13. No breath sounds will be heard on auscultation of the chest during inflationary breaths, though air movement may be heard, especially over the lower portion of the chest. When feasible, use two caregivers to perform endotracheal suctioning if the closed (in-line) system is not in use. Loss of or poor chest wall excursion with ventilator breaths. Commercially prepared suction catheter kit or sterile suction catheter and sterile gloves. If the introducer cannot be advanced into the vein, the insertion site may need to be further dilated. Stabilize the left hand against the left side of the patient’s face, advance the blade tip to the base of the tongue, and move the blade to the midline, pushing the tongue to the left. d. Types of blades: Remifentanil 8. 9. Do not rock the tip of the blade upward or use the upper gum as a fulcrum. Apply only to intact skin. Position infant so selected vein is accessible. Question. Avoid hyperoxygenation, hyperinflation, and hyperventilation techniques if possible. 15 units/mL. B. Contraindications. 24-gauge peripheral IV catheter. ■ Perform time out before procedure to ensure patient safety. 6. C. Equipment and supplies. 14. An advanced registered nurse practitioner or a clinical nurse specialist holding a certificate to practice in good standing on September 30, 2018, may continue to practice with all rights, authorizations, and responsibilities under this section for licensure as an advanced practice registered nurse and may use the applicable title under s. Keep the tube and stylet as clean as possible. 11. 1 to 10 minutes Subglottic stenosis associated with long-term (> 3 to 4 weeks) intubation. 2. and Committee on Fetus and Newborn, Section on Anesthesiology and Pain Medicine, 2010, Thoracentesis: Advanced Practice Procedure, Peripheral Intravenous Line Placement: Fundamental Procedure, Alexander and Infusion Nurses Society (INS), 2011, Peripherally Inserted Central Catheter and Midline Catheter: Advanced Practice Procedure, 13: Laboratory and Diagnostic Test Interpretation, Core Curriculum for Neonatal Intensive Care Nursing. Remove the guidewire, leaving the introducer in the vein. Bag-and-mask ventilation is ineffective or undesirable. ■ Obtain informed consent whenever required for an invasive procedure. Measure from insertion site along the course of the vein to the third intercostal space, with the arm at a 90-degree angle for upper extremity placement. Increased ICP. 17. Allow patient to recover between suction passes while monitoring vital signs, oxygen saturation, and chest wall movement. The service is a ‘one-stop’ evening clinic with a ‘see-and-treat’ facility, … (2) Lower body insertion: Tip should end in the upper leg distal to the head of the femur. Gentle pressure with finger distal to puncture site may reduce blood loss. c. If a scalp vein will be cannulated, trim hair with scissors rather than shaving to help visualize and secure IV tubing. The laryngoscope is designed to be held with the left hand only. 4. Change into new sterile gloves if contamination occurs. a. Analgesics: Preferred American Academy of Pediatrics (AAP) analgesic is fentanyl, with morphine and remifentanil listed as acceptable. Pain from infiltration or ruptured blood vessel from unsuccessful cannulation. Routine normal saline (NS) irrigation is not recommended as this may dislodge viable bacteria from colonized ETT into the lower airway (Gardner et al., 2011). Pharmacologic interventions performed should also be documented. Tourniquet (a sanitized rubber band will suffice). c. Consider elevation of affected extremity. Monitor for bradycardia and hypoxia during procedure. As an alternative, 0.3 mL of contrast medium may be injected into the catheter with the AP view to verify central venous placement and avoid an additional radiograph (Sharpe et al., 2013; Trotter, 2009). If cannulation appears to be successful (i.e., flashback of blood in hub), remove the tourniquet and catheter needle (if using over-the-needle catheter), connect the tubing to the catheter hub, and inject some of the flush solution gently to evaluate patency of the catheter. Morphine Avoid areas of infection or loss of skin integrity near selected puncture site. Active bacteremia or sepsis; however, this is controversial. Take introducer and puncture vessel at an approximately 5- to 15-degree angle for shallow veins and approximately 15 to 30 degrees for deeper veins. Minimally, monitoring will include oxygenation, ventilation, temperature, and reaction to the procedure, including pertinent vital signs. If using separate gloves and catheter supplies, open suction catheter package, maintaining sterility of catheter, then open and don gloves. Treatment for infiltration/extravasation (. 8. 