17.1 Office Procedures and Nonpharmacologic Treatment
Key Takeaways
- Domain IV scores nonpharmacologic intervention as procedures, splinting, biopsies, sutures, and imaging — the FNP question is perform versus refer, then consent, tetanus, anesthetic safety, and aftercare.
- Never shave or freeze a suspected melanoma: you need full-thickness histology for Breslow depth. Cryotherapy is for warts and selected keratoses, not undiagnosed pigmented lesions.
- Incise a simple fluctuant abscess; refer central-face, perirectal, deep-hand, neck, and sedation-needed collections. Antibiotics do not replace drainage.
- The old ban on epinephrine in fingers, toes, nose, penis, and ears is overstated. Current teaching is careful digital use, small volumes, and avoid epinephrine when perfusion is poor.
- Imaging is sometimes the intervention: Ottawa-positive ankles and knees get radiographs now; first-trimester pain or bleeding starts with ultrasound, not CT.
Domain IV of the current FNP-BC Test Content Outline scores non-pharmacologic intervention and treatment, and the official parenthetical list is procedures, splinting, biopsies, sutures, and imaging. This is not a sports-medicine sidebar and it is not optional “if you like procedures” content. It is how you implement care with your hands, a sterile tray, and a radiograph when a prescription is not the intervention. Almost every exam item in this cluster is perform versus refer, plus one safety detail: consent, tetanus, lidocaine, or aftercare.
Perform versus refer is a privilege question
You perform a procedure when you are trained, privileged in that setting, the anatomy is straightforward, and you can manage the predictable complications in the room you are standing in. You refer when the site is high risk, the diagnosis is uncertain in a way that the procedure could destroy evidence, sedation or an operating room is safer, or you have not maintained the skill. “I watched it once in school” is not competency. “The patient does not want to drive across town” is not a privilege.
Incision and drainage
A fluctuant cutaneous abscess is treated with incision and drainage. Antibiotics are adjunctive when there is surrounding cellulitis, systemic signs, immunosuppression, a failed prior drainage, or other indicated risk — they are not a substitute for letting pus out. Perform I&D on a well-localized trunk or extremity abscess in an immunocompetent adult you can anesthetize and follow. Refer or send to emergency care for the central face (danger-triangle and cavernous-sinus risk), perirectal or perianal collections, deep-space hand infections, the neck, a breast collection you cannot characterize or drain safely, and any patient who needs sedation you cannot provide. Do not incise a pulsatile mass, a suspected hernia, or a groin node you have not imaged.
Technique is part of the score. Obtain informed consent. Prepare a clean or sterile field. A field block beats injecting lidocaine into an acid pocket of pus that will not numb. Incise along relaxed skin tension lines, break loculations, and send culture when MRSA, recurrence, or systemic illness is in play. Loop drainage is often more comfortable than tight packing; packing is not mandatory for every small cavity. Aftercare is written: how to clean the site, whether warm soaks apply, when to return for fever or spreading erythema, and activity limits.
Skin biopsy: punch, shave, excisional — and the melanoma rule
Choose the technique that answers the diagnostic question without destroying staging data.
| Technique | What it samples | Typical FNP use | Do not use when |
|---|---|---|---|
| Punch | Full thickness, dermis and some subcutis | Inflammatory rashes; small suspected nonmelanoma skin cancer | You need the entire pigmented lesion for Breslow depth |
| Shave | Epidermis ± superficial dermis | Raised nonpigmented lesions, seborrheic keratosis, some BCC/SCC | Any lesion you think might be melanoma |
| Excisional | Entire lesion with a narrow diagnostic margin | Suspected melanoma if you are trained; cysts you can close | Large defects, facial H-zone, closures beyond your skill |
Never shave a suspected melanoma. Breslow thickness drives staging and treatment. A shave that transects the base can make thickness unmeasurable. If the lesion is asymmetric, irregular, changing, or otherwise melanoma-suspicious and you are not trained to complete a diagnostic excision with appropriate narrow margins, refer to dermatology. Refer also for the facial H-zone (central face, eyelids, ears, lips), large lesions that need flaps, and children who need sedation.
Simple interrupted sutures
The FNP closes a linear, clean, well-approximated laceration when deep structures are intact. Simple interrupted sutures are the workhorse because one broken stitch does not open the whole wound. Face typically uses 5-0 or 6-0 nylon or equivalent, removed in 3–5 days. Scalp often takes 4-0 suture or staples, about 7 days. Trunk and extremities use 3-0 or 4-0, 7–10 days, longer over joints. Refer tendon, nerve, or vessel injury; vermillion-border and eyelid lacerations; intraoral repairs you do not do often; heavily contaminated or crush wounds; most clenched-fist and complex bite injuries; and delayed dirty wounds that need delayed closure plus antibiotics rather than a tight cosmetic close.
Check tetanus on every open wound. Give Tdap if the primary series is incomplete or a booster is due — about 10 years for a clean minor wound, about 5 years for a dirty or more severe wound if the series is complete. Think tetanus immune globulin for a dirty or tetanus-prone wound in a person with unknown or incomplete primary immunization. Aftercare names the removal date, activity, signs of infection, and analgesia that is not a default opioid.
Procedures that require documented training
Copper or hormonal IUD placement and etonogestrel implant (Nexplanon) insertion or removal are primary-care procedures only if you are trained and privileged. A negative pregnancy test when indicated, STI risk assessment, consent that names perforation, expulsion, and bleeding-pattern change, and a pain-control plan are not optional. Distorted uterine cavity, unexplained bleeding that has not been evaluated, and immediate postpartum insertion if you lack that skill set are referral situations. Implant work requires manufacturer training — do not improvise from a YouTube memory.
