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:
1.
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!