In lieu of the traditional case study of the week, this week I will highlight a procedure. If you are a family nurse practitioner, chances are you have drained many abscesses. If you are an NP student or work in a specialized clinic, you may not yet have experience with this procedure. It can be very difficult to learn procedures as there are limited opportunities so I will attempt to familiarize you with the process so you are better prepared for your first abscess incision and drainage (I&D).
1. Appropriately Diagnose a Cutaneous Abscess
Abscesses can occur anywhere in the body from the teeth to the intestines and the skin. As a nurse practitioner, you will likely only deal with draining cutaneous (skin) abscesses. Abscesses present as pustules or boils of varying size often with surrounding redness and induration. Drainage may or may not be present. Treatment of an abscess requires drainage. Simply putting the patient on antibiotics will not cure an abscess. Nearly all abscesses are caused by MRSA infection.
2. Prepare to Drain the Abscess
Once you have accurately diagnosed a cutaneous abscess, you must make an incision to drain the area. Gather your supplies including gloves, 4×4’s, hemostats, 1/4in packing, an 11 blade scalpel, lidocaine, an injection device and bandage materials. Abscess drainage is not a sterile procedure so sterile precautions do not need to be taken. Inject the “head” of the abscess (the area with a scab or any already present drainage or the center of the most fluctuant area) with lidocaine. Be sure to wear protective clothing and/or eyewear and cover the area with a 4×4 as you do this in order to prevent flying pus!
3. Incision and Drainage
Once the area is appropriately numbed, you are ready to make an incision. Using the 11 blade scalpel, carefully cut the abscess open. The length of opening will vary depending on the size of the abscess, but the incision should be just large enough to allow the purulent drainage inside of the abscess to flow freely out of the incision. Try not to make the incision larger than necessary to prevent scarring. Push the sides of the abscess to encourage complete drainage of the area. Next, explore the abscess with the hemostats to break up any innoculations.
4. Pack the Abscess
Using your hemostat, gently guide the 1/4 inch packing into the incision you have made. This will ensure that the abscess remains open and continues to drain as the infection heals. The abscess will heal internally toward the surface of the skin. You do not need to pack every last millimeter of the abscess, just enough to keep the incision open and the packing in place. You should have your patient return every 2-3 days for repacking of the abscess until it heals completely. Note: You should avoid packing facial abscesses to reduce scarring.
Not All Abscesses Are Created Equally
Use caution when treating abscesses on the face, abdomen, neck, near joint lines, nerves or blood vessels. Accidentally incising a nerve or blood vessel can lead to serious complications. Always, always get a second opinion if you are uncertain about an I&D and if an area is safe to drain. See this slideshow for some helpful precautions. And of course, the first time you do a procedure you should always have another experienced nurse practitioner or physician help you out!
FNP student says:
Soooo helpful, thanks so much, will be sharing with my classmates!
erin says:
No problem! Are there any other procedures you would like to see featured?
VND says:
Thanks.
Can you also show us the procedure to remove 1 part of the nail in ingrowing nail
Xavier says:
Great post! I would like to see a picture of the major nerves we should avoid.
erin says:
We will work on this for you, thanks for the feedback Xavier!
Doris Neng says:
Hello Erin, thanks for all the information, can you do diagnostic or thereapeutic paracentensis.it will be nice to have skills like that
Thanks
Jerry Goddard, MD says:
Loop drainage is an improved skin abscess drainage procedure. For significantly large or continuously draining abscesses, bipolar small incisions are made at the abscess borders and a drain may be left in place as needed and for up to several days, to facilitate complete resolution [14]. This technique has significantly decreased the failure rate for appropriate treatment (1.4%, compared with 10.5% in the standard group) https://www.aliem.com/2012/08/trick-of-trade-incision-and-loop/