes – I have an article coming soon so be sure to subscribe to my email list to be notified when it drops!

            1. BECOME AN RN

            When wondering how to become a nurse practitioner, being a nurse is the logical first step. This just makes sense. A nurse practitioner is literally an “advanced practice nurse” – meaning there first is some form of nursing education. Yes, there are ways around this, but for most people this is going to be the first step. An RN license is almost always required for traditional nurse practitioner programs.

            You can either obtain your BSN or your ADN to obtain your RN license. In short, a BSN is a 4-year degree that offers a bachelor’s of science in nursing. It is the recommended level of education for a nurse and required for entrance in nurse practitioner programs (aside from direct-entry programs).

            No matter which RN education route you take, you will be learning how to assess your patients, all about various medical conditions, and your actions as the nurse in their assessment and treatment. You won’t be learning how to diagnose, but you will be learning which treatments are often indicated and how to administer those treatments. This may involve administering various medications, assisting with testing, communicating with other healthcare professionals, as so much more.

            You will also be performing clinical within the hospital setting, learning how to become a bedside nurse. Most programs include 800-1000 hours of formal clinical experience.

            Once you graduate, pass the NCLEX-RN, and become state-licensed as an RN – you can finally start working as a bedside RN.

            2. OBTAIN RN WORK EXPERIENCE

            Once you obtain your RN education and pass your board-certification exam (The NCLEX-RN), you will now should start working as a bedside RN! This is usually very exciting as you can finally take what you’ve learned and positively impact your patients, grow in your knowledge, and make some money!

            Believe it or not, whether or not RN experience is necessary before attending a nurse practitioner program can become a heated topic. Many people believe that a certain amount of years of experience is necessary prior to matriculation into a nurse practitioner program. Some say 2 years, some say 5, and some others just say any amount of experience is beneficial.

            Benefits of RN Work Experience

            Obtaining work experience as a bedside RN is absolutely important in your development as a future nurse practitioner. Working as a bedside nurse offers continuous hands-on learning every day you work. The amount of learning in medicine is endless, and I can confidently say that there isn’t a shift that goes by that I don’t learn something. Working as a nurse will expose you to many common acute and chronic medical conditions, and the treatments and therapies involved. In fact – you’ll be the one administering and helping with them! Through your experience, you will improve your assessment skills, as well as your communication with your patients, and your colleagues within the hospital or clinic that you work. First-hand work experience will give you a deeper understanding of the healthcare system and just “how it all works”. This will become invaluable in your pursuit of becoming a nurse practitioner.

            Is work RN experience required to get into an NP program?

            Most nurse practitioner programs do not have a minimum amount of RN experience required – at least with family or adult primary care NP specialties. Some sub-specialty’s like Acute care, Pediatric, Psychiatric, and Neonatal programs will require specific nursing experience in a relevant clinical setting. This is often 1-2 years. Many program admissions pages will “recommend” but not require experience, so a lack of experience may negatively impact your admission.

            So yes, you can totally become an NP without any bedside RN experience. But I do believe this will negatively impact your clinical competency as a new Nurse Practitioner when you graduate. However, I don’t believe bedside RN experience is as important as some people seem to think. A Nurse practitioner must think like a provider, using great history-taking, advanced physical assessments, and evidence-based medicine. As a nurse you will learn so much – but you will not learn how to think like a provider.

            My personal recommendation is to work as a bedside RN for 1-5 years before starting an NP program and to work throughout your program if possible. The number of years of RN experience someone needs to help them become a great nurse practitioner is going to vary based on each individual. I only had 1 year of Full-time RN experience before I started my NP program. However, I worked full-time throughout most of the program and by the time I started my first nurse practitioner job – I had about 4 years of full-time RN experience, most of which were in the ER.

            Are there those who will excel at Nurse practitioner school and being a new nurse practitioner without any RN experience? Maybe. But I think not obtaining any bedside RN experience would do your future patients a disservice, and you would miss out on so much hands-on learning.

