In-Office Clinical Procedures, ECG Interpretation & Minor Surgical Skills

AANPCB Adult-Gerontology Primary Care Nurse Practitioner A-GNP

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1 Exam Structure, APRN Foundations & Geriatric Assessment

A-GNP Exam Logistics, Blueprint & Scoring Structure APRN Scope of Practice, Consensus Model & Interprofessional Collaboration Comprehensive Health History & Subjective Assessment Across Adult Lifespan Comprehensive Physical Examination & Clinical Assessment Skills

2 Health Assessment, Diagnostic Reasoning & Clinical Procedures

Diagnostic Reasoning, Test Interpretation & Clinical Decision-Making Screening Guidelines & Evidence-Based Health Promotion (USPSTF) Comprehensive Geriatric Assessment (CGA), Frailty & Function In-Office Clinical Procedures, ECG Interpretation & Minor Surgical Skills

3 Cardiovascular & Peripheral Vascular Disorders

Essential Hypertension & Hypertensive Urgency/Emergency Management Coronary Artery Disease, Acute Coronary Syndromes & Post-MI Care Heart Failure (HFrEF & HFpEF) Diagnosis, Staging & 4-Pillar GDMT Arrhythmias (Atrial Fibrillation), Valvular Heart Disease & PAD

4 Respiratory, HEENT & Dermatological Disorders

Asthma Management across the Adult Lifespan (GINA Guidelines) Chronic Obstructive Pulmonary Disease (COPD) Staging & Management (GOLD Guidelines) Community-Acquired Pneumonia & Lower Respiratory Tract Infections Common HEENT Disorders: Otitis, Sinusitis, Pharyngitis, Glaucoma & Macular Degeneration

5 Endocrine, Metabolic & Renal/Genitourinary Disorders

Type 2 Diabetes Mellitus Management Thyroid Disorders: Hypothyroidism, Hyperthyroidism & Subclinical Disease Chronic Kidney Disease (CKD) Staging & Diabetic/Hypertensive Nephropathy Genitourinary Disorders: BPH, Urinary Incontinence, UTIs & Prostatitis

6 Gastrointestinal, Hematologic & Immunologic Disorders

Upper Gastrointestinal Disorders: Dyspepsia, GERD, PUD & H. pylori Lower Gastrointestinal Disorders: IBS, IBD, Diverticulitis & Colorectal Screening Liver, Biliary & Pancreatic Disorders: NAFLD/MASLD, Cirrhosis & Cholecystitis Hematologic & Immunologic Disorders: Anemias, Anticoagulation & Immunizations

7 Neurological, Cognitive & Psychiatric Disorders

Cognitive Assessment: Delirium, Dementia & Mild Cognitive Impairment Neurological Disorders: Stroke, TIA, Parkinson's Disease & Headache Syndromes Major Depressive Disorder & Anxiety Disorders in Adults & Older Adults Sleep Disorders, Insomnia & Restless Legs Syndrome

8 Geriatric Syndromes, Polypharmacy & Deprescribing

The Beers Criteria & STOPP/START Criteria for Potentially Inappropriate Medication Use Polypharmacy Management, Pharmacokinetics/Pharmacodynamics in Aging & Deprescribing Protocols Fall Risk Assessment (CDC STEADI), Gait/Balance & Mobility Impairments Pressure Injury Prevention/Staging, Urinary/Fecal Incontinence & Frailty Assessment

9 APRN Professional Practice, Ethics, Quality & Healthcare Policy

Musculoskeletal Disorders: Osteoarthritis, Osteoporosis, Gout & Back Pain Dermatological Disorders: Lesions, Skin Cancers, Infections & Rash Evaluation Palliative Care, Advance Care Planning, Pain Management & End-of-Life APRN Professional Practice, Quality Improvement, Ethics & Healthcare Policy

In-Office Clinical Procedures, ECG Interpretation & Minor Surgical Skills

Key Takeaways Explain This Topic AI

Systematic 12-lead ECG analysis evaluates rate, rhythm, axis, hypertrophy (Sokolow-Lyon criteria >35mm), and ischemic ST changes in contiguous vascular leads.

