NURSING
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Skin
Cryosurgery – freeze should be spread laterally 2-3 mm from the edge of the lesion. One
freeze-thaw cycle should be sufficient. If thicker, more keratotic lesions (plantar warts and large
seborrheic keratosis) two freeze-thaw cycles are recommended
**Avoid bacitracin r/t ↑ contact dermatitis**
Electrocautery – acrochorda, actinic keratosis, small angiomata, compound nevi, warts, and
seborrheic keratoses. Clean with non-alcohol skin cleanser, 1 or 2% lidocaine with or without
epi. More useful in treatment of vascular lesions
Curettage – seborrheic keratoses, some warts, molluscum, and some types of skin cancer. Local
anesthesia required. Send specimen for pathology. Hemostasis with electrocautery or aluminum
chloride.
Biopsy – remove with at least 1mm margin. Prep with alcohol, 1-2% lidocaine with or without
epi. Do not use epi at tips of digits, nose or glans penis. Use drape and sterile gloves.
Lesions
Moist, weeping – Burrow solution
Exudative – wet dressing
Dry dermatitis – creams or ointments
Choice of medication strength and amount prescribed depends on size and type of lesion:
Hand 15g
Arm, foot, face, neck 30g
Leg or trunk 60g
Strength = Ointments>Creams>Lotions>Solutions
Corticosteroids class 1-4 never be used on the face or genitals
Avoid Rx for class 1-3
Screening
ACS Q3 years for 20-40 year olds, annually for > 40 years
Ob/gyn screen females with habitual sun exposure > 13 years old
ABCDE pneumonic for assessment
DD: Actinic keratoses
BCC, SCC
MM
Dysplastic nevi
Eyes
Screening
>65 yo every 1-2 years
DM I, then 3-5 years after the diagnosis, then annually
DM II, at the time of diagnosis, then annually
, Page |2
If pregnancy desired in DM, exam prior to conception, then early in first trimester
History
Inherited conditions: glaucoma, color blindness, cataracts, macular degeneration, retinal
degeneration, corneal dystrophy, retinoblastoma
Medications: sildenafil/Viagra = cyanopsia (blue-tinted vision), timolol (for glaucoma) can
exacerbate SB and asthma
Exam
Visual acuity – test prior to any other exam with the use of patient’s refractive aids. Snellen
chart, tumblins Es, etc. If unable to read Snellen chart (20/200), the use a card of 20-200 Snellen
E or count fingers (CF) or waving hand motion (HM). If still unable to see, then assess for light
perception (LP). If none seen, documented as (NLP). Near vision is tested with Rosenbaum
near card at 14 inches. Presbyopia occurs naturally at 42-43 yo.
Pupil response – normal range 2.6-5.0, variance is anisocoria and exists in 20% of the
population. Normal consensual constriction – if not, may be injury to optic nerve (RAPD –
relative afferent pupillary defect or Marcus-Gunn pupil).
Intraocular pressure – normal 10-20 mm Hg. Air-puff tonometer, Tono-Pen, Goldmann
applanation tonometry(GOLD STANDARD). Tono-Pen used in primary care – instill
proparacain, touch cornea with center of penlike device. Not as accurate but quick and easy to
use. If you don’t have, palpate globes through closed lids. Normal – grape like, Abnormal –
rock-hard. Firm, painful eye that is inflamed and cloudy cornea = acute rise in intraocular
pressure = Emergency referral
Extraocular movements – Hirschberg test – pen light prompting a light reflex. Deviation
medially (nasally) = exotropia laterally (temporally) = esotropia
Ocular alignment: cover-uncover test or alternate-cover test
When covered eye is uncovered, if movement = strabismus. Should be no movement.
Ocular motility: Assess 9 diagnostic positions with your finger.
Cardinal directions of gaze: right, upper right, upper left, left, lower left, and lower right
Cranial nerve III (oculomotor) palsy – down & out position of affected eye. Cannot
move up or down ptosis and non-responsive pupil (emergent neuroimaging and eval).
Causes: microvascular effects of HTN and DM, compressive lesions, aneurysm.
Cranial nerve IV (trochlear) palsy – motility may be normal but may have ↓ looking
Traumatic/
Ischemic
down in adducted position. Head tilt away from affected side will diminish diplopia.
Cranial nerve VI (abducens) abnormality: cannot abduct involved eye, head tilt away
from affected side will diminish diplopia.
Positioning of eyes: assess protuberance (exophthalmos or proptosis) bilaterally may be
thyroid, unilaterally may be tumor.
