Practice Questions Related to Registered Professional Nurses

Anesthesia

At its February 10-11, 1993 meeting, the Board reconsidered its position on its June, 1990 advisory ruling regarding injection of anesthetic agents to produce anesthesia following placement of the needle by the physician.

The Board has determined that the registered professional nurse (RN) may assist in the procedure by acting as a "third hand" for the anesthesiologist/anesthetist. The Board further determined that the anesthetic agents are to be drawn up by the anesthetist; the physician must be present and appropriate policy should be developed by the medical and nursing staff. The RN who is not a CRNA is not to insert or place the needle. The RN is strictly assisting as a "third hand" while the anesthetist administers the anesthesia.

At its December 4, 2008 meeting, the Board reconsidered its position on its February 10-11, 1993 advisory ruling regarding injection of anesthetic agents to produce anesthesia (regional blocks) following placement of the needle by the anesthesia provider.

The Board determined that the registered professional nurse (RN) may assist the anesthesia provider as a "third hand" for performing regional block procedures, and that the tasks of assistance may include:

  • prepare and label local anesthetics as prescribed,
  • adjust peripheral nerve stimulator and/or ultrasound as directed,
  • operate the nerve block syringe attached to the anesthesia provider's needle via extension tubing as directed.

The RN who is not a CRNA is not to insert or place the regional block needle. The Board further determined that this advisory ruling not include the administration of anesthetic medications (such as Diprivan (propofol)) for analgesia, muscle relaxation, or sedation. See following anesthetic agent information

Anesthetic Agents

At its April 10-11, 2002 meeting the Board reiterated that a registered professional nurse may not administer anesthetic medications for the purpose of anesthesia unless the nurse is a certified registered nurse anesthetist. However a registered professional nurse may administer anesthetic agents, such as Diprivan, for the purpose of analgesia, muscle relaxation, or sedation provided that the nurse has received the appropriate documented training based on the facility's established policies and procedures.

Reviewed March 2, 2006.

The Board rescinded a portion of its previous position that “a registered professional nurse may, after appropriate documented training based on the facility’s established policies and procedures, administer Propofol (Diprivan) for the purpose of analgesia, muscle relaxation, or sedation.”  Other agents used for the purpose of analgesia, muscle relaxation or sedation may continue to be administered by the registered professional nurse.

The Board supports safe practice to include Propofol (Diprivan) administration by registered professional nurses only in the following circumstances: to intubate; to maintain sedation for mechanically ventilated patients; and, to sedate or those patients undergoing emergency intubation.  The Board recognizes that Propofol administration for analgesia, muscle relaxation, or sedation may rapidly lead to deep sedation and or short duration general anesthesia requiring intubation.  Therefore, effective June 4, 2010, administration of Propofol for nonventilated patients is restricted to certified registered nurse anesthetists.

Reviewed March 3-4, 2010

At its September 16-17, 2015 meeting, the Board revisited its previous position on the administration of Propofol (Diprivan) by registered professional nurses and has included administration of Propofol (Diprivan) for the purpose of palliative sedation under the following circumstances:

  1. The patient has a do not resuscitate order (DNR) and has been placed on comfort care measures only.
  2. The registered professional nurse has completed a competency based education and training program on the administration and monitoring of palliative care sedation based on the facility/organizaiton's policies and procedures.
  3. The first dose of palliative care sedation is administered by a physician, nurse practitioner, or nurse anesthetist.

At its August 10, 2017, the Board reviewed its March 2, 2006 practice statement on the administration of Propofol (Diprivan) by registered professional nurses during rapid sequence intubation and provided the following clarification:

A registered professional nurse (RN) may assist a licensed provider by administering Propofol in situations where the provider is present at the bedside but unable to personally inject the agents because the provider is performing the critical task of airway management for the patient during rapid sequence intubation, provided the RN has the educational preparation and clinical competence to inject such agents.

