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Exploring Nurses' Roles in Limited Ultrasound

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Page 1: Exploring Nurses' Roles in Limited Ultrasound

commen tar9

Catherine Tramor. RNC. MS 3

Exploring Nurses' Roles in Limited Ultrasound he use of diagnostic ultrasound has revolutionized health care. Portable and less expensive ultra- sound machines are often available in clinical

areas outside the traditional radiology/ultrasound depart- ment. As with other areas of medicine, ultrasound has changed the face of obstetric and infertility care, con- tributing to the quality of patient evaluation and diagno- sis. However, nowhere else in medicine has the use of ultrasound as a diagnostic and evaluation tool heralded such controversy as in obstetrics and gynecology.

The presence of an ultrasound machine is now com- mon in clinics, private offices, and labor and delivery suites. The arrival of the ultrasound machine is typically greeted with great fanfare and excitement about new capabilities. The health care provider's questions can be answered quickly and patients don't have to go searching for reassurance, especially in an emergency. However,

0 Identify limited exam situations, as defined by ACOG, which were appropriate for the obstetridgynecologic nurse to perform, and,

needed by nurses to perform the limited exam 0 Describe the minimum education and competencies

AWHONN's guidelines apply to any nurse who per- forms limited ultrasound, such as antepartum nurses who perform biophysical profiles, clinic or office nurses who perform limited ultrasound, the intrapartum nurse who is asked to assess fetal position and/or amniotic fluid volume, and to gynecologic infertility nurses who track follicle growth. Although many nurses are aware of these guidelines, some either choose to ignore or fail to apply these guidelines to their practice.

Recently, AWHONN (1998) revised those guidelines to reflect the changing scope, demands, and concerns

regarding nurses who perform limited ultra- sound. All nurses whose practice involves per- forming a limited ultrasound exam, regardless of their clinical settings, should be familiar with the

ul&mu& & fd a d guidelines and the impact these guidelines have I on their clinical practice.

Expanded Nursing Skills j b m p m f e s k M i n ubmndalong

Sonography is not a part of nursing education,

well-trained ultrasound personnel are in short supply. Ultrasound machines are perceived as easy to operate, which may lead to inadequate training. In fact, personnel may receive even less in-service instruction and training than for a new N pump or blood glucose monitor. Clinical application often precedes educational prepara- tion, competency validation, or the development of insti- tutional policies and protocols (Afriat Menihan, 1998).

Impact on Practice In 1993, AWHONN, responding to questions and requests from nurses, published the Nursing Practice Competencies and Educational Guidelines for Limited Ultrasound Examinations in Obstetric and Gynecologidlnfertility Settings (AWHONN, 1993). The guidelines were developed using ACOG's ( 1 993) recog- nition of clinical situations or circumstances in which a "limited ultrasound examination" may be desired. AWHONN's purpose was twofold:

yet labor and delivery nurses commonly use ultrasound to confirm fetal presentation. Because ultrasound machines seem easy to operate, many people assume that minimal training is required

(Afriat Menihan, 1998). This is not a correct assump- tion. However, with proper educational preparation and clinical training, nurses have demonstrated competency in performing limited ultrasound procedures (MUM, 1994). Nurses must remember that this ability represents an advanced skill and an expanded nursing role, which increases responsibility and liability (Gegor et al., 1994). Nurses who perform limited ultrasound exams should demonstrate educational and clinical expertise in obstet- rics and/or gynecologic infertility before assuming such an advanced nursing role. Limited ultrasound exams shouldn't be performed by the novice or inexperienced obstetridgynecologic nurse (Gegor et al., 1994).

Catherine Treanor, RNC, MS. is chairperson of the AWHONN tusk force on guideline revision for the Nursing Practice Competencies and Educational Guidelines for Limited Ultrasound Examinations in Obstetric or Gynecologic/lnfertiiiity Settings.