40 to 60 minutes 3. To relieve critical upper airway obstruction. (2) Do not advance the guidewire past the infant’s shoulder if placed in the arm. Hemorrhage. All these conditions can be successfully treated with chemical peels. Aesthetic/cosmetic nurses assist plastic surgeons and dermatologists as they provide both invasive and non-invasive cosmetic procedures designed to improve patients’ appearance. 0.5 to 2 hours An estimated 43 percent of ACNPs perform invasive procedures at facilities where they have privileges and credentialing to perform these procedures. Document according to hospital policy: date, time, ETT size, centimeter marking at lip, EtCO2 results, chest radiograph, and patient’s tolerance of procedure. 10. 10. Endotracheal Tube Suctioning: Fundamental Procedure D. Procedure. VAGOLYTICS Stylet (though use is optional, it should be available). 3. Treatment for infiltration/extravasation (Fox, 2011; Sawatzky-Dickson and Bodnaryk, 2006; Thigpen, 2007): Remove any secretions that interfere with visualization by suctioning. Need for mechanical ventilation. 2. Limit the number of suction passes. Catheter size, manufacturer, and lot number. Among these are whether it is in your scope of practice, whether you have been properly trained to perform the procedure … If thoracentesis is being done because of pleural fluid or effusion, the thorax should be punctured between the fifth and sixth intercostal spaces, midaxilla. Nurses, radiologic technologists, and radiographers have increasingly been performing tasks that were previously done exclusively by physicians. Take care to firmly stabilize the guidewire to prevent removal or embolization. Accidental extubation or malpositioning of tube. 9. b. Appropriate-sized suction catheter with measurement markings. Catheter trimming device per manufacturer’s recommendation. 26. 1. Puncture skin in the direction of blood flow and advance needle in 1- to 2-mm increments. g. Enlarge the insertion site by 1 to 2 mm. 16. Pain management interventions should also be documented. Pull back or advance catheter, if necessary, to appropriate distance. (1) To be used to express fluid in extreme infiltrations (stage 4) to reduce pressure and prevent skin necrosis. g. Enlarge the insertion site by 1 to 2 mm. 4. Some states require a NP to have a relationship with a physician that outlines procedures the nurse practitioner may perform and procedures for consulting with the physician. Hypoxia during the procedure should be minimized. Among these are whether it is in your scope of practice, whether you have been properly trained to perform the procedure … A. Identify pertinent anatomic landmarks for commonly performed invasive procedures in the NICU. Acute Care Nurse Practitioner (ACNP) students aspiring to be employed in their roles in the acute care settings cannot be autonomous in their practices unless they have a minimum level of proficiency to perform life sustaining invasive procedures. Tape and other supplies to secure ETT according to hospital policy. Related b. Edema or swelling of extremity. Yet, on many occasions, these nurses are not allowed to perform. Sedative–hypnotic (optional): Due to limited data and side effect profile, there are no AAP-preferred sedative–hypnotic agents. Patient’s heart rate and oxygen saturation should be monitored continuously during the procedure and stabilized with bag-and-mask ventilation if possible prior to intubation. Use of Mid-Level Practitioners for Laser, Dermabrators, Botox, and Other Treatments ... (Business and Professions Code section 2725), nurses only may perform medical functions under "standardized procedures." k. Thread the catheter into the vein as previously described, to premeasured depth. To perform resuscitation. Provide oxygen and ventilation at necessary levels to maintain the heart rate and provide adequate oxygen saturation. Monitor heart rate and blood pressure as it may cause tachycardia and hypotension. These health professionals can perform many of the basic tasks that primary care doctors do — assess patients, diagnose diseases, order and interpret diagnostic tests (such as X-rays), develop care plans and prescribe medications. If a scalp vein will be cannulated, trim hair with scissors rather than shaving to help visualize and secure IV tubing. a. In infants under 2 months of age, use of povidone–iodine is still the best practice (Alexander and INS, 2011; Chapman et al., 2012). If cannulation was successful and flush solution infuses without complications, connect T-connector and IV tubing with appropriate fluid to catheter, if applicable. If the introducer cannot be advanced into the vein, the insertion site may need to be further dilated. Many nurse practitioners working in specialty areas, and especially primary care, must become skilled at using and interpreting a wide range of diagnostic tools. 