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Standardized Procedure PediatricsNameUnited States UniversityPrimary Health of Acute Clients/Families Across the LifespanCourseDr. Maria Luisa RamiraJuly 4, 2016Standardized Procedure for Nurse Practitioners: General PolicyI      PurposeA.   To establish a standardized procedure, in compliance with the California Board of Registered Nursing (BRN) and the 11 components of the BRN’s guidelines for Nurse Practitioners (NPs) to perform specified functions without the immediate supervision of a Physician.II    Development and ReviewA.   All standardized procedures are developed through the collaborative efforts of the members of the organization’s established interdisciplinary committee (IDC).  The IDC will consist of physicians, nurse practitioners, registered nurses and administrative representatives of the organization. B.   All standardized procedures will be approved through the IDC made readily available and contain signed and dated approval sheets of all professionals covered by the procedures.C.   All standardized procedures will be reviewed every 3 years or more often as necessary by the IDC.D.   All NPs and their supervising physicians will signify agreement to the standardized procedures upon hire, annually and with changes as needed as evidenced by a signed and dated approval sheet.E.    Signature on the statement of approval and agreement implies the following:  Approval of all procedures in the document, intent to abide by the procedures and willingness to maintain a collegial and collaborative relationship with all parties.  The signed statement of approval and agreement form will serve as the record of those NPs who have been authorized to perform the procedures.  The signature page will be kept on file and readily available together with Standardized Procedures.III   Scope and SettingA    NPs may manage those functions outlined in the standardized procedures, within their trained area of specialty and consistent with their experience and credentialing.  Such functions include assessment, management and treatment of acute and chronic illness, contraception, health promotion and overall evaluation of health status.  Additional functions include the ordering of diagnostic procedures, physical, occupational, speech therapies, diet and referral to specialty care as needed.B    NPs are authorized to practice standardized procedures in the organization’s Outpatient Clinics.IV   Education and Training/QualificationsA    NPs must have the following            1     Current California registered nurse (RN) license            2     Certification by the State of California, BRN as an NP3     Board certification from the American Nurses Credentialing 
Center4     NP furnishing number5     DEA registration number6     Current Health Care Provider Card from the American Heart Association7     Credentialed by the organization’s medical staff B    In addition to the required education and training all NPs will be required to complete competency validation upon hire and annually.  The supervising physician is charged with observing the NP and documenting competency validation.  The competency validation checklist is managed, maintained and made available by the Office of Medical Staff as a component of the privilege process.   Checklist will be reviewed and updated annually by the IDC.V    Supervision and EvaluationA NP is authorized to implement the approved standardized procedures without the direct or immediate observation or supervision of a physician unless otherwise specified within a particular procedure.B    Supervising physicians will conduct a weekly case review of a minimum of 10% of each NPs cases for the week.  The review will be documented within the electronic medical record and must be completed within 30 days of the visit selected for review. Cases will be selected randomly unless a request for review is received by a medical professional. C    No single physician will supervise more than 4 NPs at any one time. VI   ConsultationsA    Physician consultation is to be obtained as specified in individual procedures or when deemed appropriate.VII Patient RecordsA    NPs will be responsible for the documentation of a complete electronic medical record for each patient contact/encounter in accordance with existing clinic and medical staff policies.Protocol:Croup initial visit in the outpatient clinic settingI      RationaleTo assist Nurse Practitioners in the outpatient clinic setting in the differentiation between croup and other upper airway conditions and to establish guidelines for the management
of croup in this setting.II    DefinitionSwelling and erythema of the upper airway resulting in narrowing of these airways, usually as a result of viral infection and in some instances bacterial.  