Nursing Practice Decisions

Materials contained in this section have been generated by Board decision, per NAC 632.935 Advisory opinion or declaratory order. (Please note the terms Practice Decision and Advisory Opinion are interchangeable.)  

These practice decisions are listed under subheadings to expedite searches.

If they meet the requirements of NAC 632.225, 255, and NRS 450B.160, Registered Nurses MAY:

GENERAL

choose to assign the emptying, measuring, and recording output from a hemovac and/or a Jackson-Pratt surgical drain to a CNA who has documented training and competency to perform the task.
Rationale
It is the opinion of the Nevada State Board of Nursing that CNAs may perform tasks which are beyond those listed in the CNA Skills Guidelines if they complete additional training and have documented competencies, as long as the task is assigned pursuant to NAC 632.222 by a licensed professional nurse. Supervision requires the RN to ascertain that the task:

• Is considered safe and routine for the specific client,
• Poses little potential hazard for the client,
• Can be performed with a predictable outcome,
• Does not require assessment, interpretation or decision-making while being performed,
• Involves a limited degree of potential client discomfort, and
• Does not require a substantial amount of scientific knowledge and technical skill.

Most importantly, the RN always maintains accountability for the overall provision of nursing practice, being responsible for the ongoing supervision and evaluation of the assigned task following the accepted standard of care which would be provided by a reasonable and prudent nurse.
Interest to the Consumer
In review of the limited literature regarding this practice, there is evidence that assignment of this task, under appropriate conditions, can be done safely. The NSBN recognizes that RNs need to work effectively with assistive personnel, underscoring the critical competencies of their abilities to assign and supervise. The RN assigns tasks based on the needs and condition of the patient, potential for harm, stability of the patient’s condition, complexity of the task, predictability of the outcomes, abilities of the staff to whom the task is assigned, and the context of other patient needs. (9/13/07)

perform intubation. (6/86)

perform postmortem enucleation. (6/87)

remove, clean and reinsert a "donut" type pessary upon successful completion of formal education and training which includes demonstration of competence in the use of this device. Documentation of annual updates of education and demonstration of competency are required. (9/99)

remove mediastinal drainage tubes. (11/86)

remove a respirator when a patient has been determined to be brain dead and pronounced dead by a physician. The nurse may refuse to remove the respirator for medical, ethical, or moral reasons. (9/87)

perform epicardial pacing wire removal, provided the following guidelines are followed: 

1. The nurse is competent to perform the procedure and has the documented and demonstrated knowledge, skill, and ability to perform the procedure pursuant to NAC 632.071, 632.224, and 632.225. Continued competency shall be documented annually and include clinical review with successful return demonstration.

2. There are facility policies and procedures and any required protocols in place for the nurse to perform the procedure. Protocols shall include specific guidelines for patient monitoring after epicardial pacing wire removal.

3. The nurse maintains accountability and responsibility for nursing care related to the procedure and follows the accepted standard of care which would be provided by a reasonable and prudent nurse.

4. The procedure is performed interdependently.  It must be based on an order by a physician, be performed under indirect supervision of a physician and per protocol. It is performed only in a licensed medical facility where a physician who has documented and demonstrated knowledge in the area of cardiovascular surgery is present within the facility and available for one hour following the procedure should complications arise. 3/12/03

replace a gastrostomy tube or suprapubic catheter that is not sutured in a patient, has been in place for an extended time, and there is a clearly established passageway. (9/86)

advance or withdraw endoscope and colonoscope. The procedure is performed when the RN is visualizing the lumen. The RN is permitted to advance or withdraw a flexible sigmoidscope without direct visualization. The procedure is carried out under the direct supervision of a licensed physician. Written policy and procedure are in place. (3/96)

administer intrahepatic arterial chemotherapy (provided procedure is approved by Chief Nurse and included in facility policies and procedures). (9/94)

administer medications for the purpose of induction of sedation for short-term therapeutic, diagnostic, or surgical procedures (procedural sedation). There are multiple sedation and anesthetic agents that cause profound changes in respiratory status even at low doses. Some of these medications do not have reversal agents and require the support of competent clinicians in advanced airway management. Licensed Professional Nurses (RNs) who administer these agents should be qualified to rescue patients whose level of sedation is deeper than intended or those who enter the state of general anesthesia.

MANAGEMENT OF NURSING CARE

The RN is held accountable for any act of nursing provided to a patient. The RN managing the care of the patient receiving procedural sedation shall not leave the patient unattended or engage in tasks that would compromise continuous monitoring of the patient by the registered nurse. The complex nursing functions, including vital signs, shall not be assigned to unlicensed assistive personnel. The RN has the right and obligation to act as the patient’s advocate by refusing to administer or continue to administer any medication not in the patient’s best interest.

RESOURCES:

Conscious Sedation, California Nurse Practice Act, NPR-B-06

AORN Recommended Practices for Monitoring the Patient Receiving Intravenous Sedation, Association of Operating Room Nurses, Inc.

Position Statement on the Role of the Registered Nurse in the Management of Patients Receiving IV Conscious Sedation for Short-Term Therapeutic, Diagnostic, or Surgical Procedures, American Nurses Association

Qualified Providers of Conscious Sedation, American Association of Nurse Anesthetists

ISMP Medication Safety Alert! Acute Care, Institute for Safe Medication Practices. November 3, 2005. Volume 10, Issue 22.