The RN should be educated and competent in all aspects of rapid sequence intubation, mechanical ventilation and advanced cardiopulmonary resuscitation. This should include knowledge of the equipment, medical devices used, and medications to be administered.

Assessment

The Board determined that the performance of a nursing assessment is a proper function of the registered professional nurse and is NOT within the purview of a practical nurse license. The act of performing a nursing assessment can NOT be delegated by a registered nurse to a licensed practical nurse on the basis of the limitations within the curricula of practical nursing programs. Such curricula do not include the theoretical and clinical preparation necessary for the effective performance of nursing assessments. December 18, 1990

Dispensing Medication

A RN or LPN legally may NOT dispense drugs at any time. Dispensing means the pouring or placing of drugs from stock supplies into bottles or containers, the labeling of such items with the patient's name, medication, dosage and directions and the giving of such bottles or containers to personnel for administering to patients. This is the role of the pharmacist and may not be assumed by nurses. (1986)

The Board reaffirmed that LPNs and RNs are NOT authorized to dispense medications. The administration of medications as prescribed by a legally authorized person is within the scope of practice of nurses licensed in Maine. (Dec. 27, 1990)

The Board of Nursing determined that nurses licensed in Maine may provide patients with limited quantities of prescribed/ordered medication which has been pre-labeled and prepackaged by the hospital pharmacist. These "starter packs" will be administered to the patient in the emergency department setting following an evaluation by a physician. This same procedure will also be used in inpatient leave of absence situations. (May 1, 1991)

In response to a query in April, 1993, the Board stated that a telephoned order for drugs at night for an in-patient is an example of administering a medication, not dispensing.

A nurse providing medications to a patient not evaluated by a physician in the emergency department is acting as a pharmacist in dispensing medications and exceeds the scope of nursing practice.

Endoscope

At its February 1993 meeting, the Board determined that it is not within the scope of practice for nurses to maintain the position of the endoscope.

At its June 9-10, 1999 meeting, the Board restated its position that it is not within the scope of a registered professional nurse's practice to advance the endoscope under any circumstances.

At its February 14-15, 2001 meeting, the Board revisited the issue and determined that licensed nurses, who are educationally prepared according to the organization/facility's established policies and procedures, may assist the physician, who is present in the procedure room, to maintain the position of the endoscope, advance the endoscope, and manipulate the polypectomy snares as directed by the physician.

Epidural Catheters

At its February, 1987 meeting, the Board was requested to issue an advisory ruling regarding the instillation of medications into epidural catheters for long term pain management. It is the opinion of the Board that it is within the scope of practice of a registered professional nurse to instill analgesics into an epidural catheter as follows:

  1. Bolus doses of epidural analgesics may be given by a registered nurse (RN) who has had supervised instruction in the proper method of bolus administration.
  2. Nursing responsibilities re: instillation of medications into epidural catheters are as follows:
    1. assessment of medication effectiveness;
    2. assessment and management of side effects related to the epidural administration of narcotics;
    3. maintenance of the integrity and sterility of the epidural line; and
    4. patient/family teaching.

In June, 1987, the Board amended the previous advisory ruling re instillation of medications into epidural catheters by a registered nurse to include the additional method of continuous infusion.

In May,1988, the Board included postoperative pain management via epidural catheter.

In December, 1988, the Board determined by consensus that it is within the scope of practice of a RN to instill anesthetic medications, e.g., marcaine .5% into epidural catheters for pain management, under the conditions indicated in the previous advisory ruling.

In February, 1993, the Board determined that the RN may manage the care of patients in labor receiving epidural analgesia by continuous infusion under the following conditions:
1. Placement of catheter, administration of the initial dose of medication and establishment of analgesic dosage parameters are done by the specialty of anesthesia or an obstetrician who has been granted privileges by the institution;
2. A qualified anesthesia provider must be immediately available as defined by institutional policy;
3. Only those RNs with documented education beyond licensure which is specific to obstetric analgesia may adjust the drug infusion rates in compliance with the anesthesia provider's specific written orders and institutional policy.

