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Introduction   

When hearing the phrase fluoroscopy, what comes to mind? Whether you’re new to advanced practice nursing or have been a nurse for many years, fluoroscopy is a booming aspect of radiology with lots of potential for advanced practice registered nurses (APRNs) of all specialties and educational backgrounds. People will always need someone to help with radiology, imaging, and patient care in health care settings. The information in this course will serve as a valuable resource for APRNs interested in learning more about fluoroscopy and APRN supervision for fluoroscopy procedures.

Defining Fluoroscopy 

To begin, fluoroscopy is a type of radiological imagining procedure that uses several pulses of an x-ray beam to take multiple images in real-time of internal tissues of a patient’s body. Fluoroscopy has existed in the United States for several decades and has improved in accuracy and diagnostics over the past few decades as a result of technological advances. The biggest difference between fluoroscopy compared to a standard x-ray image is that an x-ray takes one image of someone’s internal tissues at a time. In contrast, fluoroscopy gives the patient and provider continuous, real-time, high-resolution images of internal tissues as a result of multiple, short pulses of radiation. Fluoroscopy can be performed on patients of all ages. Given the rise of advances in radiological imaging, the APRN’s role in fluoroscopy supervision and education is increasing (1,2). 

Fluoroscopy examples include angiography, the viewing of arteries in the body, and esophagogram, also known as a barium swallow, to view the esophagus, throat, stomach, and parts of the small intestine. Fluoroscopy can also be used during surgical procedures, such as orthopedic knee replacements or fracture repairs. Given the wide variety of fluoroscopy uses, the role of nurses has also been brought into several discussions regarding fluoroscopy, radiological imaging, and supervision. In some states, registered nurses (RNs) can supervise fluoroscopy or perform fluoroscopy procedures themselves. In other states, only APRNs can do both or either. Some states do not allow nurses of any licensure to perform or supervise fluoroscopy procedures. Because of the wide variety in legislation and scope of practice by state for fluoroscopy procedures, it is important to check with your place of work and board of nursing for the most updated regulations on APRN supervision in your state(s) (1,2,3,4,5,6).

How and Where Are Fluoroscopy Procedures Performed?

Healthcare providers use fluoroscopy to help monitor and diagnose certain conditions and as imaging guidance for certain procedures. Fluoroscopy procedures are typically performed by doctors, radiology technicians, and nurses (depending on their scope of work and state practice regulations). Given the rise in technological advancements, many fluoroscopy procedures can be performed in outpatient settings, such as community health centers, private practices, and surgical centers. Fluoroscopy in outpatient settings is usually done for diagnostic testing and examinations, whereas fluoroscopy in inpatient settings, such as hospitals, usually involves preparation for inpatient procedures. For instance, a fluoroscopy procedure performed at an outpatient gastrointestinal specialist office might examine causes of a patient’s dysphagia, and a fluoroscopy procedure performed at a hospital might determine the placement of a coronary stent (1,2).  

Because fluoroscopy procedures involve radiation exposure, proper personal protective equipment (PPE), functioning imaging equipment, machinery set on certain values, and proper education on your workplace’s policies for fluoroscopy is a must. Given the wide variety of fluoroscopy devices, it is recommended that APRNs are extremely comfortable and proficient and familiar with the device settings, PPE requirements, scope of work requirements, and workplace requirements prior to supervising someone performing a fluoroscopy procedure. Some states and workplaces require APRNs to have additional licenses, permits, or education regarding fluoroscopy supervision, whereas other locations do not. Fluoroscopy uses can also vary significantly, such as use during surgery with an unconscious patient compared to a patient who is conscious awaiting angioplasty (3,4,5).  

How Much Does a Fluoroscopy Procedure Cost?

Cost for fluoroscopy administration can vary significantly depending on the type of fluoroscopy procedure, insurance, procedure location, duration, and other factors. Fluoroscopy is often an expensive medical intervention, but for many patients, it is essential care and possibly the only way for some patients to receive adequate medical care. Cost is among a leading reason why many patients cannot maintain their medication regime or access health care services, especially if fluoroscopy is recommended in an outpatient setting. If cost is a concern for your patient, consider reaching out to your local patient care teams to find cost-effective solutions (1,2,7).  

What Are the Risks and Benefits of Fluoroscopy Procedures?

Fluoroscopy is a medical procedure, and like all medical procedures, there are risks and benefits. Benefits of a fluoroscopy include more detailed, serial, real-time imaging, providing a more realistic approach to care and management for a patient. Fluoroscopy is painless, non-invasive, and can often be done the same day (depending on the purpose of the fluoroscopy and patient condition). Fluoroscopy can also have less radiation exposure compared to other forms of imaging. Some risks of fluoroscopy include exposure to radiation, inability to be 100% accurate in assessment and diagnosis with fluoroscopy alone, and patient discomfort. Given the possible risks and benefits associated with fluoroscopy, it is important to discuss these with patients prior to fluoroscopy if possible (1,2,3,4,5).

Defining Advanced Practice Nursing

What Is Advanced Practice Nursing? How and Where Are APRNs Working?