April 1998 A W H O N N L i f e l i n e s 13

Page 2: Exploring Nurses' Roles in Limited Ultrasound

Limited ultrasound exams can be performed by nurs- es in a variety of clinical settings, but nurses must under- stand the difference between comprehensive and limited ultrasound. Basic or comprehensive ultrasound examina- tion is used to evaluate such things as fetal anatomy,

All nurses wbosepradke invohes/x@orming a limited ulbmound mizm regardm of the clinkul setting should be familhr with the

gttktklines a d what impact these gukklines hatje on their clinical practice.

identify anomalies, assess gestational age and fetal weight, and detect maternal pelvic masses or other pathologic conditions. “Limited ultrasound exams” can’t and don’t replace the basic or comprehensive exam and typically are used for evaluations such as fetal bio- physical profiles, obtaining amniotic fluid volumes, iden- tifying ovarian follicles, indicating the number and size of early gestational sacs, and measuring embryotic lengths (Gegor et al., 1994)

of a limited obstetriclinfertility uterine survey and pos- sess the skills to imagine and interpret those compo- nents. A nurse who performs a limited ultrasound exam for an obstetric and gynecologic infertility indication must be aware that all of the components of the limited exam (i-e., obstetric of gynecologic infertility) must be evaluated and documented. Assessing only one compo- nent of a limited ultrasound exam is not appropriate or recommended. If the limited exam is technically diffi- cult, the information gained is not conclusive, or an ear- lier recommendedhequired ultrasound exam hasn’t been performed, the nurse’s responsibility is to consult with the woman’s care provider. This will allow the practi- tioner an opportunity to have the patient evaluated with a more comprehensive ultrasound.

The nurse must know the components of the two types of ultrasound exams performed during pregnancy as identified by the American Institute of Ultrasound Medicine (1994) and ACOG ( 1 993), as well as ACOG’s definition of “limited ultrasound examination” for preg- nancy and infertility. The nurse must also know which components of the “limited examination” are and are not within her or his scope of clinical practice, and be aware of her or his responsibilities regarding patient education, the limitations of a limited exam, the mini- mal required components of the exam that must be doc- umented, and accountability issues. Most important, the nurse must possess an understanding of ultrasound physics and instrumentation (Gegor et al., 1994).

tion and clinical skills verification from professionals skilled in ultrasound along with continuing education to maintain these skills. Although documentation of the theoretical content, “hands on” practice sessions, and learning validation are the responsibilities of the

Nurses must know the minimal technical components

Nurses who perform limited ultrasound need educa-

provider, skill maintenance and continuing education is the responsibility of the professional nurse performing limited ultrasound.

Obstetric and gynecologiclinfertility nurses are able to competently perform limited ultrasound examination,

enhancing the quality of patient care by enabling management decisions to be made more rapidly (AIUM, 1994). However, nurses must remember that such an expanded nursing role also means increased responsibility and liability. Therefore, nurses must acknowledge the associated risks and take measures to minimize those risks. It’s the responsibility of the obstetric and gynecologic nurse to be cognizant of AWH0N”s guidelines and the policies, procedures, and laws that govern practice in specific settings; these recommenda- tions can then be incorporated into their profes- sional practice. +

References Afriat Menihan, C. (1998). The application of limited sonogra-

phy to obstetric and gynecologic triage. In C. Afriat Menihan (Ed.) Limited Sonography in Obstetrics and Gynecologic Triage ( 1 st ed.). Philadelphia: Lippincott.

Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN). (1993). Nursing practice competencies and educational guidelines for limited ultrasound examinations in obstetrical and gynecologicaVinfertility settings. Washington, DC: AWHONN.

American College of Obstetricians and Gynecologists (ACOG). (1993). Ultrasonography in pregnancy (Technical Bulletin No. 187). Washington, DC: ACOG.

Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN). (1993). Nursing practice competen- cies and educational guidelines for limited ultrasound examinations in obstetrical and gynecologicaVinfenility set- tings. (2nd ed.) Washington, DC: AWHONN.

Gegor, C., Paine, L., Costigan, K. &Johnson, T.R.B. (1994) Interpretation of biophysical profiles by nurses and physi- cians. Journul of Obstetric, Gynecologic and Neonatal Nursing, 23(5), 114-119.

American Institute of Ultrasound Medicine (AIUM). (1994). Guidelines for the performance of the antepartum obstetri- cal ultrasound examination. Laurel, MD: AIUM.

Revdsing the Limited Ultrasound Guideline: Tmk Force Catherine Treanor, RNC, MS; Chairperson Meredith Fresquez, RNC, RDMS Carolyn L. Gegor, CNM, M S , RDMS Cydney Afriat Menihan, CNM, MSN, RDMS Merle Siegel, RNC, BSN

Getting the N a u Guidelines To order a copy of the new limited ultrasound guide- lines, call (800) 354-2268 and request resource #G12, ”Nursing Practice Competencies and Educational Guidelines for Limited Ultrasound Examinations in Obstetric and Gynecologic/lnfertilih/ Settings“; $15 for AWHONN members; $30 for non-members.

14 A W H O N N L i f e l i n e s Volume 2, Issue 2