October 20101Confidential

Dermatology Clinic:

Bumps, Bruises, Burns, Etc.

Kristina Vaji, MSN, FNP-CInternal Medicine and Pediatrics

Medicine and Pediatric Institute

© Cleveland Clinic 2017

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• Identify wounds that require emergent care.

• Understand basic functions and indications of wound care

equipment.

• Identify concerning skin lesions.

Objectives

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• Skin Tags

• Boils, carbuncles

• Cysts

• Suspicious lesions

• Swollen lymph nodes

Bumps

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• Usually removed by excision

• Apply petroleum or antibiotic afterward and watch for

signs of infection

• Consider diabetes in these patients

• Acanthosis nigricans

Skin Tags

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• Usually caused by staph

• People with history of acne and eczema are more prone

• Diabetics and immunosuppressed as well and in addition

have more risk for cellulitis

• Prevention

‒ Hand washing or use of alcohol-based hand sanitizer

‒ Careful cleaning of cuts, scrapes, and other wounds

‒ Keeping wounds covered

‒ Not sharing towels, sheets, razors, etc.

‒ Home treatment

Boils

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• Closed pocket of tissue filled with pus, fluid or other

material

• Benign, slow growing, usually painless

• Commonly seen are the following:

‒ Epidermoid cysts (sebaceous cyst) (removal of sac of fluid)

‒ Lipoma

‒ Cherry Angioma

‒ Neurofibroma

• Treatment depends on the appearance and contents of

the cyst

• Usually removal, drainage of fluid, incision and drainage

or injection of cortisone are common treatments

Cysts

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• Apply warm, moist compresses several times a day to

help a boil open and drain.

• Keep it clean

• Warm compresses

• Change the bandage often and wash hands well

• Resist the urge to squeeze or pop the lesion

• When to call

‒ A boil on the face or spine

‒ Fever

‒ the boil becomes large and painful

‒ recurrence

Patient Information

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• Ask about mechanism of injury

• Consider structures under the bruise

• Is swelling significant or potential fracture, sprain or strain

• Any numbness or weakness

• Check circulation distal to the bruising/injury

• Consider bleeding disorder

• Provide immobilization if necessary

Bruises

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• Bruise to the muscle usually from trauma

• Grades of contusions

‒ Grade 1 Mild: mild bruising, little pain and no swelling

‒ Grade 2 Moderate: Slightly deeper, mild pain and some swelling

‒ Grade 3 Severe: Very painful, noticeable swelling, obvious

bruising at site of injury

Contusion

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Bruises

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• Compression, elevation, ice and pain control (NSAIDs)

• Moderate-to-severe contusions take an average of 4-6

weeks to heal

• Call for any of the following

‒ Numbness

‒ Weakness

‒ Rapidly increasing swelling

‒ Fever

Contusion / Bruise Aftercare

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• What caused the burn (heat, water, chemical)

• How extensive

• Infection present?

• If the affected area is in an extremity, is there severe

swelling or is the burn circumferential

• Tetanus status

• Treatment

‒ Cleanse with saline if available.

‒ Bottled water may also be a consideration

‒ Keep moist

‒ Manage pain

‒ Medihoney with thin breathable dressing

Burn Assessment

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Classification of Burns

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Rule of Nines

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• Remember ABCDEs of lesions

• Advise patients to seek evaluation by dermatology

• Discuss risk factors with patients

• Offer support and provide resources

Suspicious Lesions

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• Usually done by shave or punch

• Many times can use petroleum jelly or aquaphor

• If slight infection

– Mupiricin ointment twice daily

– Follow up in 1-2 days

• Step up care for moderate to severe infection

‒ May require oral antibiotics

‒ Reevaluation by provider

Care of Biopsy Sites

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• Bilateral or unilateral

• How many

• Freely moveable or fixed

• Signs of infection

• Associated symptoms

• Medical history

• Social history (include sex history)