Visual fields – confrontation exam to assess peripheral vision using fingers in 4 quadrants
Structure of the eye:
External Periorbital exam (eyelids, eyelashes, and lacrimal system)
Page |1
Skin
Cryosurgery – freeze should be spread laterally 2-3 mm from the edge of the lesion. One
freeze-thaw cycle should be sufficient. If thicker, more keratotic lesions (plantar warts and large
seborrheic keratosis) two freeze-thaw cycles are recommended
**Avoid bacitracin r/t ↑ contact dermatitis**
Electrocautery – acrochorda, actinic keratosis, small angiomata, compound nevi, warts, and
seborrheic keratoses. Clean with non-alcohol skin cleanser, 1 or 2% lidocaine with or without
epi. More useful in treatment of vascular lesions
Curettage – seborrheic keratoses, some warts, molluscum, and some types of skin cancer. Local
anesthesia required. Send specimen for pathology. Hemostasis with electrocautery or aluminum
chloride.
Biopsy – remove with at least 1mm margin. Prep with alcohol, 1-2% lidocaine with or without
epi. Do not use epi at tips of digits, nose or glans penis. Use drape and sterile gloves.
Lesions
Moist, weeping – Burrow solution
Exudative – wet dressing
Dry dermatitis – creams or ointments
Choice of medication strength and amount prescribed depends on size and type of lesion:
Hand 15g
Arm, foot, face, neck 30g
Leg or trunk 60g
Strength = Ointments>Creams>Lotions>Solutions
Corticosteroids class 1-4 never be used on the face or genitals
Avoid Rx for class 1-3
Screening
ACS Q3 years for 20-40 year olds, annually for > 40 years
Ob/gyn screen females with habitual sun exposure > 13 years old
ABCDE pneumonic for assessment
DD: Actinic keratoses
BCC, SCC
MM
Dysplastic nevi
Eyes
Screening
>65 yo every 1-2 years
DM I, then 3-5 years after the diagnosis, then annually
DM II, at the time of diagnosis, then annually
, Page |2
If pregnancy desired in DM, exam prior to conception, then early in first trimester
History
Inherited conditions: glaucoma, color blindness, cataracts, macular degeneration, retinal
degeneration, corneal dystrophy, retinoblastoma
Medications: sildenafil/Viagra = cyanopsia (blue-tinted vision), timolol (for glaucoma) can
exacerbate SB and asthma
Exam
Visual acuity – test prior to any other exam with the use of patient’s refractive aids. Snellen
chart, tumblins Es, etc. If unable to read Snellen chart (20/200), the use a card of 20-200 Snellen
E or count fingers (CF) or waving hand motion (HM). If still unable to see, then assess for light
perception (LP). If none seen, documented as (NLP). Near vision is tested with Rosenbaum
near card at 14 inches. Presbyopia occurs naturally at 42-43 yo.
Pupil response – normal range 2.6-5.0, variance is anisocoria and exists in 20% of the
population. Normal consensual constriction – if not, may be injury to optic nerve (RAPD –
relative afferent pupillary defect or Marcus-Gunn pupil).
Intraocular pressure – normal 10-20 mm Hg. Air-puff tonometer, Tono-Pen, Goldmann
applanation tonometry(GOLD STANDARD). Tono-Pen used in primary care – instill
proparacain, touch cornea with center of penlike device. Not as accurate but quick and easy to
use. If you don’t have, palpate globes through closed lids. Normal – grape like, Abnormal –
rock-hard. Firm, painful eye that is inflamed and cloudy cornea = acute rise in intraocular
pressure = Emergency referral
Extraocular movements – Hirschberg test – pen light prompting a light reflex. Deviation
medially (nasally) = exotropia laterally (temporally) = esotropia
Ocular alignment: cover-uncover test or alternate-cover test
When covered eye is uncovered, if movement = strabismus. Should be no movement.
Ocular motility: Assess 9 diagnostic positions with your finger.
Cardinal directions of gaze: right, upper right, upper left, left, lower left, and lower right
Cranial nerve III (oculomotor) palsy – down & out position of affected eye. Cannot
move up or down ptosis and non-responsive pupil (emergent neuroimaging and eval).
Causes: microvascular effects of HTN and DM, compressive lesions, aneurysm.
Cranial nerve IV (trochlear) palsy – motility may be normal but may have ↓ looking
Traumatic/
Ischemic
down in adducted position. Head tilt away from affected side will diminish diplopia.
Cranial nerve VI (abducens) abnormality: cannot abduct involved eye, head tilt away
from affected side will diminish diplopia.
Positioning of eyes: assess protuberance (exophthalmos or proptosis) bilaterally may be
thyroid, unilaterally may be tumor.
Visual fields – confrontation exam to assess peripheral vision using fingers in 4 quadrants
Structure of the eye:
External Periorbital exam (eyelids, eyelashes, and lacrimal system)