Most cases are usually mild and self-limiting however, children can be seriously ill or at risk for rapid progression of disease leading to further narrowing of the airways and respiratory compromise.III   Epidemiology A    Typically occurs in children between the ages of 6 months to 6 years, with a peak incidence between 6 and 36 months.B    Most often occurs in the fall and is usually but not limited to parainfluenza type 1 viral infection.C    Cases occurring in winter are usually but not limited to influenza A and B virusesD    Risk factors include familiar history, parental smoking and male gender.IV   HistoryA    Symptoms of upper respiratory infection for several days.B    RhinorrheaC    Cough D    Low grade feverE     Symptoms occurring most often at nightF     Sore throatG    Stridor H    Intermittent barking, seal like coughV    Physical Exam A    Barking seal like cough, stridorB    TachypneaC    Use of accessory muscles for respirationD    TachycardiaE     WheezingF     Low grade fever however, can be elevated to 104FG    Visualization of mouth and epiglottis normalVI   Diagnostic testsA    Diagnosis typically made based on clinical presentationB    Plain imaging of soft tissue of the neck may display classic pattern of subglottic narrowing (steeple sign) on posteroanterior view.C    Pulse oximetryD    Laboratory tests are not necessary for the diagnosis of croup however, may be used to assist with differential diagnosis.1     CBC2     Viral Serology3     Tissue cultureVII Differential DiagnosisA    EpiglottitisB    Foreign body aspirationC    Retropharyngeal or peritonsillar abscessD    Compression due to tumors, trauma or congenital malformationsE     Angioedema F     Asthma exacerbationG    Bacterial traceitisVIIIManagement – According to severity of disease by means of the Westley Croup Score based on the presence or absence of stridor at rest, degree of chest wall retractions, air entry, the presence or absence of pallor or cyanosis and the mental status.A    Mild croup (Westley croup score of ≤2) No stridor at rest (although stridor may be present when upset or crying), a barking cough, hoarse cry, and either no, or only mild, chest wall/subcostal retractions.B    Moderate croup (Westley croup score of 3 to 7)Stridor at rest, has at least mild retractions, and may have other symptoms or signs of respiratory distress, but little or no agitation.C    Severe croup (Westley croup score of ≥8) Significant stridor at rest, although the loudness of the stridor may decrease with worsening upper airway obstruction and decreased air entry. Retractions are severe (including indrawing of the sternum) and the child may appear anxious, agitated, or pale and fatigued.D    Impending respiratory failure (Westley croup score of ≥12) Fatigue and listlessnessMarked retractions (although retractions may decrease with increased obstruction and decreased air entry)Decreased or absent breath soundsDepressed level of consciousnessTachycardia out of proportion to feverCyanosis or pallorE     TreatmentMild Croup: 1     Single dose of dexamethasone 0.15 to 0.6 mg/kg orally or parentally to a max dose of 10mg.  2     Disposition home with the following instructions:a     Fever management with acetaminophen 15mg/kg po every 4-6hrs as needed not to exceed 75mg/kg/day.b     Anticipatory guidance of potential worsening and instructions on when to seek care.c     Use of humidified air, cool mist or hot streamd     Return for follow-up next day.Moderate Croup1 Follow mild croup guidelines 2 Observe patient for up to 4 hours  If improved3 Disposition home following  instructions for mild croupIf no improvement            a     Consult with supervising physician and prepare to administer b    Inhaled racemic epinephrine 0.05 ml/kg per dose (maximum of 0.5 ml) of a 2.25% solution diluted with normal saline for a 3ml total volume via nebulizer.c     If pulse oximetry is <92% provide supplemental oxygen at a rate to maintain 02 Sat < 92%d     Refer or disposition child via emergency transport to emergency department            Severe croup and impending respiratory failure  a     Activate 911 and provide the following until emergency transport arrives:                          b     Ensure open airwayc     Administer supplemental 02 to maintain 0s sat 92%                        d     Single dose of dexamethasone 0.15 to 0.6 mg/kg parentally.e     Inhaled racemic epinephrine 0.05 ml/kg per dose (maximum of 0.5 ml) of a 2.25% solution diluted with normal saline for a 3ml total volume via nebulizer.f      Notify supervising physician of need for emergency transportIX   Development and Approval of the Standardized ProcedureThis standardized procedure was developed and approved through the organization’s Interdisciplinary Committee and will be reviewed and approved every 3 years or more often as needed.Revision Date_____________           Review Date______________X    Standardized procedure was approved by the following members of the Interdisciplinary Committee._______________________________          Date_______________________Pediatric Department Chair_______________________________          Date_______________________Supervising Physician_______________________________          Date_______________________Director of Nursing Practice_______________________________          Date_______________________AdministrationXI   Practitioners authorized to function under this standardized procedure:This list of Nurse Practitioners will be maintained on file in  the department in which Nurse Practitioners practice and hospital administration.ReferencesAn explanation of standardized procedure requirements for nurse practitioner practice. (1998). Retrieved from, C., & Johnson, D. (2015). Croup. Retrieved from, C. E., Dunn, A. M., Brady, M. A., Starr, N. B., & Blosser, C. G. (2013). Pediatric Primary Care (5th ed.). Philadelphia, PA: Elsevier.Ferri, F. F. (2016). Ferri’s Clinical Advisor. Philadelphia, PA: Elsevier.Woods, C. R. (2015). Croup. Retrieved from, R., Sidani, M., & Murray, J. (2011). Croup: An overview. Retrieved from