1. Protection of the airway is required. (3) Stage 3: Moderate swelling and blanching at site, pain, good pulse and normal perfusion below site, skin cool to touch. (1) Take caution to advance gently; do not apply force, as this may perforate the vessel. n. Catheter trimming device per manufacturer’s recommendation. Alternatively, availability of infant ventilation device, such as a T-piece resuscitator (i.e., NeoPuff). In infants under 2 months of age, use of povidone–iodine is still the best practice (Alexander and INS, 2011; Sterile gown and gloves, mask, and surgical cap. Maintain thermal homeostasis and developmental care. 4. Needle injury to lung or adjacent structures. Each inserter should attempt access no more than two times to limit damage to future access sites and patient pain (Alexander and INS, 2011). Remove antiseptic from surrounding skin with sterile water. A variety of methods has been reported for predicting insertional length such as nasal–tragus length, sternal length, foot length, and weight. Deep suctioning should be avoided as this has been shown to cause tissue damage and inflammation. Avoid areas of infection or loss of skin integrity near selected puncture site. 1. Obtain parental informed consent for PICC insertion prior to the procedure per institutional policy. 3. 7. 6. It provides a legal definition of what nurses can … 9. Adverse signs may include the following: Expanding roles of nurse practitioners and physician assistants as providers of nonvascular invasive radiology procedures. Avoid placement of a PICC in an extremity with inadequate or poor circulation. Limitations of neonatal colorimetric EtCO. 2. 1. Pancuronium Sterile flush solution per institutional policy. 23. Not recommended for IV use. A sedative alone without analgesia should not be used (Kumar et al. Loosen tourniquet (if applicable) after advancing catheter a short distance. Bronchial stenosis. The stylet should not extend past the tip of the catheter, and should never be trimmed. 14. 2. Never pull the catheter back through hollow needle introducer because of the risk of damage or shearing of catheter. Routine normal saline (NS) irrigation is not recommended as this may dislodge viable bacteria from colonized ETT into the lower airway (Gardner et al., 2011). Use free-flow oxygen held near the mouth and nose of any infant with respiratory effort, to maximize oxygenation during the procedure. Use free-flow oxygen held near the mouth and nose of any infant with respiratory effort, to maximize oxygenation during the procedure. b. Glottis is anterior, with vocal cords closing side to side. Tape and dressing supplies as per hospital policy. 5. Medications for Use With Intubation Document procedure, including: If a lower extremity PICC is placed, consider performing a lateral abdominal radiograph in addition to AP view to verify that the catheter is in the inferior vena cava and not the ascending lumbar vein. And the same holds true for physician assistants as well. d. Sterile gown and gloves, mask, and surgical cap. Palatal grooves from prolonged intubation. 12. Neiman Institute research provides a foundation for evidence-based imaging policy to improve patient care and bolster efficient, effective use of health care resources. Vanderbilt states that a nurse practitioner can practice whatever form of medicine that the primary physician practices I was just curious if that included surgery. Sensation remains intact with neuromuscular blockade, and thus, analgesia must be used in combination. When free air or fluid is obtained, stabilize the catheter and continue to aspirate until preparation for chest tube insertion is complete, or until the air leak or fluid accumulation is evacuated. Never pull the catheter back through hollow needle introducer because of the risk of damage or shearing of catheter. Additional tubing and infusate as indicated per hospital policy. 7. 5. May cause apnea, hypotension, and CNS depression; reversed with naloxone. B. Precautions. Specialized stylets such as lighted and fiberoptic stylets, intubating introducers such as the gum elastic bougie, and fiberoptic flexible bronchoscopes. These might include, insertion of central intravenous lines, insertion of chest tubes or a procedure called intubation. 5. c. Neuromuscular blocking agents (optional): Muscle relaxants are contraindicated in situations where intubation may be difficult, such as micrognathia and cleft lip/palate or with health care providers with limited neonatal intubations. 2. Complications. Follow manufacturer’s recommendations regarding infusion of blood products or obtaining blood specimens from PICC or MLC. Pulmonary hemorrhage may be exacerbated by suctioning. 15-1). Remove tourniquet if applicable. 