Local anesthesia dosing limits must be strictly maintained (Lidocaine plain max 4.5 mg/kg vs Lidocaine with Epinephrine max 7 mg/kg); buffering with sodium bicarbonate reduces injection pain.

Suture selection matches wound location and tissue tension; facial sutures (5-0/6-0) are removed at 3-5 days, while joint/extremity sutures (3-0/4-0) remain for 10-14 days.

Abscess I&D requires Langer's line incision and loculation breakdown; synovial fluid analysis differentiates non-inflammatory, inflammatory (gout/pseudogout), and septic arthritis (>50,000 WBC/mcL).

Last updated: July 2026

• In-Office Clinical Procedures, ECG Interpretation & Minor Surgical Skills
• Principles of Outpatient Clinical Procedures

Advanced Practice Registered Nurses perform minor surgical procedures in primary care settings. Competency requires a firm grasp of anatomy, sterile technique, local pharmacology, wound healing principles, and procedural safety. Clinicians must obtain informed consent , confirming the patient understands the purpose, benefits, risks (bleeding, infection, scarring, nerve damage), and alternatives.

12-Lead Electrocardiogram (ECG) Interpretation

A systematic 6-step method prevents misinterpretation of 12-lead ECG tracings:

Rate: Calculate using 300-150-100-75-60-50 method for regular rhythms.

Rhythm: Assess R-R regularity and P waves. Atrial fibrillation displays an irregularly irregular rhythm without visible P waves.

Axis: Evaluate leads I and aVF. Positive QRS in both indicates Normal Axis ( 0 ∘ 0^\circ 0 ∘ to + 90 ∘ +90^\circ + 9 0 ∘ ). Positive I / Negative aVF indicates Left Axis Deviation. Negative I / Positive aVF indicates Right Axis Deviation.

Intervals: PR interval (120-200 ms), QRS duration ( < 120 ms < 120\text{ ms} < 120 ms ), and QTc interval ( < 450 ms < 450\text{ ms} < 450 ms in males, < 470 ms < 470\text{ ms} < 470 ms in females). Prolonged QTc increases Torsades de Pointes risk.

Hypertrophy & Conduction Blocks:

Left Ventricular Hypertrophy (LVH): Sokolow-Lyon Criteria : S wave in V1 + R wave in V5/V6 > 35 mm S\text{ wave in V1} + R\text{ wave in V5/V6} > 35\text{ mm} S wave in V1 + R wave in V5/V6 > 35 mm .

Right Bundle Branch Block (RBBB): QRS > 120 ms > 120\text{ ms} > 120 ms with r s R ′ rsR' rs R ′ pattern ("rabbit ears") in V1-V3.

Left Bundle Branch Block (LBBB): QRS > 120 ms > 120\text{ ms} > 120 ms with broad monophasic R waves in I, aVL, V5-V6. Clinical Pearl: New-onset LBBB with chest pain is a STEMI equivalent .

Ischemia, Injury & Infarction:

ST Elevation (STEMI): ≥ 1 mm \ge 1\text{ mm} ≥ 1 mm ST elevation in ≥ 2 \ge 2 ≥ 2 contiguous leads (Anterior V1-V4 LAD, Inferior II/III/aVF RCA, Lateral I/aVL/V5-V6 LCx).

Pathologic Q Waves: Width > 0.04 s > 0.04\text{ s} > 0.04 s and depth > 25 % > 25\% > 25% of R wave height, indicating established necrosis.

Local Anesthesia & Regional Field Blocks

Local anesthetics block voltage-gated sodium channels to prevent nerve action potential conduction.

Pharmacological Properties & Dosing Limits

Lidocaine 1% (10 mg/mL): Rapid onset (2-5 min), duration 30-120 min.

Maximum Dose (Plain Lidocaine): 4.5 mg/kg 4.5\text{ mg/kg} 4.5 mg/kg (max 300 mg 300\text{ mg} 300 mg total).

Maximum Dose (Lidocaine with Epinephrine): 7.0 mg/kg 7.0\text{ mg/kg} 7.0 mg/kg (max 500 mg 500\text{ mg} 500 mg total).

Bupivacaine 0.25%: Slow onset (5-10 min), prolonged duration (4-8 hours).

