Ateneo de Zamboanga University College of Nursing

NUSING SKILLS OUTPUT (NSO) Report No. _3_ BIOPSY I. DESCRIPTION: Skin biopsy is one of the most important diagnostic tests for skin disorders. Punch biopsy is considered the primary technique for obtaining diagnostic full-thickness skin specimens. It requires basic general surgical and suture-tying skills and is easy to learn. The technique involves the use of a circular blade that is rotated down through the epidermis and dermis, and into the subcutaneous fat, yielding a 3- to 4-mm cylindrical core of tissue sample. Stretching the skin perpendicular to the lines of least skin tension before incision results in an elliptical-shaped wound, allowing for easier closure by a single suture. Once the specimen is obtained, caution must be used in handling it to avoid crush artifact. Punch biopsies are useful in the work-up of cutaneous neoplasms, pigmented lesions, inflammatory lesions and chronic skin disorders. Properly administered local anesthesia usually makes this a painless procedure. II. MATERIALS/ EQUIPMENTS NEEDED: 30 gauge needle Iris scissors Toothed forceps (Adson) Sterile punch Skin hook 4 x 4 gauze

III. PROCEDURE 1. After the patient has been gowned, a clinical history has been taken, and the procedure explained, the area of skin where the biopsy is to be performed is prepared with an alcohol swab to insure sterile conditions. 2. Once the skin has been prepared with alcohol, the next step is to anesthetize the area to be biopsied by injecting a solution of Lidocaine (HCL 1% and Epinephrine 1:100,000) just under the epidermis (subepidermally) using a cc Tuberculin Syringe. The injection should continue until a bleb or bubble has formed under the skin greater than 3mm in diameter. The injection will burn slightly (much like a bee sting) due to a pH difference between the skin and the solution. The slight burning will quickly subside and the site will become numb. 3. After the initial Lidocaine injection the area to be biopsied should be checked to insure that the skin is properly anesthetized. The point of the syringe is used to poke the area of the bleb or bubble. Great care should be taken not to force the needle into the skin. The test site should be somewhere around the periphery of the bleb. Both of these precautions insure a viable biopsy for diagnosis later. If the patient experiences neither pain nor sharp

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sensation, the biopsy continues. A pressure sensation is normal and expected but there should be no pain. If the area requires more anesthesia, another injection (with a new syringe) is made until the skin is completely anesthetic. 4. After the area to be biopsied is anesthetized, the biopsy continues. Using a sterile 3mm skin punch, the physician applies pressure and twisting in a drilling motion until the blade of the skin punch has pierced the epidermis of the skin. The blade should be about exposed. It is normal for the patient to experience a pressure and twisting sensation but no pain. 5. After the blade has sufficiently cored or carved out a 3mm cylinder of skin the skin punch is removed. It is normal for the area to bleed after the punch is removed. Excess blood is wiped off with sterile 2 x 2 gauze to expose the biopsy site. The entire process resembles the cookie cutter effect. The only purpose of the skin punch is to core the skin and not to remove the biopsy, much like a cookie cutter. 6. When the skin has been cored and cleared of excess blood, the next step is to remove the biopsy from the rest of the skin. Great care should be taken not to damage the epidermis by crushing it with forceps or by cutting it with a scalpel unnecessarily. The physician uses the forceps to grab the dermis of the cored skin, pulls up the core to reveal excess dermis and subdermal fat, and uses the scalpel in one or two cutting motions to cut the cored skin free. 7. Notice the position of the scalpel during the excision process. The scalpel is placed under the forceps and is moved in the opposite direction of the forceps pulling on the dermis. This motion stabilizes the biopsy and aids in preventing a chopping or slicing affect when trying to free the biopsy. The physician simply utilizes one or two strokes of the scalpel to excise the biopsy with a clean cut. 8. Once the biopsy has been removed from the skin there will usually be some degree of bleeding which should be absorbed with sterile 2 x 2 gauze. The biopsy site is then covered with a standard band-aid and possibly fortified with sterile gauze and paper tape if the bleeding threatens to soak the band-aid and/or the patients clothing. This hole in the skin will continue to bleed for the rest of the day and may or may not form a scab in a few days time. IV. DIAGRAM/ ILLUSTRATIONS:

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V. NURSING RESPONSIBILITIES: 1. BEFORE PROCEDURE Your physician will explain the procedure to you and offer you the opportunity to ask any questions that you might have about the procedure. You will be asked to sign a consent form that provides permission to perform the procedure. Read the consent form carefully and ask questions if something is not clear. Notify your physician if you are sensitive to or are allergic to any medications, latex, tape, and anesthetic agents (local and general). Notify your physician of all medications, especially about blood thinners such as aspirin or Coumadin.

2. DURING PROCEDURE Skin biopsies are done on an outpatient basis, and the procedure is typically completed within 1530 minutes. Biopsies are typically performed in the leg for the diagnosis of sensory neuropathy. Skin is cleaned and injected with local anesthetic. 3 mm punch biopsies are performed in the anesthetized area. Band-Aid is applied to the biopsy site. The skin heals within 23 weeks, minimal scarring may occur at the biopsy site. Other risks, which are very rare, include bleeding and infection. 3. AFTER PROCEDURE Some pain around the biopsy site. This should resolve, or at least ease over the next two or three days. Your doctor will prescribe appropriate pain relieving medication. Nurses monitor your condition for some hours and check for bleeding from the biopsy site. You may have a blood count test to double-check that you are not bleeding internally from the biopsy site.

Reference: http://www.aafp.org/afp/2002/0315/p1155.html http://neurology.uth.tmc.edu/specialty-programs/neuromuscular-program/biopsy-skin.html

JULY 9, 2013 Date

MS. CHERRYL ANN SATOR RN, MN Clinical Instructors Initials EIREES JOY A. MENDOZA BSN III-D

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