Approved by the Nevada State Board of Nursing: 3/16/05 (Replaced Anesthetic Agents Decision)

Approved by the NSBN’s Nurse Practice Advisory Committee:  12/5/06

Approved by the Nevada State Board of Nursing: 1/24/07                                      

If the RN is a Registered Nurse First Assist, prepare/harvest a saphenous vein for coronary artery bypass grafting. This procedure is within the scope of nursing for a Registered Nurse First Assistant (RNFA) and a Certified Nurse First Assistant (CRNFA) provided the following guidelines are followed. (The nurse in the following text refers to either the RNFA or the CRNFA):

1. The nurse must have successfully completed an RN First Assistant program that meets the Association of Operating Room Nurse (AORN) Education Standards for RN First Assistant Programs and a clinical preceptorship devoted to the application of knowledge and clinical skills associated with the process of harvesting a coronary conduit/saphenous vein. The nurse must maintain documentation of competency and maintain current CNOR certification.
2. The nurse will use surgical instruments to perform dissection or manipulate tissue as directed by the surgeon to accomplish preparation/harvest of a saphenous vein.
3. As part of informed consent, the patient or responsible party is informed that a nurse will be performing the procedure.
4. The nurse is competent to perform the procedure and has the documented and demonstrated knowledge, skill, and ability to perform the procedure pursuant to NAC 632.071, 632.224, and 632.225.
5. There are agency policies and procedures, a provision for privileging, and any required protocols in place for the nurse to perform the procedure. 
6. The nurse maintains accountability and responsibility for nursing care related to post-operative follow up for the procedure and follows the accepted standard of care which would be provided by a reasonable and prudent nurse.
7. The procedure is performed interdependently by the surgeon and the nurse. The surgeon must be in attendance while the nurse performs this procedure. (9/24/03; revised 3/16/05)

IV/CATHETERS

insert intraosseus lines. (9/88)

infuse antithrombolytic agents via the arterial system; physician prescribes the drug in the dose parameters that would produce the outcome effects intended. (12/93)

place a peripherally inserted central catheter. PICC insertion in the home setting should be limited to subclavian distal tip placement (12/92) and MAY, with documented training, be allowed to 1) secure peripherally inserted central lines by placement of a suture when securement devices are not available; 2) peripherally insert a central line in any setting including the home after an assessment is made regarding the safety of the setting and arrangements necessary for verification of placement prior to induction of infusion; 3) reposition, repair, flush/declot, exchange or remove a peripherally inserted nonfunctional line under the direction of a physician; and 4) assure proper placement of the catheter when the distal tip is positioned beyond the axillary vein by providing a preliminary reading of a chest x-ray for determining placement of the end of the PICC in the vena cava.(9/00, rev. 3/06)

perform upper extremity peripheral intravenous catheter placement using ultrasound guidance.

Interest to the Consumer:  Hospital admissions are creating vast challenges for nurses because of increased patient longevity, multiple organ system problems, greater survival from critical states, and obesity.  Due to these conditions, our nursing success rate for peripheral intravenous placement (PIVs) is becoming increasingly more difficult.  Using ultrasound for PIV placement, similar to nurses using ultrasound for Peripherally Inserted Central Cathethers (PICCs), can increase nursing success rates.  By increasing our success rate at PIVs through ultrasound guidance, we should see the following results:

1.      Increased patient satisfaction from fewer access failed attempts

2.      Less damage to peripheral vasculature from fewer access attempts

3.      Intravenous treatment delay is prevented

4.      Preventing delay of intravenous treatment fosters decreasing the length of hospital stays and cost containment.

These procedures are within the scope of practice for a Registered Nurse provided the following guidelines are followed:

1. The nurse is competent to perform the procedure and has the documented and demonstrated knowledge, skill, and ability to perform the procedure pursuant to NAC 632.071, 632.224, and 632.225.

2. There are agency policies and procedures and any required protocols in place for the nurse to perform the procedure.

3. The nurse maintains accountability and responsibility for nursing care related to the procedure and follows the accepted standard of care which would be provided by a reasonable and prudent nurse. (7/07)

be authorized to perform the task of removing an epidural catheter. The Nevada State Board of Nursing has determined that a Registered Nurse, who has completed the appropriate training and follows all applicable competency regulations under NAC 632, may be authorized to perform the task of removing an epidural catheter, as defined, post surgery/procedure, with a physician or CRNA order. Only nylon/silastic or derivatives of non/silastic catheters may be removed by a qualified registered Nurse. 

The following epidural catheters may not be removed by a Registered Nurse:

1. Metal or spring epidural catheters.

2. Any tunneled epidural catheter.

3. Spinal cord stimulators placed in the epidural space.

Consumer Safety:

Safety is assured by following all the recommendations of this opinion which includes a specific training program and annual competency skill validation when a qualified Registered Nurse removes an epidural catheter (as defined), that has been placed by an Anesthesiologist or a Certified Registered Nurse Anesthetist (CRNA).  This practice would be comparable to removal of femoral sheath catheters, removal of arterial line catheters and removal of PICC lines which is currently within the scope of practice of a Registered Nurse. 

