STANDARDIZED PROCEDURE PEDIATRICS 2 STANDARDIZED PROCEDURE PEDIATRICS 11 Standardized Procedure Pediatrics Name United States University Primary Health of Acute Clients/Families Across the Lifespan Course Dr. Maria Luisa Ramira July 4, 2016 Running head: STANDARDIZED PROCEDURE PEDIATRICS 1 Standardized Procedure for Nurse Practitioners: General Policy I Purpose A. To establish a standardized procedure, in compliance with the California Board of Registered Nursing (BRN) and the 11 components of the BRN’s guidelines for Nurse Practitioners (NPs) to perform specified functions without the immediate supervision of a Physician. II Development and Review A. All standardized procedures are developed through the collaborative efforts of the members of the organization’s established interdisciplinary committee (IDC). The IDC will consist of physicians, nurse practitioners, registered nurses and administrative representatives of the organization. B. All standardized procedures will be approved through the IDC made readily available and contain signed and dated approval sheets of all professionals covered by the procedures. C. All standardized procedures will be reviewed every 3 years or more often as necessary by the IDC. D. All NPs and their supervising physicians will signify agreement to the standardized procedures upon hire, annually and with changes as needed as evidenced by a signed and dated approval sheet. E. Signature on the statement of approval and agreement implies the following: Approval of all procedures in the document, intent to abide by the procedures and willingness to maintain a collegial and collaborative relationship with all parties. The signed statement of approval and agreement form will serve as the record of those NPs who have been authorized to perform the procedures. The signature page will be kept on file and readily available together with Standardized Procedures. III Scope and Setting A NPs may manage those functions outlined in the standardized procedures, within their trained area of specialty and consistent with their experience and credentialing. Such functions include assessment, management and treatment of acute and chronic illness, contraception, health promotion and overall evaluation of health status. Additional functions include the ordering of diagnostic procedures, physical, occupational, speech therapies, diet and referral to specialty care as needed. B NPs are authorized to practice standardized procedures in the organization’s Outpatient Clinics. IV Education and Training/Qualifications A NPs must have the following 1 Current California registered nurse (RN) license 2 Certification by the State of California, BRN as an NP 3 Board certification from the American Nurses Credentialing Center 4 NP furnishing number 5 DEA registration number 6 Current Health Care Provider Card from the American Heart Association 7 Credentialed by the organization’s medical staff B In addition to the.

1. STANDARDIZED PROCEDURE PEDIATRICS 2
STANDARDIZED PROCEDURE PEDIATRICS 11
Standardized Procedure Pediatrics
Name
United States University
Primary Health of Acute Clients/Families Across the Lifespan
Course
Dr. Maria Luisa Ramira
July 4, 2016
Running head: STANDARDIZED PROCEDURE PEDIATRICS
1
Standardized Procedure for Nurse Practitioners: General Policy
I Purpose
A. To establish a standardized procedure, in compliance with
the California Board of Registered Nursing (BRN) and the 11
components of the BRN’s guidelines for Nurse Practitioners
(NPs) to perform specified functions without the immediate
supervision of a Physician.
II Development and Review
A. All standardized procedures are developed through the
collaborative efforts of the members of the organization’s

2. established interdisciplinary committee (IDC). The IDC will
consist of physicians, nurse practitioners, registered nurses and
administrative representatives of the organization.
B. All standardized procedures will be approved through the
IDC made readily available and contain signed and dated
approval sheets of all professionals covered by the procedures.
C. All standardized procedures will be reviewed every 3 years
or more often as necessary by the IDC.
D. All NPs and their supervising physicians will signify
agreement to the standardized procedures upon hire, annually
and with changes as needed as evidenced by a signed and dated
approval sheet.
E. Signature on the statement of approval and agreement
implies the following: Approval of all procedures in the
document, intent to abide by the procedures and willingness to
maintain a collegial and collaborative relationship with all
parties. The signed statement of approval and agreement form
will serve as the record of those NPs who have been authorized
to perform the procedures. The signature page will be kept on
file and readily available together with Standardized
Procedures.
III Scope and Setting
A NPs may manage those functions outlined in the
standardized procedures, within their trained area of specialty
and consistent with their experience and credentialing. Such
functions include assessment, management and treatment of
acute and chronic illness, contraception, health promotion and
overall evaluation of health status. Additional functions
include the ordering of diagnostic procedures, physical,
occupational, speech therapies, diet and referral to specialty
care as needed.
B NPs are authorized to practice standardized procedures in
the organization’s Outpatient Clinics.
IV Education and Training/Qualifications
A NPs must have the following
1 Current California registered nurse (RN) license