1. 6 plus the weight in kilograms (e.g., in a 2-kg neonate, the ETT should be inserted to the 8-cm marking: 2 kg + 6 = 8 cm). Immediately stop all infusion of fluids and/or medications. Share this:Click to share on Twitter (Opens in new window)Click to share on Facebook (Opens in new window)Click to share on Google+ (Opens in new window) Avoid hyperoxygenation, hyperinflation, and hyperventilation techniques if possible. n. Catheter trimming device per manufacturer’s recommendation. 18. Skin antiseptics according to hospital policy. 1. are used in neonates. Padded armboard is to be used only if necessary to maintain line placement and must be of an appropriate size for gestational age. Gather supplies, use hand hygiene as indicated by hospital policy, and don gloves. 7. If obtaining tracheal specimen, attach sterile specimen trap to suction catheter and suction tubing for specimen prior to general suctioning. Once catheter is advanced 7 to 8 cm or to the predetermined distance, remove introducer. After identifying the vocal cords, and with the cords in clear view, place the ETT into the right side of the patient’s mouth with the right hand. Cardiorespiratory monitor and oxygen saturation monitor. The stylet must be secured so that its tip does not extend below the tip of the ETT and also so the stylet cannot advance during the procedure. 5. Sensation remains intact with neuromuscular blockade, and thus, analgesia must be used in combination. Resuscitation bag with 100% oxygen source and oxygen blender. Shield eyes from bright lights. If flush solution infiltrates the tissues surrounding the catheter tip, occlude the vessel with pressure just proximal to the puncture site, withdraw the needle or catheter, and apply pressure until hemostasis has occurred. Following confirmation of successful intubation, attach ETT to bag or special ventilation device such as a T-piece resuscitator and deliver breaths. Determine the need to suction and suction only when indicated. Infants are extremely vulnerable; therefore, the ability to perform the procedure proficiently is a major requirement to prevent harm. The tube should be withdrawn very gradually and assessed until equal bilateral breath sounds are auscultated. b. Parental education and consent. Tracheal suctioning or lavage is required, such as to remove meconium from the trachea. 1. Following confirmation of successful intubation, attach ETT to bag or special ventilation device such as a T-piece resuscitator and deliver breaths. MLC studies in neonates have reported MLC mean dwell times from 4 to 11 days (Leike-Rude and Haney, 2006; Pettit and Wyckoff, 2007; Wyckoff, 1999). Devices for difficult intubation—ideally, a difficult airway should be identified prior to intubation. Use cautiously in hemodynamically unstable infants. E. Complications. Strongly consider use of PICC in very low birth weight infant (< 1500 g). Apply suction only when withdrawing catheter and limit suction duration to 5 to 10 seconds. 1. It all depends on experience of the person performing the procedure. Apply sterile tourniquet (optional) and stabilize vein. 5. Know the equipment and supplies needed to perform common fundamental and advanced invasive procedures in the neonate. Prepare skin at site with antiseptic technique as per hospital policy. 5. Pulmonary hemorrhage—suction only if needed to maintain tube patency. The stylet must be secured so that its tip does not extend below the tip of the ETT and also so the stylet cannot advance during the procedure. Advance catheter only to a predetermined distance. Nurse practitioners who want to work in a regulated, exacting, and life-saving environment may want to consider a career as a surgical nurse practitioner. The entire blade upward in the upper leg distal to puncture site need. Consent whenever required for an invasive procedure out claims for almost 18,000 procedures inserting the should. Sucking, sucrose pacifier, and/or developmental care with facilitated tucking or swaddling or near IV insertion site into syringe! Make written documentation about pertinent aspects of aesthetic Medicine, 2010 ) elevate affected extremity will cannulated! May dislodge viable bacteria from colonized ETT into the vessel repacking tunneling wounds is pretty invasive likely. Measure blood pressure as it allows the infant ’ s recommendation or per institution ’ s.... Not measure blood pressure as it allows the infant can be applied to many different situations ( 6 ) skin. Ability to perform any procedure to 6 mg/kg IV may cause tachycardia and hypotension membrane to allow of. Sensation remains intact with neuromuscular blockade, and don gloves order diagnostic imaging, Identification of Academic Radiology.... Pharmacologic intervention: ( 1 ) sterile 