At its February, 1996 meeting, the Board determined that a RN with documented training may remove epidural catheters.

Gastric Band

At its March 11-12, 2015 meeting, the Board determined that it is within the registered professional nurse's scope of practice to perform gastric band adjustments provided the registered nurse has appropriate ducumented training according to the facility/organization's policies and procedures and has attained certification in bariatric nursing (CBN) sponsored by the American Society for Metabolic and Bariatric Surgery (ASMBS).

Hypnotherapy

The use of complementary or alternative therapies in general or hypnotherapy specifically does not expressly come under the Law Regulating the Practice of Nursing or under any specific regulations of the Maine State Board of Nursing.

At its December 6-7, 2000 meeting, the Board determined that hypnotherapy is not exclusively nursing practice but may be considered a modality that a registered professional nurse may employ if he/she has been appropriately trained and competency has been maintained.

Intrathecal Catheters

At its October, 1993 meeting, the Board determined that it is within the scope of practice of a registered professional nurse (RN), who has had appropriate supervised training in intrathecal management, to instill medications via bolus or continuous infusion into an intrathecal catheter for the purposes of pain management, administration of chemotherapy, spasmolytics and antibiotics. Administration of neurolytic agents by a RN is prohibited. Nursing responsibilities regarding administration of medications into intrathecal catheters include:

  1. assessment of medication effectiveness
  2. assessment and management of side effects related to intrathecal administration of drugs
  3. maintenance of the integrity and sterility of the intrathecal line, and
  4. patient/family teaching.

Neuromuscular Blockers

At its December 13, 1995 meeting, the Board determined that appropriately trained registered nurses may, under the direction of a physician, administer neuromuscular blockers for ventilation support.

At its December 6-7, 2000 meeting, the Board reaffirmed its December 13, 1995 decision that appropriately trained registered nurses may, under the direction of a physician, administer neuromuscular blockers for ventilation support. The intent of this decision was not to limit this practice to a hospital setting.

Registered professional nurses may deliver a neuromuscular block, in support of a ventilator patient, while caring for a patient in transport from one hospital to another in an ambulance.

Paracentesis

At its March 1-2, 2006 meeting, the Board stated that there are no provisions in the Law Regulating the Practice of Nursing or in the Board's opinion to preclude a registered professional nurse from removing a paracentesis tube from a patient in an acute care setting provided that the nurse has had the appropriate training based on the facility's established policies and procedures.

PICCs - Peripherally Inserted Central Catheters

At its April, 1992 meeting, the Board determined that it is within the scope of practice for a registered professional nurse to insert a biocompatible, flexible venous catheter via a peripheral vein under the following circumstances:

  1. The registered nurse has substantial experience in intravenous therapy and a solid understanding of central lines
  2. The registered nurse has undergone a specialized educational program which includes but is not limited to:
    1. anatomy and physiology of the insertion site and venous and arterial systems
    2. patient screening
    3. equipment
    4. sterile insertion technique
    5. supervised clinical experience
    6. complication identification management
    7. catheter care, and
    8. a mechanism for quality assurance and periodic review for competency
  3. The peripheral catheter insertion site is the antecubital area or the optimal vessel in one of the extremities.
  4. The catheter length for each patient is measured using specified anatomical landmarks for the tip location intended. The catheter tip destination may be the axillary, subclavian or brachiocephalic vein or the superior vena cava.
  5. The catheter location is confirmed radiographically prior to administration of any solutions when the tip is advanced beyond the axilliary vein.

The role of the registered nurse in placing the peripherally inserted central catheter includes patient assessment, pre-procedure instructions, post-procedure assessment of patient tolerance and frequent, periodic examinations of the site including dressing changes. The registered nurse is responsible for possessing the level of knowledge and skill to administer a variety of solutions safely through the catheter including antibiotics, antineoplastics, blood components, and parenteral nutrition. The registered nurse may also be responsible for teaching the patient/family self-care of the device and management of the symptoms.