Removal of an epidural catheter will be the responsibility of the qualified Registered Nurse only after appropriate training and documentation of catheter integrity and site integrity.  Consumer safety may be documented through Quality Assurance/Infection Control monitors. 

For consumer safety the qualified Registered Nurse may remove percutaneously inserted epidural catheters. 

Intervention and documentation with a patient should include site care and cleanliness, removal of protective barriers, hygiene, indications of infection and fluid leakage. 

Public Interest:

The removal of an epidural catheter by a Registered Nurse allows the patient to have a broader option for elective epidural pain management while maintaining a safe environment for the patient.  Continued or additional epidural pain management is not always a choice when a physician is responsible for removing the catheter at the completion of a case or procedure.

Practitioner Safety:

Only Registered Nurses with the appropriate didactic and clinical return demonstration skills training, in collaboration with the facility policies and procedural support, may participate in the removal of epidural catheters.  The didactic portion of the education program should include but is not limited to, anatomy, physiology, related pharmacology, assessment, contraindications, exceptions, emergency preparedness and intervention.

Competency Mechanisms:

A specified number of return demonstrations must be completed at the end of the initial training.  Annual skills validation must be demonstrated and documented as part of each facilities education program.  Each nurse must meet all the competency requirements as set forth in NAC 632.

Nursing Process:

Removal of an epidural catheter may be considered within the scope of practice of the Registered Nurse and only performed following the completion of didactic and clinical training.  A policy and procedure should be developed specifically for the practice, and implemented in each facility following the nursing process.

This procedure can be performed in any relevant department of each facility by a qualified Registered Nurse. The areas impacted by this practice change would include obstetrical and surgical services, post anesthesia recovery units, out-patient services, ambulatory surgical centers, critical care and medical-surgical units.

Annual documentation of competency and skills will be monitored by the Chief Nurse in accordance with NAC 632.224 and 632.225.  Infection control monitors may be employed to measure infection rates.

Literature Search:

Included in the literature search is a position statement form the American Nurses Association.  This position statement was written in collaboration with Delaware Board of Nursing (6/90), Louisiana Board of Nursing (1/90); Ohio board of Nursing (3/92); Oklahoma Board of Nursing (Fall/92); Wyoming board of Nursing (Spring/1993); and, South Carolina Board of Nursing (3/93). 
Additional references for revision on July 19, 2006:
Hayek, S.M., Paige, B., Kapural, L., Stanton-Hicks, M. & Mekhail, N. Complications of Tunneled Epidural Catheters in Non-Cancer Patients with Regional Pain, Anesthesiology 2003; 99: A1111 Aram, L, Krane, E.J. Kosloski, L.J. & Yaster, M. Tunneled epidural catheters for prolonged analgesia in pediatric patients, Anesth Analg. 2001 June: 92 (6): 1432 -1438 Epidural Administration of Medication (24867) Publish Date: 9/26/2005 Pain: Clinical Manual, page 236.Copyright 1999, Mosby, Inc.

Standardization Procedures:

The standard of practice is found in the position statements noted above.

Impact:   Fiscal/Manpower:

Removal of epidural catheters by qualified Registered Nurses will decrease cost to the patient by eliminating the additional visit by the physician or CRNA.

The impact on manpower will increase the continuity of patient nursing care.  The Registered Nurse will have the ability to assess the patient’s pain levels prior to the removal of the epidural catheter, and with specific physician orders, administer additional pain management medications through the epidural catheter in a more timely manner, if necessary.

Type of function:

The qualified Registered Nurse will work as a team member with the attending physician, consulting Anesthesiologist, or CRNA.

Application to Past Decision:

Currently, qualified nurses in the state of Nevada may:

1. remove mediastinal drainage tubes (11/86)

2. insert and remove PICC lines (12/92)

3. remove arterial lines

4. remove femoral sheaths

5. instill reversible opioid agonists, via an epidural catheter.

Definition of Terms:

1. Epidural Catheter – Catheter placed within the epidural space, the space is bordered anteriorly by the duramater and posteriorly by the ligamentum flavum and that which envelops the duramater and its contents from the foramen magnum superiorly to the sacrococcygeal membrane inferiorly.

2. Intrathecal Catheter:  Catheter placed within the subarachnoid space (usually at the lumbar level), the space within the dura and arachnoid layers surrounding the spinal cord which contains spinal fluid.

3. Epidural or Spinal Analgesia:  Terms applied to the pain relief produced by the administration of narcotics and/or dilute local anesthetic solutions into the epidural or intrathecal space or treatment or relief of pre-surgery pain (e.g., labor pain), post-surgery acute pain, cancer pain, chronic back pain, post-trauma pain, or for acute medical conditions, which may include corticosteroid treatments.

4. Epidural or Spinal Anesthesia:  Terms applied to the production of surgical anesthesia by local anesthetics, sometimes in combination with narcotics, in which the epidural or intrathecal solution is concentrated enough to provide a complete anesthetic for specific surgical or therapeutic (e.g., lithotripsy) procedures within an operating room.

5. Intrapleural Catheter:  Catheter placed with the intrapleural space.

6. Peripheral Nerve Infusion Device:  Catheter inserted to block or ease pain related to specific peripheral nerves (i.e., brachial plexus).

7. Bolus Dosing:  A concentrated mass of medication administered at one time, in a specified time period, through an intravenous and/or specialized catheter access route via syringe, i.e. push. 