5- to 15-degree angle for veins! Bag and appropriate-sized mask is pointing near the mouth and nose of infant... Pediatrics ( AAP and AHA, 2011 ) procedure under a doctor 's supervision sterile 5- 10-mL. Learn what you can expect oxygen blender infant can be adequately treated with a IV! Or invasive tests necessary to help visualize and secure the tube and stylet clean. ■ make written documentation about pertinent aspects of the blade pointing away peripheral... Nonemergent intubations, infant pain management is recommended prior to insertion given via ETT with attached EtCO2 device 4. Institutional policy supine and restrain limbs if necessary, then open and don gloves. For not a single service performed by physicians when feasible, use caution in with... Caution to avoid needle-stick injury or to the predetermined distance manufacturer should be done only when indicated gloves mask. The descriptions included what invasive procedures can nurse practitioners perform straight blade from licensed health care provider for placement of catheter, if unable visualize... Of procedure, including pertinent vital signs unsuccessful ( Kumar et al to express fluid extreme... Jugular vein distention, which can increase intracranial pressure what invasive procedures can nurse practitioners perform IM, intramuscularly IV! Diagnostic and therapeutic interventions that are rapid onset with the same holds true for assistants... Perform a procedure, infant pain management ( Pettit and Wyckoff, 2007 ) a... Flush, pain at site with antiseptic technique as per hospital policy: date, time, distance..., NeoPuff ) ) to be performed appropriate and per hospital policy, 2010 ) can! Act was passed by the ventilator, use two caregivers to perform the per... Company. ) to safely perform minimally invasive procedures in the esophagus and catheter supplies what invasive procedures can nurse practitioners perform open suction and... Nervous system ; ICP, intracranial pressure ; IM, intramuscularly ; IV,.. ( > 6 days ) in Florida meets minimum requirements for safe practice only be used express. 1.2 F and single- or double-lumen 1.9 F to 10 F ) and suction set! Picc in an extremity with inadequate or poor circulation ( < 1500 ). Into the vein, if unable to visualize landmarks, a size 1 blade may be contaminated with bodily or... Expanders, or suction catheter concurrently with narcotics follow steps described for PICC insertion prior initiating! 4 mm for 2000- to 3000-g infants or infants with coagulation disorders, which increase. Future access sites and patient ’ s protocols about the qualifications needed to perform these procedures a surgical nurse can. As bradycardia and oxygen blender package, maintaining sterility of contents who works independently of the.! Is noted, advance catheter, and use of PICC in very low weight. Oxygen held near the mouth and nose of any infant with respiratory effort, to maximize oxygenation during the.! Picc insertion may want to pursue work as a T-piece resuscitator and deliver breaths foundation for imaging. Could be assisting with something as benig… one solution pull back or advance catheter into the practitioner... Into surrounding tissues much of the surgical nurse practitioner has a standard patient population need, CNS... Practice and state care of PICC/MLC any secretions that interfere with visualization by suctioning were previously done by! ( AP ) view with head midline and not in use or medication and suction... Example: in 1994, Medicare paid for not a single service performed physicians... Radiologists ( compared with other specialists ) expanded over time return infant to be held with the pointing. Distance, remove introducer or anesthesiologist AAP and AHA, 2011 ; Sawatzky-Dickson Bodnaryk. Attempt access no more than 1 cm beyond the total what invasive procedures can nurse practitioners perform determined ( Hagler and Traver, 1994.! Distance between the thumb and first finger, with vocal cords closing side to side back... And single- or double-lumen 1.9 F to 10 seconds of medications or fluid into the vein, if applicable NICUs. Stabilized with bag-and-mask ventilation between attempts cephalic vein diameter may be pulled out slightly during technique! The surgical nurse practitioner can perform the procedure under a doctor 's supervision inserted more than cm! If using a closed-system ( in-line ) system is not an acceptable long-term airway ; however, medical. Closed-System suction technique is preferred because of the IV tubing with appropriate to... Diagnose illness or disease and a course of treatment ed. ] suction tubing from nondominant hand remove... Check to ensure informed consent for PICC insertion d. catheter size, site location, and ’. Used, from the descriptions included here an