Epinephrine & Neutralization Buffering

Epinephrine ( 1 : 100 , 000 1:100,000 1 : 100 , 000 ) induces local vasoconstriction, prolonging anesthetic duration, decreasing systemic absorption, and enhancing hemostasis. Safe for digital blocks unless severe peripheral vascular compromise is present.

Buffering Anesthetics: Neutralizing Lidocaine's acidic pH by adding 8.4% Sodium Bicarbonate in a 1:9 ratio (1 mL bicarbonate per 9 mL lidocaine) significantly reduces injection burning pain and accelerates onset.

• Minor Surgical Skills, Suturing & Wound Care
• Suture Material Selection

Absorbable Sutures: Used for deep subcutaneous/dermal closure.

Polyglactin 910 (Vicryl): Braided, high tensile strength, absorbs in 56-70 days.

Poliglecaprone 25 (Monocryl): Monofilament, absorbs in 90-120 days.

Chromic Gut: Collagen, absorbs in 10-14 days.

Non-Absorbable Sutures: Used for epidermal closure.

Nylon (Ethilon): Monofilament, low tissue reactivity, standard for skin closure.

Polypropylene (Prolene): Monofilament, high elasticity.

Suture Sizing & Removal Timelines

• Location Suture Size Removal Timeline
• Face / Eyelids 5-0 or 6-0 Monofilament 3 to 5 Days
• Scalp 3-0 or 4-0 Monofilament / Staples 7 to 10 Days
• Trunk / Abdomen 4-0 Monofilament 7 to 10 Days
• Extremities 4-0 Monofilament 10 to 14 Days
• Joint Surfaces 3-0 or 4-0 Monofilament 14 Days
• Suturing Techniques

Simple Interrupted: Standard technique for clean skin lacerations.

Vertical Mattress: "Far-far-near-near" technique providing superior wound edge eversion in high-tension skin.

Horizontal Mattress: Spreads tension along wound margins; ideal for fragile skin.

Abscess Incision & Drainage (I&D)

Anesthesia: Administer regional field block around abscess border.

Incision: Make a linear incision with a #11 scalpel along Langer's skin tension lines across cavity diameter.

Debridement & Irrigation: Insert curved Hemostat to break down loculations; copiously irrigate with sterile normal saline.

Packing: Loosely insert iodoform gauze packing if cavity is > 2 cm > 2\text{ cm} > 2 cm or in immunocompromised patients to prevent premature wound closure.

Cultures: Obtain wound cultures for recurrent abscesses, systemic toxicity, or high MRSA prevalence.

Diagnostic Skin Biopsy Methods

Punch Biopsy: Full-thickness cylindrical specimen (3 mm to 6 mm) evaluating epidermis, dermis, and subcutaneous fat. Suture closure required for lesions ≥ 4 mm \ge 4\text{ mm} ≥ 4 mm .

Shave Biopsy: Superficial removal of epidermis and upper dermis. Indicated for elevated benign lesions or superficial non-melanoma skin cancers. Contraindicated for suspected melanoma.

Excisional Biopsy: Complete elliptical excision with 1-3 mm margins into subcutaneous fat. Standard procedure for suspected melanoma.

• Joint Arthrocentesis & Intra-Articular Injections
• Synovial Fluid Analysis

Non-Inflammatory: Clear/straw, WBC < 2 , 000 / μ L < 2,000 / \mu\text{L} < 2 , 000/ μ L (Osteoarthritis).

Inflammatory: Yellow, WBC 2 , 000 − 50 , 000 / μ L 2,000 - 50,000 / \mu\text{L} 2 , 000 − 50 , 000/ μ L .

Gout: Needle-shaped, negatively birefringent monosodium urate crystals.

Pseudogout: Rhomboid-shaped, positively birefringent calcium pyrophosphate crystals.

Septic Arthritis: Opaque/purulent, WBC > 50 , 000 / μ L > 50,000 / \mu\text{L} > 50 , 000/ μ L with > 75 % > 75\% > 75% PMNs. Requires urgent surgical lavage.

Intra-Articular Corticosteroid Protocols

Combine 40 mg Triamcinolone with 1-2 mL 1% Lidocaine. Limit intra-articular steroid injections to a maximum of 3 to 4 times per year per joint to prevent cartilage degradation and tendon weakening.