Advanced practice nursing is nursing at the graduate level, often at the master’s or doctoral level, and involves practicing as a clinician. In the United States, there are thousands of APRNs working in all 50 states in various capacities. Some APRNs work in outpatient settings, such as primary care offices or pediatrician clinics, whereas other APRNs work in inpatient settings, such as hospitals. APRNs can also specialize with a primary population, such as women’s health, neonatal health, and geriatric health. In all 50 states, APRNs have prescriptive authority and can obtain multiple licenses to practice in several states. Because of the rise of APRNs in the past few decades to meet the demand for health care services in several parts of America, each state has their own scope of work for APRNs, including their role in performing and supervising fluoroscopy procedures (1,2,8).

How Can APRNs Supervise Fluoroscopy Procedures?

Depending on the type of fluoroscopy, place of work, scope of work of the health care professional, and regulations of fluoroscopy APRN supervision in your state(s) of work, APRNs can supervise fluoroscopy procedures in several settings. Often times, APRNs who supervise fluoroscopy procedures have a team of health care workers with them, such as radiology technicians, RNs, and other health care staff. APRNs in a supervisory capacity often have several years of experience as an APRN and experience with radiology equipment for liability and competency purposes. While there is no official guideline regarding the role of APRNs in the supervision of fluoroscopy procedures, some general ways APRNs can supervise fluoroscopy procedures include (1,2,3,4,5,8):  

1. Making sure patients have completed all their consent forms prior to the procedures 
2. Ensuring patients are aware of the procedure and educated about the risks, benefits, and preparation 
3. Ensuring all staff and patients are wearing appropriate PPE during the fluoroscopy procedure 
4. Documenting findings during the fluoroscopy procedure per workplace policy 
5. Discussing the procedure with the patient and ensuring the patient is handling the procedure appropriately   
6. Monitoring for any abnormalities in the fluoroscopy imaging and for any technical issues with the equipment 
7. Verifying the correct settings for the distances, magnifications, beam, screens, and more.

What Are Common Indications for Fluoroscopy Procedures?

A common indication for a fluoroscopy procedure is a patient who needs radiologic imaging. Common reasons for fluoroscopies include trauma, stent placement, angioplasty, assessment of joint placements (especially joint dislocation), cardiac catheterization, pacemaker placement assessment, and more. Fluoroscopy can also be used during orthopedic surgeries to monitor the flow of tissues during surgery. Fluoroscopy is especially important for GI-related conditions, such as with a barium swallow test, to diagnose and assess for ulcers and swallowing disorders (1,2,8).

How Can an APRN Prepare a Patient for a Fluoroscopy Procedure?

While there is no established guideline regarding the APRN role on patient preparation for a fluoroscopy, APRNs can prepare a patient for a fluoroscopy by (1,2,6,8): 

1. Answering all patient questions 
2. Reviewing the patient medical history, including allergies 
3. Obtaining informed consent 
4. Discussing with the patient the role of the APRN and other staff during the procedure 
5. Answering questions during the fluoroscopy procedure

Nursing Considerations

What Is the APRN Role in Fluoroscopy?

Nurses remain the most trusted profession for a reason and nurses, including APRNs, are often pillars of patient care in several health care settings. Patients turn to nurses for guidance, education, and support. While the scope of work of APRNs can vary state by state and by various workplaces, here are some general recommendations into the role of APRNs in fluoroscopy supervision (1,2,3,4,5,6,8): 

1. Take a detailed health history. Often times, obtaining a detailed health history prior to a fluoroscopy is complex and dismissed in health care settings, even in emergency situations. APRNs have some of the highest rates of patient satisfaction and are known for their detail to care. Especially as the supervisor for the fluoroscopy procedure, knowing a patient’s health history, including allergies, is essential for you, the patient, and medical team. Regarding the fluoroscopy itself, if a patient is complaining of symptoms, inquire more about the complaint, especially if it pertains to the area receiving the fluoroscopy. Ask about how long the symptoms have lasted, what treatments have been tried, if these symptoms interfere with their quality of life, and if anything alleviates any of these symptoms. If you feel like a patient’s complaint is not being taken seriously by other health care professionals, advocate for the patient to the best of your abilities. Take the time to establish care with the patient.  
2. Review medication history at every encounter. Often times, in busy clinical settings, reviewing health records can be overwhelming. While millions of people take medications, there are many people who take medications and are no longer benefiting from the medication. Ask patients how they are feeling on the medication, if their symptoms are improving, and if there are any changes to medication history. Make sure to ask about any over-the-counter supplements or herbs as well. Medication drug interactions are important to note if a patient will be administered barium or other contrast dye in preparation for a fluoroscopy as well. Make sure you are aware of your workplace’s anaphylaxis protocol in case of an allergic reaction.  
3. Be willing to be honest with yourself about your comfort level discussing topics and providing education on medication and medical procedures, including fluoroscopies. If you are not comfortable discussing something, please refer to another staff member. 
4. Communicate the care plan to other staff involved for continuity of care. For several patients, imaging is not something they can share with another provider. Ensure that patients’ records are up to date for ease in record sharing and continuity of care. 
5. Review your fluoroscopy equipment prior to use and make sure you adjust the settings specifically for the patient, as every patient and procedure can have variance in the types of frequencies, nodules, and intensities. If you suspect any complications with the fluoroscopy equipment, be sure to stop the procedure immediately and obtain new equipment.  
6. Monitor the patient during the procedure, especially their vital signs and responses to pain. Fluoroscopy is a painless, non-invasive procedure, so if a patient is complaining of pain, inquire more. If the patient is unconscious during a fluoroscopy, make sure to monitor their vital signs and skin integrity.  
7. Ensure that all staff and patients always wear appropriate PPE during the procedure and remove the PPE after the procedure per workplace protocol.  
8. Stay up to date on continuing education related to nursing, radiology, and fluoroscopy, as evidence-based information is always evolving and changing. You can then present your new learnings and findings to other health care professionals and educate your patients with the latest information.  
9. Many people in the general public are not aware of the scope of work of APRNs. Be sure to take your time in explaining to your patients your work capabilities and the roles of your collaborating team members.