8. Regulated Medication Administration Delivery System:  An implantable devise or external electronic pump designed to control, over a period of time, the administration of the medication in order t maintain a constant, consistent medication level.  This system should include a security method/device which would prevent bolus dosing/test, i.e., PAC pump.

9. Tunneled Epidural Catheter:  A catheter placed in the epidural space and tunneled subcutaneously resulting in an exit site some distance away from the insertion site, usually the patient’s abdomen. 

Prepared by Caroline R. Copeland 11/19/98

Approved by the Nursing Practice Advisory Committee 1/20/99

Adopted by the Nevada State Board of Nursing 5/14/99

Revised by the Nevada State Board of Nursing 7/19/06

instill reversible opioid agonists (e.g., Fentanyl is reversed by Narcan) via an epidural catheter. (12/88)

with the appropriate training, and working in a cardiac catheterization lab with a direct physician order, insert a collagen plug to achieve vascular hemostasis after intravascular catheterization and/or intervention. (11/99)

in an acute care setting, care for, maintain, and remove external jugular peripherally inserted central catheters (EJ PICC) and external jugular peripheral intravenous catheters (EJ PIV)

Background:  The Infusion Nurses Society Position Paper approved on March 20, 2008, states that advances in the field of vascular access devices have resulted in an associated increase in the scope of practice of registered nurses.  This research shows that registered nurses are increasingly being asked to perform external jugular catheterization for peripheral and central venous access.

Definitions:  External Jugular Peripherally Inserted Central Catheters are defined as catheters placed trough the external jugular vein and advanced into position where the distal tip swells in the lower 1/3 of the superior vena cava to the junction of the superior vena cava and the right atrium.  External Jugular Peripheral Intravenous Catheters are peripheral catheters placed in the external jugular vein.

Indications for use:  EJ PICCs are used for non-emergent access when other veins cannot be accessed and are used in giving high-pressure injections when appropriate. Central venous pressure monitoring may also be performed through an EJ PICC.

EJ PIVs are used for emergent access or when other veins cannot be accessed and used for a limited dwell time.

These procedures are within the scope of practice for a Registered Nurse provided the following guidelines are followed:

1. The nurse is competent to perform the procedure and has the documented and demonstrated knowledge, skill, and ability to perform the procedure pursuant to NAC 632.071, 632.224, and 632.225.
2. Prior to incorporating the practice of inserting EJ PIVs, the nurse must have a minimum of two years of experience in infusion therapy.  To incorporate the insertion of EJ PICCs, the nurse must have a minimum of two years of experience in infusion therapy and certification in PICC insertion.  The nurse must have successfully completed an external jugular educational program that included theoretical content and clinical instruction to add insertion of either EJ PIVs and/or EJ PICCs to his practice.
3. There are agency policies and procedures and any required protocols in place for the nurse to perform the procedure.

Bibliography:

Infusion Nurses Society Position Paper, March 20, 2008.

Arizona State Board of Nursing, Advisory Opinion, Peripherally Inserted External 

      Jugular Catheters, September 21, 2005.

Wyoming State Board of Nursing, Advisory Opinion, External Jugular Vein IV

     Cannulation—RN, October 12, 2004.

North Carolina Board of Nursing, Infusion Therapy/Access Procedures, Position

     Statement, September, 1976, revised October, 2007

Nursing Practice Advisory Committee review:  August 12, 2008

Approved by the Nevada State Board of Nursing: September 18, 2008

OB/GYN

perform vaginal speculum examination and specimen collection/ evaluation if: 1) procedure is performed for routine STD screening and/or routine pelvic/pap evaluation; 2) collection, exam and screenings are an extension to a physician/APN and under his/her direct supervision; 3) appropriate formal specialized training and education is completed; 4) treatment prescription is by authorized practitioner via standardized policy/procedure; and 5) competency evaluations by APN, MD and/or employer are established and maintained. (9/94)

perform post-coital testing (including the examination and interpretation of specimens). (12/92)

insert an intrauterine pressure catheter to assist with the evaluation and management of labor following specific Board guidelines. (12/97)

administer prostaglandin products in the case of fetal anomaly or congenital abnormality pursuant to all existing state laws and in all practice settings. (5/99)

insert prostaglandin suppositories or gel for the induction of labor when fetal demise has occurred. (6/90)

administer prostaglandin or other cervical ripening agents in term pregnancy (36 weeks or greater) prior to labor induction if the following guidelines have been met:
1. The RN has been educated and is competent in the pharmacology, physiology, assessment, monitoring, contraindications and interventions related to the administration of these products, including advanced fetal monitoring. The instruction must include a didactic portion and a clinical portion.

2. The RN is competent to perform the procedure and has the documented and demonstrated knowledge, skill, and ability to perform the procedure pursuant to NAC 632.071, 632.224, and 632.225.
3. There are agency policies and procedures in place for the nurse to perform the procedure.
4. Critical care facilities and OB coverage must be available 24 hours per day at the site of the procedure.
5. The RN must have documented competence in advanced fetal monitoring.
6. The RN may not simultaneously administer agents such as oxytocin and prostaglandin. 
7.  If there are contraindications, the medications must be administered by the physician or other attending practitioner.
8. Administration must be a direct medical order, not part of a standing order or protocols.
9. The nurse maintains accountability and responsibility for nursing care related to the procedure and follows the accepted standard of care that would be provided by a reasonable and prudent nurse.

