Extremity X-ray Ordering Guidelines for RN’s in SPH Emergency

CRNBC Guidelines Ordering the Application of energy: 6 (1) (j.1) in the course of assessment, issue an instruction or authorization for another person to apply, to a named individual, (i) ultrasound for diagnostic or imaging purposes, including any application of ultrasound to a fetus, or (ii) X-rays for diagnostic or imaging purposes, except X-rays for the purpose of computerized axial tomography.

CRNBC Limits and Conditions: Registered nurses order X-ray or ultrasound only under the following circumstances: Registered nurses who order X-ray or ultrasound must follow established decision support tools. Registered nurses who order X-ray or ultrasound for the purpose of screening or triage or treating a condition must successfully complete additional education. Registered nurses order X-ray or ultrasound for the purpose of routine management only when organizational processes are in place to direct test results to the appropriate health professional for follow up.

SPH Emergency Nursing Protocols Extremity X-ray Any patient with fracture/suspected dislocation may have these orders: assess limb for: appearance, deformity, CWMS, ROM, and skin injury. See Neurovascular Assessment (CWMS): Procedure for, in Nursing Practice Standards Manual. Refer to EXTREMITY INJURY protocol and follow interventions listed. 2. Suspect fracture/dislocation? Order appropriate x-ray under EP (Dan Kalla). 3. Notify EP if 2 hr. target approaching. 4. Document on ED Nursing Record: - time/type of x-ray(s) ordered - reason for order (tick appropriate box) - signature of RN recording

“RN's should order extremity x-ray's when it looks apparent (ie swelling and/or deformity) or [it appears] that there is something wrong.” Chris Dewitt

How do we know what the appropriate X-ray is??? Use the following tips

Foot Foot x-ray series is required if there is: any pain in midfoot zone Inability to bear weight both immediately and in the emergency department.

Ankle Ankle x-ray series is required if there is: Deformity Inability to bear weight both immediately and in the emergency department. Pain in the malleolar zone

Knee Knee x-ray series is required if: Tenderness of patella or head of fibula Inability to flex to 90 degrees Inability to bear weight both immediately and in the emergency department

Hand Hand x-ray series is indicated for Pain Deformity Immobility Mechanism (crush injury)

Wrist Wrist x-ray series is required if there is: deformity pain Immobility of joint. Scaphoid views are required if there is tenderness in the anatomic snuffbox.

Extra Tips! Always assess the joint above and below the injury for pain and immobility. When in doubt, consult a physician, they are happy to advise. All extremity x-rays should be ordered “URGENT” The fracture rate amongst HIV+ patients is 5x that of normal!