What are Considerations for Nurses Interested in Supervising Fluoroscopy Procedures?

Truly, a nursing career in radiology and radiology supervision, such as fluoroscopy supervision, can be extremely rewarding personally, professionally, financially, and emotionally. If a nurse is interested in advanced practice nursing, they should consider why they want to be an APRN and what they love about nursing and radiology. A nurse should also consider how comfortable they are with the nature of radiology equipment, imaging, the responsibility associated with fluoroscopy supervision, and the experience of being a direct care provider. If an APRN is interested in fluoroscopy supervision, they should check with the board of nursing and state(s) regulations in addition to workplace practices on next steps on being a supervisor for fluoroscopy procedures (1,2,8).

What Should Patients Know About APRNs Who Supervise Fluoroscopy Procedures?

Patients should know that APRNs can supervise fluoroscopy procedures in some states and perform them independently as well. If patients are concerned about your scope of work, APRNs can educate patients on the APRN scope of work in that state and per workplace protocol (1,2,6,8).

Upcoming Research 

Regarding the type of research that exists today on advanced practice nursing and fluoroscopy procedures, there is extensive publicly available literature on radiology, including fluoroscopy, via evidence-based journals and in nursing research.

APRN Fluoroscopy Supervision in Iowa

APRNs in Iowa can provide direct supervision for fluoroscopy procedures according to the Department of Inspections, Appeals, and Licensing (DIAL). Per Iowa’s DIAL, the APRN needs to have completed fluoroscopy education that must include radiation physics, radiobiology, radiology safety and management, including time, dose, distance, shielding, and radiation effects. APRNs must be able to provide documentation regarding fluoroscopy education completion. APRNs must also remain in compliance with their workplace’s protocols regarding fluoroscopy and APRN fluoroscopy supervision. Iowa’s Board of Nursing (BON) remarks that they will audit APRNs who supervise fluoroscopy procedures. Per Iowa’s DIAL and BON, questions regarding APRN fluoroscopy supervision requirements can be addressed to either Iowa’s DIAL or BON directly (9,10).

Case Study 

Barbara is a 39-year-old woman working as a family nurse practitioner at an outpatient orthopedic surgical center in Iowa. She specializes in orthopedic care and assists physicians sometimes with minor outpatient procedures. She has worked in outpatient orthopedics for four years and enjoys her work. Her office recently upgraded its technology, and the practicing physician states that there will be a surgical room with brand-new fluoroscopy technology installed in a few weeks.   

• How would Barbara be able to determine if she can perform fluoroscopy in her state? 

• What are some barriers with cross-collaboration you have encountered in the workplace? 

• Who would be responsible for ensuring all health care providers are aware of their scope of work in the workplace?  

Barbara and her collaborating physician have discussed Barbara using the fluoroscopy equipment once installed. Barbara has also looked into Iowa’s requirements regarding APRNs and fluoroscopy equipment. She has completed the requirements per Iowa state of nursing regulations and is starting to become comfortable with the equipment after a year of use. The practice has started to expand in the past year and a new part-time radiology technician with extensive experience in radiology has been hired. Barbara is assigned to train and supervise the radiology technician with fluoroscopy equipment.  

• How would Barbara make sure she is supervising the new hire adequately? 

• What are some things you would recommend Barbara be aware of during her supervision?  

A few months later, Barbara and the practice manager meet to discuss changes in the workplace. The practice manager states that the practice is expanding to Illinois in the following year, and they would like Barbara to also work in the Illinois office a few days a month depending on the patient flow. Barbara is eager to work in another office, but has some concerns about working in another state, as she is currently only licensed to practice as an APRN in Iowa.  

• What are some differing APRN scope of work practices to consider between Iowa and Illinois?  

• How are fluoroscopy requirements different in Iowa compared to Illinois for APRNs? 

• What are some perspectives a nurse can bring to the team that may differ from those of other members in clinical care and technology services?

Conclusion

Nursing and fluoroscopy are here to stay, and nurses are the forefront of patient care in many settings. While many people may be unaware of the role of APRNs and their prevalence in many health care settings, APRNs provide essential health care to thousands of people every day in America, including supervising fluoroscopy procedures.

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