Universal Protocol
What are the three phases of the Universal Protocol?
Pre‑procedure verification, site marking, and the time‑out.
What must the IR nurse verify during patient intake upon arrival?
Consents, pre‑procedure questionnaire, H&P, allergies, and patient identity.
Which sedation level is most commonly used in IR?
Moderate sedation.
What does ALARA stand for?
As Low As Reasonably Achievable.
What is the “sterile touch rule”?
Only sterile touches sterile.
Who is the ONLY person allowed to perform site marking?
The primary attending proceduralist.
How far in advance must the pre‑procedure intake call be completed?
Within 1 week, but at least 24–48 hours before the procedure.
How often are vital signs documented during moderate sedation?
Every 5 minutes.
Name the three core radiation safety principles.
Time, distance, shielding.
What should be done immediately if a sterile break occurs?
Stop and reglove/regown or replace the contaminated item.
What must occur before ANY IR procedure begins, where all work stops?
The time‑out.
What lab values are essential to check before IR procedures?
INR, platelets, renal function (creatinine/eGFR).
What tool is used to assess sedation depth during procedures?
RASS score.
What personal safety device must be worn during all fluoroscopy?
A dosimetry badge.
Where is a sterile gown considered sterile?
Mid‑chest to waist and cuffs to mid‑arm.
Name two situations where site marking is not required in IR.
Single-organ non‑lateral procedures or procedures where the insertion site cannot be predetermined (e.g., cardiac catheterization).
What are two essential education points reviewed during the intake call?
NPO instructions and medication management (e.g., anticoagulants, insulin).
What monitoring modality allows early detection of respiratory depression?
ETCO₂ (capnography).
Give two examples of shielding used in IR.
Lead aprons, thyroid shields, lead glasses, mobile lead barriers.
What environmental practice reduces sterile-field contamination?
Minimizing traffic and keeping doors closed.
During pre‑procedure verification, the consent reflects a “right lung biopsy,” but the ambulatory referral lists “left pleural mass biopsy.” The patient says, “I’m pretty sure they said left, but I could be wrong.” The proceduralist is currently in another case and cannot immediately clarify.
What is the correct nursing action?
Do not proceed to the procedure room. The nurse must halt workflow, escalate the discrepancy, and ensure the proceduralist reviews all documentation and reassesses the patient before any site marking or prep occurs. The ambiguity must be resolved with authoritative confirmation before continuing.
A patient arrives for an IR procedure, but their chart shows:
Do not send the patient to the procedure room.
The nurse must halt the workflow, obtain an updated H&P, verify current coagulation labs, clarify anticoagulation timing with the patient and/or provider, and escalate to the procedural team to determine safety before proceeding.
A patient receiving moderate sedation begins showing a rising ETCO₂ from 38 → 52 mmHg over several minutes, but their SpO₂ remains 95% and they still respond to verbal stimuli. The proceduralist asks you to “give just a little more Versed to keep them comfortable.”
What is the safest nursing response?
Withhold further sedation, notify the proceduralist of suspected early hypoventilation, initiate airway‑supportive measures (reposition, jaw thrust, increase O₂), reassess ventilation status, and continue close monitoring. Additional sedatives are contraindicated until ventilation stabilizes.
During a long fluoroscopic procedure, you notice the C‑arm has been repositioned so that your usual lead shield no longer protects your lower body. The proceduralist is mid‑needle placement and says, “Just stay where you are for a second.”
What is the correct response based on ALARA principles?
Do not remain in an unshielded radiation field. The nurse must reposition behind adequate shielding or increase distance unless doing so would create immediate patient risk. ALARA requires continuous protection; convenience does not override safety.
While circulating, you observe the Fellow accidentally brush the edge of a non‑sterile monitor cable with their gown sleeve but continue preparing instruments. The Fellow insists, “It didn’t touch anything important.”
What should the circulating nurse do?
Immediately call out the break in sterility, stop the setup, and require the scrub to regown/reglove and replace any contaminated items. IR’s sterility standards prohibit continuing if gown contamination is observed, regardless of perceived significance.