• Smoking

• Immunizations

Lymphadenopathy Assessment

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• Stable

‒ Can watch for two weeks

‒ May be related to recent illness

‒ Educate patient on when to call

• Concerning

‒ Elevate level of care

‒ May require CT or MRI

Swollen Lymph Node Management

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• Ulcerations

• Lacerations

Wounds

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• Usually due to vascular disease

• High potential for infection

• Difficult to have complete resolution in many instances

• Impaired patient adherence

Ulcerations

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• Is the wound life threatening

• Acute or chronic

• Tetanus status

• Smoking history

• Past medical history

• Medications

• Mechanism

• Concern for rabies

Wound Assessment

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‒ Never band aids, always gauze, especially to legs.

‒ Never NON stick like a telfa pad. Traps too much moisture and

macerates everything making wound larger.

‒ For Burns something all purpose is medihoney. You can get it on

Amazon. Works on any wound, especially with slough and a burn.

‒ Vaseline is cheap and can be used around a wound if wound

dressing may stick.

‒ The trick with most leg wounds is compression. They need to have

ace wraps from base of toes to just below knee. Any lower will

cause leg to swell up and acts as a tourniquet. OTC desitin is

great for periwound that is moist and good to protect. Its fairly

cheap.

‒ Skin tears are to have skin rolled back into place and steri strips

used. Sutures don’t usually work. The flap usually dies from the

tension and swelling from sutures

Peet’s Wound Tips

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My Two Cents:

• Another good tip for wound care is Boudreaux's Butt

Paste. Use around the perimeter of the wound to aid in

faster healing. Many wound care clinics use this.

• Liquid Dial antibacterial foam soap can be used to

cleanse wounds

• Always rule out the worst

Other Wound Tips

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• Clean and debride well

• Elevate

• Provide compression

• Open chronic wounds usually wet to dry dressing

• Assess for any infection

• Educate patients on signs of infection and when to call

• Encourage close follow up if indicated

• Assess resources needed

• Know when to elevate care

Wound Care

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Steri Strips can be used to close skin tears and surface

wounds

‒ Inform patient to let them stay in place until they fall off

(about 7-10 days)

‒Can cut the edges if they start to lift up

‒No petroleum products

Steri Strip S can be used much like sutures

‒ No petroleum products

Dermabond: can be used on many wounds, but not in high

tension areas like joints

‒ Basically wound glue

‒ No petroleum products

‒ Clean with soap and water

Wound Closure

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• Common Materials

‒ Nonabsorbable Nylon (Ethilon) and Polypropylene (Prolene)

‒ Absorbable Fast or Plain Catgut, Vicryl Rapide

‒ Silk braided usually used for securing lines and tubes

• Three main techniques

– Simple interrupted

– Uninterrupted

– Vertical mattress

Sutures

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• Size O: Largest Suture

• Size 7-O is the largest

• Suture by location

Suture by Location

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Examples of Wound Closure

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Examples of Wound Closure

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yourskinbynature.info

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• Cleanse with betadine or chlorhexadine prior to removal

• Cut at the opposite end of the knot and pull knot to remove

• Advise patient to cleanse with soap and water

• May use triple antibiotic ointment after removal for 1-2 days

• Advise to call for any signs of infection, fever or drainage

Suture Removal

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Suture Materials

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medical.com/photo/original_a2b08e9e2c0452afbfc929e3fe2399fd/chromic-catgut.jpg

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• Closure of scalp wounds

‒ If hair is long enough scalp wound can be closed by knotting the

hair and securing the knot with adhesive

• Using common materials to close wounds

‒ Can close wounds with silver duct tape, paper clip and string or

just duct tape folded

• Nu skin or super glue for surface wounds

• Staples

Other Options

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Getting Creative Within Your Scope

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• http://www.fpnotebook.com/Surgery/Pharm/StrMtrl.htm

• Expert Consult: John Queen MD, 1/9/17

– Emergency Room Physician

• Expert Consult: Amy Peet BSN, RN 1/2/17

– Wound care specialist

• https://global-help.org/publications/books/help_basicwoundcare.pdf

References

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