3. 2 Certification by the State of California, BRN as
an NP
3 Board certification from the American Nurses
Credentialing Center
4 NP furnishing number
5 DEA registration number
6 Current Health Care Provider Card from the American
Heart Association
7 Credentialed by the organization’s medical staff
B In addition to the required education and training all NPs
will be required to complete competency validation upon hire
and annually. The supervising physician is charged with
observing the NP and documenting competency validation. The
competency validation checklist is managed, maintained and
made available by the Office of Medical Staff as a component
of the privilege process. Checklist will be reviewed and
updated annually by the IDC.
V Supervision and Evaluation
A NP is authorized to implement the approved standardized
procedures without the direct or immediate observation or
supervision of a physician unless otherwise specified within a
particular procedure.
B Supervising physicians will conduct a weekly case review
of a minimum of 10% of each NPs cases for the week. The
review will be documented within the electronic medical record
and must be completed within 30 days of the visit selected for
review. Cases will be selected randomly unless a request for
review is received by a medical professional.
C No single physician will supervise more than 4 NPs at
any one time.
VI Consultations
A Physician consultation is to be obtained as specified in
individual procedures or when deemed appropriate.
VII Patient Records
A NPs will be responsible for the documentation of a
complete electronic medical record for each patient

4. contact/encounter in accordance with existing clinic and
medical staff policies.
Protocol:
Croup initial visit in the outpatient clinic setting
I Rationale
To assist Nurse Practitioners in the outpatient clinic
setting in the differentiation between
croup and other upper airway conditions and to establish
guidelines for the management of croup in this setting.
II Definition
Swelling and erythema of the upper airway resulting in
narrowing of these airways, usually as a result of viral infection
and in some instances bacterial. Most cases are usually mild
and self-limiting however, children can be seriously ill or at
risk for rapid progression of disease leading to further
narrowing of the airways and respiratory compromise.
III Epidemiology
A Typically occurs in children between the ages of 6 months
to 6 years, with a peak
incidence between 6 and 36 months.
B Most often occurs in the fall and is usually but not limited
to parainfluenza type 1 viral infection.
C Cases occurring in winter are usually but not limited to
influenza A and B viruses
D Risk factors include familiar history, parental smoking and
male gender.
IV History
A Symptoms of upper respiratory infection for several
days.
B Rhinorrhea
C Cough
D Low grade fever
E Symptoms occurring most often at night
F Sore throat
G Stridor

5. H Intermittent barking, seal like cough
V Physical Exam
A Barking seal like cough, stridor
B Tachypnea
C Use of accessory muscles for respiration
D Tachycardia
E Wheezing
F Low grade fever however, can be elevated to 104F
G Visualization of mouth and epiglottis normal
VI Diagnostic tests
A Diagnosis typically made based on clinical
presentation
B Plain imaging of soft tissue of the neck may display classic
pattern of subglottic narrowing (steeple sign) on posteroanterior
view.
C Pulse oximetry
D Laboratory tests are not necessary for the diagnosis of
croup however, may be used to assist with differential
diagnosis.
1 CBC
2 Viral Serology
3 Tissue culture
VII Differential Diagnosis
A Epiglottitis
B Foreign body aspiration
C Retropharyngeal or peritonsillar abscess
D Compression due to tumors, trauma or congenital
malformations
E Angioedema
F Asthma exacerbation
G Bacterial traceitis
VIII Management – According to severity of disease by means
of the Westley Croup Score based on the presence or absence of
stridor at rest, degree of chest wall retractions, air entry, the
presence or absence of pallor or cyanosis and the mental status.
A Mild croup (Westley croup score of ≤2)

