FNP application scenario

  1. I'm a new FNP APRN and about to start my first job in an outpatient office. I'm putting my pride away and hoping I can ask some scenario-based questions and get some answers as what would you do? I feel like I'm constantly thinking of situations where I can't get clear cut answers right away. I apologize if these are dumb and obvious. I don't have an experienced APRN I can bounce ideas off of. I'll start with this situation...

    Patient comes in with an abscess and is on coumadin. What antibiotic would you prescribe empirically? Normally I'd choose Bactrim or doxycycline...however these affect the INR? Would you prescribe these medications and just check the INR more frequently or prescribe another medication? If so, how often would you check the INR? Otherwise, would you use clindamycin? Lastly, would you have them follow up in like 2 days? Thanks in advance!
    Last edit by ilovensg on Sep 12
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  2. 6 Comments

  3. by   Dodongo
    Is it a single/focal, cutaneous abscess? Uncomplicated - no fever, VS changes, etc? No associated cellulitis/erysipelas/folliculitis? How big is the abscess? I assume you're going to do an I&D? If the abscess is small and the patient has no comorbid conditions, then do you think an I&D will be sufficient without antibiotic coverage? If you think you need antibiotics after the I&D, and you're not concerned with MRSA or uncommon pathogens, I would just use a beta-lactam - keflex would work well, I think.

    From what I can tell from a quick google search (utilizing only the links that provide peer reviewed, scholarly literature), if you're concerned, make sure you know the patient's baseline INR and then you can re-draw the INR in ~3 days. (The following was redacted as it might encourage people to ignore standards of practice as sarcasm is difficult to recognize over the internet).

    Would be interested in hearing from experienced providers.

    AND OF COURSE, IF YOU'RE NOT TRAINED IN SOMETHING, OR DON'T KNOW WHAT TO DO, DON'T JUST DO IT ANYWAYS.
    Last edit by Dodongo on Sep 12
  4. by   BostonFNP
    Quote from ilovensg
    I'm a new FNP APRN and about to start my first job in an outpatient office. I'm putting my pride away and hoping I can ask some scenario-based questions and get some answers as what would you do?
    Make sure you identify a mentor or mentors and utilize them frequently. Good luck.

    Quote from ilovensg
    Patient comes in with an abscess and is on coumadin. What antibiotic would you prescribe empirically? Normally I'd choose Bactrim or doxycycline...however these affect the INR? Would you prescribe these medications and just check the INR more frequently or prescribe another medication? If so, how often would you check the INR? Otherwise, would you use clindamycin? Lastly, would you have them follow up in like 2 days? Thanks in advance!
    As a generalized FYI, make sure you check with your office protocol and the other providers in your clinic before you engage in invasive procedures. You need to have on-hand supervision if you are new to a procedure and you need to have emergency coverage if a complication arises.

    For uncomplicated cutaneous abscess the treatment of choice is I&D without subsequent abx coverage. However, if this patient is anti-coagulated you will likely not be handling an I&D on the initial visit. Be very careful with novels here because I have seen providers do minor surgical procedures in clinic because they checked for coumadin but not a novel and run into trouble. Be very aware of your knowledge of the adjacent anatomy as well.

    Many offices don't do I&Ds at all, they refer out to either the ED or general surgery/derm consult.

    If there is sign of systemic infection then ED may be appropriate.

    This leaves you two options: abx or referral. Either is a valid option. Your abx choice will be based on your individual patient, their risk factors, and your local bacteriogram. Keflex is the cellulitis abx of choice but with a collected abscess you may want to cover MRSA which leave you Doxy and Bactrim DS. Both can safely be used in most situations (be aware of allergies and renal function). If the patient is on coumadin then consider a 1-2 dose hold when starting abx (1 for doxy, 2 for bactrim is generally safe). Get a baseline INR. Monitor INR every 3-5 days after starting treatment.

    Cellulitis and abscesses are normally a 72 hour follow-up for me. Mark the borders.
  5. by   BostonFNP
    Quote from Dodongo

    From what I can tell from a quick google search, if you're concerned, make sure you know the patient's baseline INR and then you can re-draw the INR in ~3 days. OR, you don't even have to worry about it. Haha.

    Would be interested in hearing from experienced providers.
    Don't just "google" it (and don't just blindly take advice from posters here either, myself included and perhaps least of all..)!

    You should have access to experienced providers/mentors, guidelines/p&p, and point of care resources that should inform your clinical practice. You do not want to be telling a lawyer that you checked google to make your decision.
  6. by   Dodongo
    Quote from BostonFNP
    Don't just "google" it... You do not want to be telling a lawyer that you checked google to make your decision.
    SIIIIIIIGH. You are aware that google is just a search engine, right? You get to choose what sources you pick! It's crazy.

    You can even go to google scholar which will only return an index of scholarly literature.

    Boston, sometimes I think you just like to be contrary for the sake of being contrary... Haha! I updated my post to reflect your concerns.
  7. by   traumaRUs
    My disclaimer is that I care for ESRD pts or those with severe renal impairment.

    My go to for pts on coumadin is doxycycline - not the best (I would prefer Keflex), I lower the coumadin dose by 0.5mg per day and recheck INR 48-72 after antibiotics started. I am also the provider managing their coumadin.
  8. by   Melissa1522
    This is what concerns me about multiple comments on this thread.

    First of all, please find a mentor before you practice on patients. They deserve to have someone who is well trained and knows what they are treating and how to treat it.

    With that said, I&D's do not need to go to derm, surgery or for goodness sakes the ED. This is bread and butter of primary care. Please learn how to approach these because patients will come to you, expecting you to know how to handle something like this.

    Second of all, recommendations are to decrease dose of Coumadin by 10% of the weekly dose when starting a medication that could cause a Supra-therapeutic INR. Check at 72 hours.

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