10. This practice is not within the scope of an LPN.

(revised 7/09)

perform amniotome, place spiral (fetal scalp) electrodes. (9/87) 

use Real Time and Doppler Ultrasound for antepartum testing to assess fetal well-being. (10/89)

initiate the administration of vitamin K, erythromycin eye ointment, and hepatitis B vaccine for newborns based on standing protocols.

Interest to the Consumer: 

Timely administration of these medications is in the best interest of the newborn for the prophylaxis against gonococcal ophthalmia neonatorum, to prevent vitamin K-dependent hemorrhagic disease of the newborn and prevent Perinatal Transmission of the Hepatitis B Virus.

There is documentation that these medications are never contraindicated and may be safely given to all newborns.  Historically, there have been no adverse outcomes from administration of these medications

These procedures are within the scope of practice for a Registered Nurse provided the following guidelines are followed:

1. There are standing protocols and policies and procedures in place which have been approved by medicine and nursing within the facility where this procedure is practiced.

2. The nurse is competent to perform the procedure and has the documented and demonstrated knowledge, skill, and ability to perform the procedure pursuant to NAC 632.071, 632.224, and 632.225.

3. The nurse maintains accountability and responsibility for nursing care related to the procedure and follows the accepted standard of care which would be provided by a reasonable and prudent nurse. (7/07)

MISCELLANEOUS

function as a sexual assault nurse examiner provided the following guidelines are followed: 

1.  The dimensions of the specialty practice of the SANE include the collection of forensic material from an acute victim of sexual assault through the use of a “Rape Kit.”  A victim of sexual assault is considered acute if there is reason to believe that there may be forensic evidence on a victim’s body.  Non-acute exams shall be referred appropriately.  A “Rape Kit” is utilized by the SANE to collect forensic material as appropriate for age and situation of the victim.

2. The Registered Nurse shall demonstrate competency, knowledge, skill, and ability pursuant to NAC 632.071, 632.224, and 632.225.  The nurse shall maintain documentation of continued competency which shall be completed annually and include successful return demonstration and peer review of the minimum number of cases required for continued certification by IAFN. 

3.  Initial and ongoing certification through the IAFN as a Sexual Assault Nurse Examiner-Adult/Adolescent Certified shall be maintained to allow the nurse to practice in this capacity and to use the designation “SANE-A” to indicate his/her practice specialty.  The SANE-A certification requirement becomes effective as of January 1, 2005.  The SANE shall maintain available age-specific certification.

4. There are agency policies and procedures and any required standardized protocols in place allowing the SANE to administer and dispense specific drugs and devices. These protocols are approved by both medicine and nursing.
5. The nurse maintains accountability and responsibility for nursing care related to this procedure and follows the accepted standard of care, which would be provided by a reasonable and prudent nurse.  Protocols for this procedure are to be maintained at the practice site and be available for review by the board.
6. The SANE performs this procedure in consultation with the physician or advanced practice nurse, never independently.

Additional requirements for pediatric cases (individuals of less than thirteen years of age) include:

1. Every pediatric case shall undergo retrospective peer review.
2. All exams, which are deemed to have abnormal genital findings, shall be referred to a recognized child abuse expert who is a physician or advanced practice nurse or final diagnosis.
3. Collection of evidential material on a pediatric victim shall only be performed by a SANE who has ongoing, documented competency based on the Pediatric Education Guidelines for Sexual Assault Nurse Examiners of the IAFN. 

(4/1/04; supersedes previous decision of 12/6/91)

utilize complementary therapies to meet nursing and client goals developed through the nursing process. Nurses may employ complementary therapies as part of an overall plan of nursing care following the specific guidelines below. (9/99)

    Complementary therapies have been used in the holistic model of nursing which incorporates a philosophy of nursing practice that involves recognition of the individual as an integrated whole interacting with and being acted upon by both internal and external environments. 

    Nurses may employ complementary therapies as part of an overall plan of nursing care under the following guidelines: 

1. The nurse has the documented competence, knowledge, skill and ability in application of the therapy per NAC 632.224, 632.225, 632.071 and 632.242.   

2. The nurse must follow the accepted standard of care which would be provided by a reasonable and prudent nurse.  Utilization of a complementary therapy must include an evaluation as to whether the therapy is simple (non-invasive, minimal intervention, non-chemical, minimal risk of harm) or complex (invasive, chemical, physical, medications, maximum harm).  For purposes of this advisory opinion, the use of herbal medicines, recommendations of megadoses of vitamins and any other complex therapy is not considered within the scope of practice for nurses at this time. 

3. Clients have granted informed consent.  In obtaining informed consent for a nursing intervention, the nurse shall provide the patient/client/family with the nature and consequences of any procedure, the reasonable risks (if any), possible side effects, benefits and purposes of the procedure and any alternative procedures available. 