The Board at its June 9-10, 1992 meeting determined that a registered nurse may use a guidewire when inserting a peripherally inserted central catheter (PICC).

At its April 2-3, 2003 meeting, the Board determined that a registered professional nurse may use the Microintroducer and Ultrasound Technique to place peripherally inserted central lines (PICC) provided that the nurse has had the appropriate education and training according to the organization/facility's policies and procedures.

At its March 11-12, 2015 meeting, the Board revisited its April 1992 practice question regarding Peripheral Inserted Central Catheters (PICCS) and added electrocardiogram (ECG) verification of PICC tip by registered professional nurses provided the registered nurse has appropriate documented training (including ECG interpretation) according to the facility/organization's policies and procedures. The Board replaced confirmation of tip advanced beyond the axillary vein with confirmation of tip advanced in the Superior Vena Cava (SVC).

Subfascial Catheter

At its April, 1993 meeting, the Board determined that it is within the scope of practice for the registered professional nurse to inject 10 cc of ).5% marcaine with epinephrine, for the purpose of pain management, into the subfascial catheter inserted by the physician. the nurse should have the appropriate training and supervision prior to assuming responsibility for subfascial administration.

The Board at its October 6-7, 1999 meeting determined that it is not within the registered professional nurse's scope of practice to inject Marcaine into an interscalene catheter, placed by the anesthesiologist into the brachial plexus, for the purpose of anesthetic block to the patient's shoulder.

Tracheostomy

At its October 6-7, 1992 meeting, the Board determined that it is within the scope of practice for the registered professional nurse to remove a tracheostomy apparatus and replace it with a new apparatus in patients who have had tracheostomies for a long period of time.

At its April 7 and 8, 1999 meeting, the Board determined that it is within the scope of practice for the licensed practical nurse to remove a tracheosotomy apparatus and replace it with a new apparatus in patients that have well established stomas.

Transfusions

The Board determined that it is appropriate for RNs in Maine to participate in out of hospital transfusions provided that the agency has policies and procedures in place that are in accord with the current AABB protocol for out of hospital transfusions. (January 28, 1991)

Vaginal Exam

ADVISORY RULING June 12, 1997
It is within the scope of practice of a registered professional nurse (RN) to perform vaginal speculum examinations and collect specimens for cytology and/or culture if the following requirements are met:

  1. General Requirements
    1. Written policy and procedures are maintained by the employer.
    2. The registered professional nurse performing the procedure must have satisfactorily completed an instructional program that included supervised clinical practice.
    3. Documentation of satisfactory completion of the course of instruction and supervised practice is on file with the employer.
  2. Course of Instruction
    The course of instruction shall include, but not be limited to, the following:
    1. anatomy and physiology of the female reproductive system
    2. indications and contraindications for performing speculum examinations
    3. proper methods of specimen collection
    4. intervention for potential side effects
    5. nursing care responsibilities

Vagus Nerve Stimulator

At its December 6-7, 2000 meeting, the Board determined that a registered professional nurse may use the vagus nerve stimulator on demand therapy to end or shorten seizure activity. The registered professional nurse must have appropriate documented training according the facility/organization's established policies and procedures. The Board determined that a registered professional nurse may not delegate the task of performing this type of therapy to certified nursing assistants.

At its October 17-18, 2001 meeting, the Board determined that a licensed nurse may use the vagus nerve stimulator on demand therapy to end or shorten seizure activity. The licensed nurse must have appropriate education and supervision based on defined competencies and established facility/organization policies and procedures. The Board revisited the issue of a registered professional nurse delegating this task to a certified nursing assistant. The Board determined that a registered professional nurse may delegate this task to a certified nursing assistant who has had appropriate education and supervision based on defined competencies and established facility/organization policies and procedures.

Wound Debridement

At its April, 1992 meeting, the Board determined that it is within the scope of nursing practice for a registered professional nurse to debride non-viable tissue provided that he/she has had appropriate, documented training according to protocols established by a health care facility. Sharp debridement may be included with the same conditions.