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Certified Practice: DST Update notification

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​posted Sept. 29, 2016

The CRNBC certified practice decision support tools (DSTs) undergo a regular review to ensure they reflect current evidence for the certified practice areas. The process includes a systematic review and update by clinical experts, feedback from nurses who use the DSTs, and approval by the CRNBC Certified Practices Approval Committee.

Revisions to the following DSTs are effective August 2016 and are now posted on the CRNBC website. Be sure to replace previous versions of DSTs with the revised versions.

Please see below for a summary of the changes.

 Remote Nursing

Eye assessment—Adult

Medical History (Specific to eyes):

  • “Defects” added between Eye diseases or injuries

Rationale: adding ‘defects’ alerts nurse to assess for the specifics of eye anomalies that are most pertinent. Inclusion of defects promotes identification of individuals that present with corneal defects, who are predisposed to recurrent erosions and issues with the surface of the eye.
Symptoms Requiring Urgent Referral:

  • “or bilateral eye pain” added to first bullet
  • “Ocular pain” added as second bullet

Rationale: expand to provide better descriptor, as patients may present with either unilateral or bilateral eye pain that prompts referral as they may indicate pathology.

  • “recent onset” added to sixth bullet to describe floaters

Rationale: alerts nurse to assess for the specific chronicity of floaters: floaters of new onset may indicate acute pathology versus the presence of floaters.

Access the revised DST 

Conjunctivitis—Adult

Common Findings:

  • Streamlined description of pupillary reaction
  • “Papillary reaction normal” deleted

Rationale: applicability. Papillary reaction may be an indicator of viral conjunctivitis, but was misaligned with this DST; term describes conjunctival surface finding and is not described as ‘normal’.

  • Wording added to include ‘known’ and ‘environmental’

Rationale: alerts nurse to consider common allergens when performing history related to conjunctiva

Access the revised DST​

Corneal Abrasion—Adult

Potential Causes:

  • “contact lens use” added

Rationale: Addition alerts nurse to consider the most pertinent causes for corneal abrasion. Improper contact lens use may include incorrectly fitting or soiled contact lenses – that introduce sources of trauma, infection or small foreign bodies.
Non-pharmacologic Intervention:

  • “to promote removal” added to first bullet

Rationale: intent of irrigation is the removal of the foreign body – not explicit as an intervention related to corneal abrasion – for clarification of direction, rationale
Client education/Discharge Information:

  • “or participating in contact sports” added

Rationale: provides health teaching relevant to corneal abrasion prevention
Consultation and/or Referral:

  • “there is significant worsening of vision” added

Rationale: vision that worsens is a sign of potentially serious complications and requires referral to a physician or nurse practitioner.

Access the revised DST

Use of Nitrous Oxide Oxygen in Pain Management—Adult

Contraindications:

  • “vitreoretinal surgery and intraocular gas bubble” added to list of contraindications

Rationale: alerts nurse to assess for/gather history of the additional consideration of intraocular trapped gas
Adverse Effects:

  • “including seizures” added to 1st bullet on CNS impact – to highlight that excitation may present with significant sequelae, i.e. seizures. Safety consideration.
  • “interference with B12 and folate metabolism” added to fifth bullet
  • “monitor closely during administration, note patient responsiveness, color, respiratory status” added

Rationale: Based on a review of the literature and sources, repeated risk around administration of nitrous oxide/oxygen without close monitoring; several training programs to build competency around administration and patient monitoring

Access the revised DST

Eye Assessment—Pediatric

Cardinal Signs and Symptoms (Other Associated Symptoms):

  • “squinting or keeping one eye closed in younger children” added as a descriptor for diplopia
  • “observed” added at beginning of above statement

Rationale: addition of content provides age appropriated symptom cues.
Medical History (Specific to eyes):

  • “Defects” added between Eye diseases or injuries

Rationale: alerts nurse to assess for the specific of eye anomalies that are pertinent. Inclusion of defects promotes identification of individuals that present with corneal defects, whom are predisposed to recurrent erosions and issues with the surface of the eye.
Symptoms Requiring Urgent Referral:

  • “or bilateral eye [pain]” added to second bullet
  • “Ocular pain” added
  • “recent onset” added to sixth bullet to describe floaters

Rationale: alerts nurse to assess for the specific chronicity of floaters: floaters of new onset may indicate acute pathology versus the presence of floaters.

Access the revised DST

Conjunctivitis—Pediatric

History (Bacterial and Viral):

  • Revised to include timing of red eye/unilateral or bilateral presentation

Rationale: Improved recognition of the sequencing of presentation for history taking.
Common Findings:

  • Streamlined description of pupillary reaction
  • “Papillary reaction normal” deleted

Rationale: applicability. Papillary reaction may be an indicator of viral conjunctivitis, but seems misaligned with this DST; term describes conjunctival surface finding and is not described as ‘normal’.
Allergic, History:

  • Alternate wording added to include ‘known’ and ‘environmental’

Rationale: alerts nurse to consider common allergens when performing history related to conjunctiva

Access the revised DST
Corneal Abrasion—Pediatric

Potential Causes:

  • “contact lens use” added to bracketed content

Rationale: alerts nurse to consider the most pertinent causes for corneal abrasion. Improper contact lens use may include incorrectly fitting or soiled contact lenses – that introduce sources of trauma, infection or small foreign bodies.
Non-pharmacologic Intervention:

  • “to promote removal” added to first bullet

Rationale: intent of irrigation is the removal of the foreign body – not explicit as an intervention related to corneal abrasion – for clarification of direction, rationale
Client/Caregiver Education and Discharge Information:

  • “Or participating in contact sports” added to fifth bullet

Rationale: provides health teaching relevant to corneal abrasion prevention
Consultation and/or Referral:

  • “There is significant worsening of vision” added

Rationale: vision that worsens is a sign of potentially serious complications and requires referral to a physician or nurse practitioner.

Access the revised DST

 RN First Call

GI-GU Assessment—Adult
Cardinal Signs and Symptoms (Nausea and Vomiting):
  • ‘red or coffee ground emesis’ re: hematosis added in 3rd bullet

Rationale: alerts nurse to assess for the additional characteristics of hematemesis; it may present as either fresh blood [upper GI] or digested blood [lower GI] and the descriptors (red or coffee ground) allow for improved identification of pertinent signs of GI bleeding.

Access the revised DST
Lower UTI (Female)—Adult

Diagnostic Tests:

  • “treatment failure” added as a clinical descriptor for an unresolved infection where the client presents back with persistent symptoms, i.e. persistence of the UTI signs and symptoms related to the infection

Rationale: variable resistance and response patterns to standard therapy are noted in the literature. Given the scope of the DST a patient may return with treatment failure and require a C&S to receive appropriate subsequent antimicrobial therapy.
Client Education and Discharge Information:

  • “encouragement for use of alternative contraception” added

Rationale: spermicide use has been linked with UTIs; the proposed understanding is that the spermicides have varying impact on the normal bacterial of the vagina, leading to an overgrowth of bacteria that lead to infections. As such, detailed information on alternative contraception is of benefit to the target group of young sexually active women.

Access the revised DST

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