[NP-Clinical] cerumen removal

Tue Jan 2 06:43:00 PST 2007

We get a lot of this at my college health practice and I typically send them
out of wax softening drops before I order any irrigation or removal efforts
by our staff.  Otherwise it just takes too long and is not as effective.
But after 3 days of debrox or something similar, 5 minutes with our Welch
Allen irrigator and they are clean as a whistle, and no bleeding.  When I've
had to scrape with a curette and minor bleeding ensues, I typically do not
rx antibiotics.

Andy Craig, NP
Charlotte, NC

-----Original Message-----
From: np-clinical-bounces at nurse.net [mailto:np-clinical-bounces at nurse.net]
On Behalf Of ed piasecki
Sent: Tuesday, January 02, 2007 12:35 AM
To: np-clinical at nurse.net
Subject: RE: [NP-Clinical] cerumen removal

I had a new years from hell in the ER here in blessed Iowa.

One of the cardiologist pops in needing his cerumen impaction resolved stat.
Of course because I am the "mid-level" on duty I get the privlege to remove
his wax. 

The part that urked me was he was upset when it bleed after colace and
irrigation only. This guy had some real potatoes growing up there. 

My question is does the group prophylax with otic antibiotics after they get
bleeding? How far do you go to remove the impaction?

Thanks for your input in advance,

Ed Piasecki

  _____  

From: "Christine Smith" <chrisbsmith at mindspring.com>
Reply-To: NP Clinical <np-clinical at nurse.net>
To: "NP Clinical" <np-clinical at nurse.net>
Subject: [NP-Clinical] INGROWN NAILS
Date: Sun, 31 Dec 2006 19:01:45 -0800

I do about 5 ingrown toe nails a week. If they are really against a wedge
resection then I will have them try the soapy soaks and wedge a piece of
cotton under the nail like Andy does. This seldom works in  my opinion, but
I suspect it is because it is painful and hard to get the cotton under. If
you are going to recommend that the best way to get the cotton under the toe
nail is give the patient an cuticle  stick (those wooden sticks that have a
beveled edge for pushing cuticles down sold in cosmetic section). I bought a
bunch and just stock them so I can show them how. Take a regular cotton ball
and wrap a dab of cotton around the beveled portion of the  stick like
wrapping cotton candy. Then wedge it under the nail. 

However, for the most part I do a resection, wrap with a pressure dressing,
have them remove it in 24 hours and start warm soaks TID before our recheck.
. I see them 48 hours afterwards. They are doing well by then. I rarely ever
give antibiotics unless the erythema has spread up into the toe - which is
seldom. Most times, once the offending section of nail is removed, it clears
up.

I also do the digital block with Bupivicaine and I give them Motrin 800 in
the office with a Vicodin rx #12. I tell them to pop two Vicodin right after
they fill it, go home, elevate foot and sleep. By morning, almost all of
mine return to work on Motrin all day with a Vicodin back up. Suckers hurt -
I know from experience. Especially since most my patients are male laborers
and need to get right back to work the next day. I try to get them to let me
do it the night before their day off so they can limit walking but not
always feasible.

I once "operated" on my daughters boyfriends toe on my bed. I put him on
Motrin and sent him home. That night he called me at 2am in tears due to the
intense pain. I was sure I did something wrong, sure I was going to lose my
license, sure the kid was going to lose his toe. I was panicked! I drove one
hour to his house, assessed a normal looking toe and a crying 22 yo 220lb
kid. I repeated the digital block with marcaine (even though the toenail was
now resected) and gave him two old Percocet I had. He ended up fine. I
thought he was a wimp, until I had my own toe done. I am telling you, these
puppies  hurt!

I talked to my own podiatrist about this (Lorraine Loretz's old professor).
He told me that he always give Motrin 800 to women and Vicodin to most men.
He said men are either wimpier or just need it more - he is not sure why,
but that Motrin seems to be enough for females. He also told me antibiotics
are rarely needed but if there is very much infection it can be more
difficult to get a good digital block.

I am sure Lorraine has her own thought on this.

Christine Smith, NP
Antioch, CA

----- Original Message ----- 
From: Andy Craig <mailto:aec-618 at carolina.rr.com>  
To: 'NP Clinical' <mailto:np-clinical at nurse.net>  
Sent: Sunday, December 31, 2006 12:09 PM
Subject: RE: [NP-Clinical] Foot/nail care by NP's

If I see someone with an ingrown nail that is real early and mild severity,
I offer conservative treatment as an option: warm soapy soaks TID and a
small piece of cotton tucked under the end of the nail to lift it up a bit
off the nail fold and relieve some of the pressure.  But 9 times out of 10,
my tx of choice is cold, hard steel ;)  (wedge resection.)  Especially if
it's infected.  And if it is I typically rx Keflex for 7 days while they
heal.  I leave them in a bulky dressing with a small piece of vaseline gauze
tucked into the proximal nail fold for the first 2 days; After 2 days I see
them back, remove the gauze, apply a band aid and have them do warm soapy
soaks TID for a week

Andy Craig, NP
Charlotte, NC

-----Original Message-----
From: np-clinical-bounces at nurse.net [mailto:np-clinical-bounces at nurse.net]
On Behalf Of ed piasecki
Sent: Sunday, December 31, 2006 2:27 AM
To: np-clinical at nurse.net
Subject: RE: [NP-Clinical] Foot/nail care by NP's

To the Group:

Same topic, different piece:

Infected ingrown toe nails. Do most treat with antibiotics and then remove
nail or do both together?

Ed Piasecki

  _____  

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