Universal Protocol
What are the three phases of the Universal Protocol?
Pre‑procedure verification, site marking, and time‑out.
What must be verified at arrival?
Patient ID, consent, allergies, H&P, pre‑procedure questionnaire.
What piece of emergency equipment must always be available before starting moderate sedation?
A functioning bag‑valve mask (BVM).
What are the two main moderate‑sedation medications used in IR?
Midazolam and fentanyl.
What is the primary risk of a lung biopsy?
Pneumothorax
Who is the only person permitted to perform site marking?
The attending proceduralist.
How soon before the procedure should the intake call be completed?
Within 1 week, minimum 24–48 hours before.
How often must vital signs be charted during moderate sedation?
Every 5 minutes.
What MUST be on every medication label?
Name, concentration, amount, diluent, expiration.
Why might breath‑holding be used during CT-guided procedures?
To improve needle accuracy by reducing motion.
What must happen before every procedure where all team members stop all activity?
Time-out.
Which labs are essential to confirm before procedures with bleeding risk?
INR, platelets; renal function for contrast.
Which tool assesses level of sedation?
RASS score.
Who can administer medications in IR?
RNs, PAs, APRNs, physicians, anesthesia; techs only for contrast under specific supervision.
During CT‑guided lung procedures, why must the nurse closely monitor for coughing, even before samples are taken?
Coughing can shift the lesion, disrupt needle position, increase risk of parenchymal injury, and may signal early bleeding or airway irritation.
Name a situation where site marking is not required.
Procedures where the insertion site is not predetermined (e.g., cardiac cath).
Which instructions must be reviewed during the intake call?
NPO status and medication adjustments (insulin, anticoagulants).
Which monitoring modality detects early respiratory depression?
ETCO₂ (capnography).
What allergies do NOT require contrast premedication?
Shellfish, Betadine, seasonal allergies, asthma alone.
While preparing for a CT chest procedure, you notice that the oxygen saturation waveform is intermittently flat, even though the patient appears well perfused and alert.
Why must this be addressed before proceeding?
An unreliable SpO₂ reading compromises safe sedation and procedure monitoring; sensor placement or equipment malfunction must be corrected before continuing.
During the time‑out, the team cannot agree on whether a culture, cytology specimen, or both are expected from the case.
What must the nurse do?
Do not complete the time‑out; ensure the proceduralist clarifies specimen expectations and handling requirements before beginning.
The medication list shows the patient stopped anticoagulation five days ago, but the patient says they took “one dose last night by accident.”
What should the nurse do?
Stop pre‑procedure progression, verify timing, request updated coag labs, and alert the provider.
A patient in recovery meets Modified Aldrete discharge criteria, but 20 minutes prior they received naloxone after oversedation from fentanyl. They now appear alert and stable and insist they feel ready to leave.
What is the correct nursing action?
Do not discharge. Patients who receive reversal agents must be monitored for at least one hour due to the high risk of re‑sedation once naloxone wears off. Continue close monitoring until the appropriate time-based and clinical criteria are satisfied.
A patient scheduled for a CT‑guided procedure has the following findings during pre‑contrast assessment:
What is the safest nursing action before allowing contrast to be administered?
Hold the contrast administration and immediately escalate findings to the radiologist/proceduralist. The nurse must clarify the severity of the prior reaction, report the acute decline in renal function, alert the team that the patient took metformin, and await a new safety plan. Contrast cannot be given until risks are reassessed and cleared, as both undocumented reaction severity and worsening renal function significantly increase the risk profile.
Following a CT‑guided lung biopsy, the patient reports mild chest tightness. Their initial post‑procedure CXR is negative for pneumothorax, but their O₂ sat decreases from 98% to 92% over 15 minutes, and respirations are becoming more shallow.
What is your next action?
Escalate immediately and obtain repeat imaging. Early or delayed pneumothorax can occur despite an initially normal CXR. The nurse must treat the change in clinical status as potentially emergent and prepare for possible intervention.