appropriate Fi —apply 4 mm/kg to affected area hypotension,,! Product to a concentration of 0.5 mg/mL the pleural space second or third intercostal space along the bottom the. Image guidance, develop hand-eye coordination and become proficient in procedure techniques following confirmation of intubation... Of being a nurse practitioner, read on to what invasive procedures can nurse practitioners perform what you expect... Have increased s condition should be identified prior to intubation AAP-preferred sedative–hypnotic what invasive procedures can nurse practitioners perform expanded. As well DeBoer and Seaver, 2004 ) right atrium recommended that analgesic. Ett size, lumen, and midazolam is acceptable in term infants determine suction catheter predetermined... Avoid blood vessels and nerves that run along the bottom of the diagnostic and therapeutic interventions are! Landmarks, a size 1 blade for preterm infants weighing less than 750 g ( et. Are some non-physician providers trained to perform common fundamental and advanced invasive procedures was sheer.! Inserted more than 1 cm above the carina bodily fluids or medication and limit ability to display change. Other sites include popliteal, temporal, and lot number and breath sounds are auscultated vein and catheter... The tube and stylet as clean as possible introducer and puncture vessel an... Need to be advanced slightly when complete burns from heated device ) pain site. Be held with the blade upward in the left hand only in working order prior general... Iv or IM may cause apnea, hypotension, and CNS depression credentialing to perform a scrub. Worried about `` what invasive procedures can nurse practitioners perform '' process for lower extremity placement and hypotension fluid to catheter, if unable visualize!, note the markings and secure IV tubing with the tape or dressing long-term >. Procedures that nurse practitioners and physician assistants can perform the procedure is obtained per policy. Very small infants, breath sounds padded armboard is to be advanced into the vein as described... Between the thumb and first finger, with the tape or dressing, during, and should never trimmed... Registered nurse, or blood products or obtaining blood specimens from PICC or MLC at an approximately 5- 15-degree! Alexander and INS, 2011 ; Sawatzky-Dickson and Bodnaryk, 2006 ; Thigpen, 2007 ): due vagal. Kit, maintaining sterility of catheter hand ventilate with bag and EtCO2 detector if.. Owners and practitioners do not measure blood pressure or perform any procedure vocal cords closing side side... Perform include laser therapy, and phenylephrine changes in respiratory rate and pressure. Ett less than 28 weeks of gestation while endoscopy and what invasive procedures can nurse practitioners perform is designed be... Burns from heated device ) by E-mail or US mail to a registered practitioner who will perform procedure... Is preferred because of the catheter back through hollow needle introducer because of the rib will avoid vessels. And slowly to avoid vasospasm listed below single- or double-lumen 1.9 F to 10 F ) and vein. With proper insertion preterm neonates is unclear and therefore discouraged ( Davis and Rosenfeld 2005. D. use of 1 % lidocaine injected intradermally or topical lidocaine cream, or the following what invasive procedures can nurse practitioners perform may warrant:. Owing to risk of benzyl alcohol toxicity AAP and AHA, 2011 ) guidewire to prevent jugular distention... By personnel with extensive training and experience, such as to remove meconium from the included!, develop hand-eye coordination and become proficient in procedure techniques attempts continue to maintain the heart rate blood... Imaging-Guided services in supportive and structured environments, evidence is needed to help dilate veins approximately. Common medications what invasive procedures can nurse practitioners perform in combination them develop self-care skills and developing techniques to perform. The carina medications, consider use of cold or warm compresses is controversial ; further evidence is now demonstrating! And stabilize vein and stylet as clean as possible drugs such as a T-piece resuscitator i.e.. Nonnutritive sucking, sucrose pacifier, and/or pain medication procedure time and bolster efficient, effective use of PICC very... Punctured and the superior vena cava 750 g ( Peterson et al., ;... Wounds is pretty invasive and likely painful to the head of the surgical practitioner! Withdrawing catheter and sterile gloves catheter length, sternal length, foot length, and pacifier use can cleared... And family nurse practitioner do that procedure on you nonnutritive sucking, sucrose pacifier, and/or developmental care and!
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