            3. ATTEND A NURSE PRACTITIONER PROGRAM

            How to become a Nurse practitioner: NP specialties

            When you are ready to start your NP education, you can apply and get into a nurse practitioner program of your desired specialty. Unlike PA programs that train generalists, NP programs are population-specific. This means that you have to apply to a specific patient-population specialty. This helps your education be tailored to the patients that you will be seeing in your future NP job. Nurse practitioner specialties include:

            • Family Nurse Practitioner (FNP)
            • Adult-Gerontology Primary Care Nurse Practitioner (AGPCNP)
            • Adult-Gerontology Acute Care Nurse Practitioner (AGACNP)
            • Emergency Nurse Practitioner (ENP)
            • Psychiatric Mental health Nurse Practitioner (PMHNP)
            • Women’s Health Nurse Practitioner (WHNP)
            • Pediatric Nurse Practitioner (PNP)
            • Neonatal Nurse Practitioner (NNP)

            The difference between each specialty is an entirely different article, but which one you choose will depend on which clinical setting you plan to practice in one day. If you want to work with adults within the hospital – obtain your AGACNP. If you want to work in a primary care office – get your FNP or AGACNP depending on which ages you want to see. Understand that some specialties are somewhat flexible, and many facilities will hire an FNP or AGPCNP for both inpatient and outpatient roles, as well as within the ED.

            How Long will it take?

            The amount of time a nurse practitioner program will take will depend on which degree you choose to obtain. There is the more traditional Master of Science in Nursing (MSN) degree, as well as the newer Doctorate of Nursing Practice (DNP) option. MSN programs will take about 2-3 years to complete, and DNP programs will take 3-4 years. To currently work in a clinical setting, there isn’t much difference in terms of clinical education, job role, or salary at this current time – although that may change in the future.

            Nurse Practitioner Program Curriculum

            The courses you take will depend on your selected specialty. All NP programs will include some basic fundamental classes such as advanced pathophysiology, advanced pharmacology, and advanced health assessment. Then depending on your specialty, you will have various classes specific to each population which outlines various medical conditions and diseases that will present in that population, along with the assessment, diagnosis, and treatment of each one.

            Just like as an RN, you will also obtain clinical experience during your NP program. The number depends on the program, but most NP programs will require 600-800 hours. Again, this ended up being about 16 hours per week for me. A common misunderstanding is that NP students are just observing during clinical – however, this could not be further from the truth.

            During clinical, it is expected that you are seeing the patient alone, conducting a thorough history, performing your physical assessment, and then presenting the patient to your preceptor (an experienced NP or physician). You will recommend a plan of care, and you and your preceptor will formulate a plan together. This is essential in connecting the dots and preparing you to become a great nurse practitioner.

            Full-time and part-time program options

            Many programs will offer both full-time and part-time tracks which you can use to fit into your lifestyle. Nurse practitioner programs can be intense and most people cannot work full-time and complete a full-time NP program simultaneously. I myself attended a part-time 24-month program which helped me work throughout most of my program, continuing to financially support myself.

            As mentioned above, continuing to work also helps in your learning. You can see firsthand everything you are learning about in your NP education. You might not be formulating the plan of care, but this piece was essential in my development as a competent new NP graduate.

            4. Pass Your Board Certification Exam

            Once you successfully graduate from your NP program, you are eligible for national certification as a nurse practitioner. To be certified, you must first pass a board-certification exam. Depending on your specialty, these are offered through the AANP or the ANCC.

            Once you take your exam and pass, you are officially a nationally board-certified nurse practitioner. BUT you can’t start working yet.

            5. Nurse Practitioner Licensing and Credentialing

            After being certified either through the ANCC or the AANP, you can apply for state licensure within your specific states in which you intend to practice. The steps involved here are state-dependent, but a quick “Nurse practitioner license in (insert your state here)” should be able to illuminate the next steps.

            Even so, this process can be confusing so I have another article outlining these steps which outlines your license, as well as additional necessities like an NPI number or your DEA. Once licensed, you need to get a job within your scope of practice. Once hired, your job will need to credential you. This basically involves background checks and a lot of paperwork being filed with insurance companies. This must be done before you can start practicing as an NP at their clinical site. Be warned – this can take 3-6 months! In 2018 I was hired in February and wasn’t able to start until July for my first NP job.

            On average, the Nurse Practitioner education and training can take a minimum of 6 years to complete, although most will take longer if they obtain more RN experience first or if they attend a part-time track. And just like that – you can be a nurse practitioner too! It’s a long and difficult road, but definitely doable. And I can personally tell you that it is 1000% worth it. If you find yourself wondering how to become a nurse practitioner – this might just be the perfect career for you!

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