4. A nurse may not use any complementary therapy that is otherwise unlawful or that requires licensure or certification by another regulatory body unless the applicable laws have been met.  The use of complementary therapies does not authorize the licensed nurse to diagnose or prescribe.

if nurses want to practice as paramedics in the EMS system, they must be certified as such and not present themselves as a nurse. (12/88)

give medical directions to EMS field personnel (632.235). (4/89)

practice telenursing, defined as the provision of nursing care or advice from a remote location through the use of telecommunications equipment including, but not limited to, a telephone, teletype, facsimile machine or other equipment capable of transmitting a video image. Telenursing involves the use of comprehensive written protocols for potential implementation of treatment by nurses. The Nevada State Board of Nursing has established the following practice guidelines. 1) Only Registered Nurses, currently licensed in the State of Nevada, may practice telenursing in relation to patients in Nevada.
2) Per NAC 632.249, the nurse practicing telenursing must identify himself by name and title. 3) After completion of a nursing assessment of the patient, the nurse practicing telenursing may provide advice based on the use of written physician protocols (which may include over-the-counter medications), published reference guides or software protocols approved by the medical staff. 4) All telenursing interactions including, but not limited to, the collection of demographic data, health history, assessment of chief complaint, protocols followed, referrals and follow-ups, must be electronically recorded. (6/02)

perform procedures which utilize:
a.       lasers and intense pulse light devices for skin rejuvenation and to remove hair, spider veins, and tattoos;
b.      dermabrasion to remove scarring, blemishes, or wrinkles;
c.       chemical peels; and
d.      Botox injections. 
These procedures are within the scope of nursing for a Registered Nurse provided the following guidelines are followed: 

1. The nurse is competent to perform the procedure and has the documented and demonstrated knowledge, skill, and ability to perform the procedure pursuant to NAC 632.224 and 632.225.

2. There are agency policies and procedures and any required protocols in place for the nurse to perform the procedure.

3. The nurse is in compliance with licensure or certification by any other regulatory body (other than the Nevada State Board of Nursing) and has met all requirements established by any other regulatory agency which has authority over the procedure.

4. The nurse maintains accountability and responsibility for nursing care related to the procedure and follows the accepted standard of care which would be provided by a reasonable and prudent nurse.
5. The use of any of these procedures does not authorize the licensed nurse to diagnose or prescribe. The nurse is following the physician's plan of care.
6. Clients have granted informed consent.  In obtaining informed consent for a nursing intervention, the nurse shall provide the patient/client/family with the nature and consequences of any procedure, the reasonable risks (if any), possible side effects, benefits, and purposes of the procedure and any alternative procedures available.
7. The procedure is not performed independently.  It is authorized pursuant to NAC 632.071 and is performed under the direct supervision of a physician who is licensed in the state of Nevada and readily available by telephone within a 30-minute physical response time at the site where the procedure is performed and has the knowledge, skill, and ability to perform the procedure. 

(1-22-03, revised 5-19-04)

If they meet the requirements of NAC 632.242, Licensed Practical Nurses MAY:

GENERAL

remove, clean and reinsert a "donut" type pessary upon successful completion of formal education and training which includes demonstration of competence in the use of this device. Documentation of annual updates of education and demonstration of competency are required. (9/99)

insert and check placement of NG tube. (9/86)

insert oral gastric tubes. (11/86)

perform postmortem enucleation. (6/87)

remove a respirator when a patient has been determined to be brain dead and pronounced dead by a physician. The nurse may refuse to remove the respirator for medical, ethical, or moral reasons. (9/87)

MISCELLANEOUS

utilize complementary therapies to meet nursing and client goals developed through the nursing process. Nurses may employ complementary therapies as part of an overall plan of nursing care following the specific guidelines below. (9/99)

    Complementary therapies have been used in the holistic model of nursing which incorporates a philosophy of nursing practice that involves recognition of the individual as an integrated whole interacting with and being acted upon by both internal and external environments. 
    Nurses may employ complementary therapies as part of an overall plan of nursing care under the following guidelines: 
1. The nurse has the documented competence, knowledge, skill and ability in application of the therapy per NAC 632.224, 632.225, 632.071 and 632.242. 
2. The nurse must follow the accepted standard of care which would be provided by a reasonable and prudent nurse.  Utilization of a complementary therapy must include an evaluation as to whether the therapy is simple (non-invasive, minimal intervention, non-chemical, minimal risk of harm) or complex (invasive, chemical, physical, medications, maximum harm).  For purposes of this advisory opinion, the use of herbal medicines, recommendations of megadoses of vitamins and any other complex therapy is not considered within the scope of practice for nurses at this time. 
3. Clients have granted informed consent.  In obtaining informed consent for a nursing intervention, the nurse shall provide the patient/client/family with the nature and consequences of any procedure, the reasonable risks (if any), possible side effects, benefits and purposes of the procedure and any alternative procedures available. 
4. A nurse may not use any complementary therapy that is otherwise unlawful or that requires licensure or certification by another regulatory body unless the applicable laws have been met.  The use of complementary therapies does not authorize the licensed nurse to diagnose or prescribe.