Partial toenail avulsion, with or without phenol matricectomy, is reasonable for recurrent ingrown nails in a well-perfused, nondiabetic adult. Refer diabetes with neuropathy or ischemia, spreading infection, or suspected osteomyelitis.
Cerumen removal is irrigation or instrumentation only after you have reason to believe the tympanic membrane is intact. Do not irrigate a perforated drum, a child with tubes, the only hearing ear, or an ear you cannot see. Soften first. Failed attempts and suspected cholesteatoma go to otolaryngology.
Fluorescein finds a corneal abrasion and must not miss a dendritic (herpetic) ulcer or a leaking globe. A Seidel-positive wound is a ruptured globe: stop manipulating, place a rigid shield, and transfer. Chemical injury is irrigated before you hunt for a pretty stain. A contact-lens infiltrate is an ulcer until proven otherwise — same-day ophthalmology, not a sample of antibiotic drops and hope.
Joint injection is a trained-clinician skill, most often the knee in family practice. Never inject corticosteroid into a joint you have not excluded as septic. Fever, exquisite warmth, inability to bear weight, and a single hot joint are arthrocentesis-and-send, not a steroid shot. Hip injection and complex shoulder work belong with clinicians who do them regularly.
Cryotherapy treats verrucae and selected actinic keratoses. Do not freeze a pigmented lesion you have not diagnosed. Cryotherapy destroys histology. The exam trap is the “dark mole the patient wants burned off today like a wart.”
Splinting and imaging as the intervention
Primary care splints and refers. A splint is rigid on one or more sides and accommodates swelling. A circumferential cast on an acutely swollen limb is how compartment syndrome starts. Match the splint to the injury — sugar-tong for a distal-radius pattern, thumb spica for scaphoid (anatomic-snuffbox) tenderness even when the first film is negative, posterior slab for an unstable ankle — and arrange orthopedic follow-up for suspected fracture, instability, open injury, neurovascular compromise, or growth-plate injury. Chapter 15.4 carries the rehabilitation detail; here the implementation point is that immobilization and the radiograph are the treatment.
Sometimes imaging is the nonpharmacologic intervention because it changes what you do with the limb or the pregnancy.
| Situation | Imaging that is the next act | Why it is implementation |
|---|---|---|
| Ottawa ankle or midfoot positive | Radiograph now | Malleolar, navicular, or fifth-metatarsal bone tenderness, or inability to take four steps, means you do not “walk it off” |
| Ottawa knee positive | Radiograph now | Age ≥55, isolated patellar tenderness, fibular-head tenderness, inability to flex 90°, or inability to bear weight |
| First-trimester bleeding or pelvic pain | Ultrasound first | Pregnancy location and viability without ionizing radiation — not CT, not a pelvic film |
| Low-back pain, no red flags | No routine image | Imaging here is low-value care, not an intervention |
| Scaphoid snuffbox tenderness | Film now; treat as fracture if negative | Thumb spica plus repeat or advanced imaging — the first negative film does not clear the bone |
Ottawa rules are decision tools. Do not skip them when criteria are met, and do not irradiate every anxious sprain that fails the rule just to “be sure” without a clinical indication.
Lidocaine, epinephrine, and the end-artery myth
Classic teaching banned epinephrine in fingers, toes, nose, penis, and ears as “end arteries.” That folklore is overstated. Contemporary hand-surgery and emergency evidence supports dilute epinephrine in digital blocks for most patients without vascular disease, and it improves hemostasis and duration. Current FNP-safe teaching is more precise: be careful in digits, use the smallest effective volume, and avoid large volumes or epinephrine in peripheral vascular disease, Raynaud phenomenon, or poorly perfused diabetic digits. Prefer plain lidocaine when perfusion is in doubt.
Know local-anesthetic systemic toxicity (LAST): perioral numbness, tinnitus, metallic taste, then seizure and cardiovascular collapse. Stop injecting, support the airway, and treat as LAST — do not add “a little more.” Approximate adult maxima that belong in working memory: lidocaine about 4.5 mg/kg without epinephrine and about 7 mg/kg with epinephrine, staying under commonly cited adult caps (about 300 mg and 500 mg). You do not invent a custom formula on the exam. You do refuse to empty a 50-mL bottle into a finger.
Consent, field, tetanus, aftercare
Every procedure needs informed consent: what you will do, why, material risks (infection, bleeding, scar, incomplete removal, uterine perforation, nerve injury), alternatives including no procedure, and who performs it. A sterile or appropriately clean field is part of the intervention. Tetanus status is part of wound care. Aftercare is specific and written: suture-removal date, wound checks, activity, analgesia, and return precautions. If you cannot explain aftercare in one page plus teach-back, you are not ready to do the procedure.
Three afternoon vignettes carry this section. A 28-year-old wants a changing dark plaque frozen because a friend had warts treated that way — you do not cryotherapy it. A 41-year-old has a fluctuant thigh abscess and no fever — I&D today, culture if MRSA risk, written wound care. A 19-year-old jammed a thumb skiing and is tender in the snuffbox with a normal first film — thumb spica and treat as scaphoid, not “it is just a sprain.”
A 54-year-old has a 7-mm asymmetric dark plaque on the calf that has darkened over 6 months. He wants it “burned off today like a wart.” What is the correct FNP action?
Which statement matches current teaching about lidocaine with epinephrine for a digital block in a healthy 30-year-old with a fingertip laceration and no vascular disease?
A 26-year-old at 7 weeks by last menstrual period has unilateral pelvic pain and spotting. Vital signs are stable. What is the correct first imaging implementation?
After incision and drainage of a simple, fluctuant thigh abscess in an immunocompetent adult without surrounding cellulitis or fever, which plan is correct?