6. No stridor at rest (although stridor may be present when upset
or crying), a barking cough, hoarse cry, and either no, or only
mild, chest wall/subcostal retractions.
B Moderate croup (Westley croup score of 3 to 7)
Stridor at rest, has at least mild retractions, and may have other
symptoms or signs of respiratory distress, but little or no
agitation.
C Severe croup (Westley croup score of ≥8)
Significant stridor at rest, although the loudness of the stridor
may decrease with worsening upper airway obstruction and
decreased air entry. Retractions are severe (including indrawing
of the sternum) and the child may appear anxious, agitated, or
pale and fatigued.
D Impending respiratory failure (Westley croup score of ≥12)
Fatigue and listlessness
Marked retractions (although retractions may decrease with
increased obstruction and decreased air entry)
Decreased or absent breath sounds
Depressed level of consciousness
Tachycardia out of proportion to fever
Cyanosis or pallor
E Treatment
Mild Croup:
1 Single dose of dexamethasone 0.15 to 0.6 mg/kg orally or
parentally to a max dose of 10mg.
2 Disposition home with the following instructions:
a Fever management with acetaminophen 15mg/kg po every
4-6hrs as needed not to exceed 75mg/kg/day.
b Anticipatory guidance of potential worsening and
instructions on when to seek care.
c Use of humidified air, cool mist or hot stream
d Return for follow-up next day.
Moderate Croup
1 Follow mild croup guidelines
2 Observe patient for up to 4 hours
If improved

7. 3 Disposition home following instructions for mild croup
If no improvement
a Consult with supervising physician and prepare
to administer
b Inhaled racemic epinephrine 0.05 ml/kg per dose
(maximum of 0.5 ml) of a 2.25% solution diluted with normal
saline for a 3ml total volume via nebulizer.
c If pulse oximetry is <92% provide supplemental oxygen at
a rate to maintain 02 Sat < 92%
d Refer or disposition child via emergency transport to
emergency department
Severe croup and impending respiratory failure
a Activate 911 and provide the following until emergency
transport arrives:
b Ensure open airway
c Administer supplemental 02 to maintain 0s sat 92%
d Single dose of dexamethasone 0.15 to 0.6
mg/kg parentally.
e Inhaled racemic epinephrine 0.05 ml/kg per dose
(maximum of 0.5 ml) of a 2.25% solution diluted with normal
saline for a 3ml total volume via nebulizer.
f Notify supervising physician of need for emergency
transport
IX Development and Approval of the Standardized Procedure
This standardized procedure was developed and approved
through the organization’s Interdisciplinary Committee and will
be reviewed and approved every 3 years or more often as
needed.
Revision Date_____________ Review
Date______________
X Standardized procedure was approved by the following
members of the Interdisciplinary Committee.
_______________________________
Date_______________________
Pediatric Department Chair
_______________________________

8. Date_______________________
Supervising Physician
_______________________________
Date_______________________
Director of Nursing Practice
_______________________________
Date_______________________
Administration
XI Practitioners authorized to function under this
standardized procedure:
This list of Nurse Practitioners will be maintained on file in the
department in which Nurse Practitioners practice and hospital
administration.
References
An explanation of standardized procedure requirements for
nurse practitioner practice. (1998). Retrieved from
http://www.rn.ca.gov/pdfs/regulations/npr-b-20.pdf
Bjornson, C., & Johnson, D. (2015). Croup. Retrieved from
https://online.epocrates.com/diseases/68111/Croup/Key-
Highlights
Burns, C. E., Dunn, A. M., Brady, M. A., Starr, N. B., &
Blosser, C. G. (2013). Pediatric Primary Care (5th ed.).
Philadelphia, PA: Elsevier.
Ferri, F. F. (2016). Ferri’s Clinical Advisor. Philadelphia, PA:
Elsevier.
Woods, C. R. (2015). Croup. Retrieved from
https://www.uptodate.com/contents/croup-approach-to-
management?source=see_link&sectionName=Respiratory+care&
anchor=H91700#H1
Zoorob, R., Sidani, M., & Murray, J. (2011). Croup: An

9. overview. Retrieved from
http://www.aafp.org/afp/2011/0501/p1067.html