OUT OF SCOPE OF NURSES' PRACTICE

The Board has determined that Registered Nurses and Licensed Practical Nurses MAY NOT:

perform intrauterine insemination (12/92)

administer epidural anesthetics. This procedure is reserved for CRNAs and physicians. Licensed nurses must not be solely responsible for management of the patient under the effects of epidural anesthesia, but may assist the physician in the patient's care. (6/90)

accept employment as a nursing assistant, unless they hold a CNA certificate; activity must be limited to the scope of practice for which the nurse is employed. (8/90)

remove medications in the event of death of a home care client. Medications ordered for that client become a part of the client's estate. A nurse removing drugs is acting unprofessionally and may be subject to disciplinary action for violating NAC 632.890, ss 15, 16, and/or 18. (12/87)

perform apnea testing for confirmation of brain death. (6/90)

advance a Swan-Ganz catheter. (12/88)

Licensed Practical Nurses MAY NOT:

perform arterial blood draws. (6/90)

insert PICC lines. (11/89, reconfirmed 12/92)

insert an intrauterine pressure catheter (IUPC). (9/87, 12/97)

WITHIN SCOPE OF PRACTICE FOR ADVANCED PRACTITIONERS OF NURSING

in OB/GYN/Women's Health may expand their scope of practice to include primary women's health only with additional education. Addition of primary women's health is considered a substantial change in medical specialty.

who have expertise in Women's Health Care, may perform intrauterine insemination. (12/92)

OTHER

Operational definition of clinical for schools of nursing in Nevada. Clinical experiences in nursing education approved by the Nevada State Board of Nursing consist of a variety of experiences with actual patients across the lifespan throughout the curriculum. Innovative teaching/learning methods such as simulation may be utilized. Nevada Nursing programs must consistently provide actual patient experiences sufficient to prepare the nursing student for competency as defined in NAC 632.212, 632.214, 632.216, 632.218, 632.220, and 632.222. (5/9/07)

Faculty Supervision of Nursing Students in Clinical Rotations
While participating in clinical rotations as part of the nursing education program, all student clinical experiences, including those with preceptors, shall be directed by nursing faculty. Public protection is of the utmost concern. Faculty must be readily available to address student and/or preceptor concerns and issues of safety.
Faculty Supervision without Preceptors
The faculty student ratio may not exceed 1 to 8 unless the nursing program has requested and received an Executive Director waiver (NAC 632.670). The supervising faculty member must remain on site during the time students are involved in the clinical experiences. In the public health or community setting, the faculty must be readily available by telephone (landline or cellular) to respond to preceptor and/or student issues.
Supervision with the Use of Preceptors
Each preceptor must have the appropriate knowledge and competence for the areas of instruction. The nursing program must:

1. Provide the preceptor an orientation concerning the roles and responsibilities of faculty and students.

2. Develop written objectives for each preceptor.

3. Limit preceptor instruction to not more than two students at any one time.

4. Require the preceptor to be at the clinical site when the students are participating in clinical experiences.

5. Require the supervising faculty to be available to the preceptor and/or student. Availability is defined as being readily available by telephone (landline or cellular) to respond to preceptor and/or student issues.

6. The need for physical availability will be defined in the contractual agreement. 

(3/16/05)

Meaning of "Field Related to Nursing"

According to NAC 632.675: 2. Of the faculty who are hired after August 13, 2004: (a) At least 75 percent of the members must hold at least a master’s degree with a major in nursing and have completed training which is related to the area of teaching of the member; and (b) Except as otherwise provided in subsection 3, the remainder of such members, if any, must hold at least: (1) A master’s degree with a major in nursing; (2) a bachelors degree with a major in nursing and a master’s degree in a field related to nursing; or (3) a graduate degree from an accredited school of nursing as defined in NRS 632.011.

It is the position of the Nevada State Board of Nursing that “masters degree in a field related to nursing” means:

 1.      A degree which the nursing program director determines is the appropriate “master’s degree in a field related to nursing” of the faculty based on:

a.      The nursing program curriculum assignment and

b.      The faculty expertise required to teach the various components of the nursing program curriculum assignment.

 2.      It is the responsibility of the nursing program director to document the rationale explaining how the degree is related to nursing and why it is appropriate for the assignment.

3.      It is the responsibility of the nursing program director to ensure the faculty member(s) are currently licensed in the State of Nevada.  The nursing program director shall submit the name and degree/credentials of any newly hired faculty, together with the rationale described in #2, as an addendum to the nursing program’s annual report to the Board. 

4.      It is the responsibility of the nursing program director to submit the percentage designation of those faculty full time equivalents who have a masters degree with a major in nursing (at least 75% of the full time equivalents must have a master’s degree with a major in nursing) and the percentage designation of those faculty full time equivalents who have a master’s degree in a field related to nursing or a graduate degree from an accredited school of nursing (no greater than 25% of the full time equivalents). (9/24/04) 

Registered Nurses knowledgeable in school nursing should direct and provide school health services. The School Nurse (R.N.) is responsible to develop, implement, evaluate and revise the plan of health care for each student with special health care needs under his supervision. Delegation/assignment of specific procedures to licensed or qualified persons is addressed in the opinion. (12/6/91, rev. 5/14/99, 11/17/04, 3/16/05, 7/19/06)

An RN license is required to perform the following: 1. Teaching nursing at any level of preparation; 2. Utilization review; 3. Case Management in Health Care; 4. Discharge Planning; 5. Risk Management; and 6. Quality Management (12/95)

An LPN may participate in the utilization review process only under very limited criteria. (3/97)
This Practice Decision is an addendum to the Practice Decision adopted 12/9/95 which described the scope of practice of the professional nurse to include case management, utilization review, quality management, discharge planning, risk management, and teaching. The Practice Decision adopted 12/8/95 nor this Practice Decision preclude the practice of delegation as outlined in NAC 632.222, nor the collaboration of personnel with other expertise.

It is the opinion of the Nevada State Board of Nursing that Licensed Practical Nurses may participate in the Utilization Review process if:

1. The employing agency has policies and procedures identifying:

a. The role and responsibilities which may be delegated by an RN pursuant to NAC 632.222; and

b. The process for assessment of the LPN’s competence to carry out the duties is identified in the job description.

2. The LPN holds certification or is actively working toward certification by ABQAURP, NAHQ, or a comparable body approved by the Board. 

3. The LPN performs these activities pursuant to NRS 632.240. 

4. The requirements of the Nurse Practice Act and the regulations implementing that act, most notably NAC 632.224 through 632.242, are met.  

A person who practices nursing or delivers patient care in relation to patients who are located within the State of Nevada must be licensed by the Nevada State Board of Nursing. The following activities include, but are not limited to, conduct that is considered to be delivering patient care in role of the licensed nurse:

1. Any intent to enter into a therapeutic relationship with the patient.

2. Any notation or documentation in an individual patient’s medical records.

3. Designation or acting as Chief Nurse.
4. Accepting an assignment for patient care.
5. Patient education.
6. Any nursing education that involves direct patient contact.
7. Designation as or acting as an RN who supervises care provided by another RN, LPN or CNA.

The following activities include, but are not limited to, conduct that is NOT considered to be delivering patient care in role of the licensed nurse:

1. Inspection of written corporate policies and procedures to evaluate compliance with same.
2. Instruction of corporate employees on issues of compliance with corporate policies and procedures.
3. Training of persons by product representatives, so long as no patient care is provided.
4. With prior patient permission, observe medication pass or wound care procedures.
5. Auditing patient records.
6. Teaching continuing education courses.
7. Making recommendations regarding the delivery of patient care. (4/04)

Operational definition of impairment: IMPAIRMENT displayed by an individual licensed or certified by this Board is behavior, cognitive processing, and/or decision–making that, projected to its conclusion, causes harm and/or the potential for harm to patients and/or the public. A single act, event and/or events constituting an imminent or clear and present danger to patient and public safety may demonstrate impairment. If the Board determines a licensee or certificate holder had demonstrated impairment, it may discipline and/or monitor the individual.  (4/89; revised 11/17/04)

CNAs

 Hours of employment for renewal of certificates

Rationale

It is the opinion of the Nevada State Board of Nursing that a person who is certified as a nursing assistant in Nevada, is working under a title other than CNA, and is performing duties other than those identified in the CNA model curriculum is not practicing as a CNA. 

Certified Nursing Assistant (CNA) practice is regulated by the Board of Nursing. A person who practices as a CNA in the State of Nevada must demonstrate minimal eligibility requirements for renewal of the certificate that are consistent with federal laws governing the nursing assistant registry, including but not limited to:

• Twenty-four hours of continuing education within the CNA scope of practice; and
• Forty hours of employment as a CNA within the scope of practice as defined in the Nurse Practice Act and outlined on the CNA Skills Guidelines.

The Nevada State Board of Nursing has previously opined that CNAs may perform tasks which are beyond those listed in the CNA Skills Guidelines if they complete additional training and have documented competencies, as long as the task is assigned pursuant to NAC 632.222 by a licensed professional nurse. Supervision requires the RN to ascertain that the task:

• Is considered safe and routine for the specific client,
• Poses little potential hazard for the client,
• Can be performed with a predictable outcome,
• Does not require assessment, interpretation or decision-making while being performed,
• Involves a limited degree of potential client discomfort, and
• Does not require a substantial amount of scientific knowledge and technical skill.

Most importantly, the RN always maintains accountability for the overall provision of nursing practice, being responsible for the ongoing supervision and evaluation of the assigned task following the accepted standard of care which would be provided by a reasonable and prudent nurse.

It is the opinion of the Nevada State Board of Nursing that hours of employment obtained   outside of the defined scope of practice do not constitute CNA practice. The use of titles and/or job descriptions including, but not limited to, the following are considered to be unlicensed assistive personnel and not within the CNA scope of practice and these will not be considered as hours to meet the renewal requirement:

            1.         EKG and/or monitor clerk/technician

            2.         Patient Care Technician

            3.         ICU/CCU/ER/OR/Mental Health/Cardiology or other unit clerk/technician

            4.         Unit Clerk/secretary and/or Health Unit Coordinator

            5.         Personal Assistant/Personal Care Assistant/Companion

            6.         Supportive Living Arrangement Aide

            7.         Medication Aide/Assistant

            8.         Restorative Aide

            9.         Private duty aide/caregiver

  Nursing assistants are certified by the Nevada State Board of Nursing and perform specific tasks and skills consistent with their training and documented competency. CNA practice is under the regulatory authority and oversight of the board to ensure public protection and safety.  Unlicensed assistive personnel (ULAPs) do not work under any regulatory oversight or authority.  There should be no confusion to the public, to employers, to the nursing assistant or to their supervising licensed nurses regarding what constitutes the legal scope of practice of the CNA. 

  References:

NRS 632.342 Renewal of certificate

42 CFR Ch.IV Code of Federal Regulations 

Approved by the Nevada State Board of Nursing:  3/18/10

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