Advisory Opinions: Nebraska Board of Nursing

Advisory Opinions: Nebraska Board of

green ball Abandonment
green ball Accountability For Professional Conduct Of Nurses
green ball Analgesia/Moderate Sedation
green ball Arterial Lines
green ball Cardioversion
green ball Casting
green ball Chest Tube Removal
green ball Chronic Ambulatory Peritoneal Dialysis (CAPD)  
green ball Cortisone Injection 
green ball Cosmetic and Dermatologic Procedures
green ball CPR: Nurses Accountability to Perform Cardiopulmonary
Resuscitation

green ball Delegation/Assignment &/or Direction w/in the Outpatient Dialysis Unit

green ball Gastric Band Adjustments
green ball Gastric Tube Insertion: Selection of Insertion Site and Type of Tube
green ball Epicardial Pacing Wires
green ball Extra-Pair Of Hands Concept
green ball Gastroenterology
green ball Gastrostomy, Jejunostomy and Suprapubic Tube Replacement
green ball Intraosseous Cannulation
green ball Intra-Uterine Pressure Catheters

green ball Internal Fetal Scalp Electrodes
green ball LPN And Gynecological Services
green ball LPN And Laboring Obstetrical Patients
green ball LPNs And Respiratory Care
green ball OB Patients Receiving Analgesia-Anesthesia by Catheter
green ball Obtaining Blood Specimens
green ball Peripherally Inserted Central Catheters (PICC)  
green ball Pronouncement Of Death
green ball Provision Of Medication When Pharmacy Is Closed
green ball RN First Assistants
green ball RNs And Airway Management
green ball RN and EMTALA Medical Screening Exam (MSE)
green ball Safety to Practice: Functional Ability  
green ballSafety to Practice: Temporary Assignments, Floating
green ball Standing Orders & Protocols
green ball Suturing
green ballUmbilical Catheters
green ballUnna Boot
green ballUse of Dermabond® and Other Topical Skin Adhesives
green ballVerbal And Telephone Orders
green ballWound Debridement
green ballWound Drains

Abandonment

This Nebraska Board of Nursing advisory opinion is issued in accordance with Nebraska Revised Statute (Neb. Rev.Stat.) 38-2216(2).  As such, this advisory opinion is for informational purposes only and is non-binding.

The Nebraska Board of Nursing believes that the term patient abandonment must be defined and differentiated from employment abandonment.  The Nebraska Board of Nursing further believes the definition of patient abandonment should be consistent throughout the health care delivery system.

 

This opinion is meant to provide general guidelines as to what may or may not constitute patient abandonment.  It is the opinion of the Nebraska Board of Nursing that for patient abandonment to occur, the nurse must:

1.    Have first ACCEPTED the patient assignment, thus establishing a nurse-patient relationship. Accepting a patient assignment varies from setting to setting and requires a clear understanding of workload and agreement to provide care, AND then

2.    DISENGAGED the nurse-patient relationship without giving reasonable notice and report to the qualified person (supervisor, nurse, etc.) so that others can make arrangements for continuation of nursing care.

 

Examples of patient abandonment include, but are not limited to:

1.    Leaving without giving the supervisor or qualified person adequate notice.

2.    Leaving without giving report to a qualified person.

3.    Accepting an assignment of patient care and then leaving the nursing unit or patient care setting without notifying the qualified person.

4.    Sleeping while on duty, thus being unavailable to assigned patients.

5.    Leaving a facility or work place if the nurse is the only licensed individual on duty (if required by the facility to be present the entire shift).

6.    Not reporting for an assignment where the nurse is the sole provider of care (e.g., private duty/home health/hospice care).

 

Situations NOT considered to be patient abandonment, but are examples of employer-employee issues (salary, work conditions, hiring and termination policies) include:

1.    No call/no show for work.

2.    Refusal to work mandatory overtime.

3.    Refusal to accept an assignment or a nurse-patient relationship.

4.    Refusal to work additional hours or shifts.

5.    Ending the employer-employee relationship without providing the employer the amount of notice required by the facility, or without providing the employer a period of time to obtain replacement for that specific position (e.g., resigning without notice).

6.    Refusal to work in an unfamiliar, specialized, or “high tech” area when there has been no orientation, no educational preparation or employment experiences. (refer to Nebraska Board of Nursing Advisory Opinion, Safety to Practice: Temporary Assignments, Floating)
7.    Resigning from a position and not fulfilling the remaining posted work schedule.

8.    Failure to return to work from a scheduled leave.
 
The Nebraska Board of Nursing believes that both nurse managers and nurses in direct patient/client care positions are accountable for providing safe nursing care to their patients/clients.  During periods of understaffing or limited numbers of well-qualified staff, it is essential that nurse managers and nursing staff work together to provide safe care to all clients in a manner consistent with the Nurse Practice Act.
 
On occasion, patient abandonment has been used as a means of intimidation in order to ensure continued staffing at facilities.  If the employer makes threats to “take a nurse’s license away for abandonment,” it must be stated that the employer has no authority to take any type of disciplinary action against a license, including revocation of the license.  In order for any license to be disciplined, the license holder must go through the disciplinary process defined in statute that includes a review and recommendation by the board.  That recommendation is not based on the supervisor’s recommendation.  While a supervisor/employer may file a complaint against the nurse, each case is considered on an individual basis.

 

Adopted March, 1994
Revised November 1995
Affirmed May 2000; Reaffirmed July 2001

Revised April 2011

Top of Page 

 

RNs and Airway Management

This Nebraska Board of Nursing advisory opinion is issued in accordance with PDF File Neb. Rev. Stat. (NRS) 38-2216(2). As such, this advisory opinion is for informational purposes only and is non-binding.

It is the opinion of the Nebraska Board of Nursing that airway management including the use of adjunctive interventions is within the scope of practice for the RN. Airway management may include the use of sedative and neuro-muscular blockade agents within the parameters of specific and appropriate protocols.

It is also the opinion of the board that endotracheal intubation and/or insertion of a laryngeal mask airway in a critical situation is within the scope of practice of the RN.    An RN may administer medications, such as Etomidate, Diprivan and neuromuscular blocker agents under the following conditions:

  1. Administration is under the direct supervision of a physician or CRNA;

  2. The RN is educationally prepared and clinically competent to perform the act in a safe, competent manner, and;

  3. The facility has a policy in place that allows the RN to administer the medications and provides for education and a mechanism to validate clinical competency.

The decision to provide airway management techniques should be based upon self-assessment of competency, and following an assessment of the client and environment. A licensed nurse is accountable to be competent for all nursing care that he/she provides. Competence means the ability of the nurse to apply interpersonal, technical and decision-making skills at the level of knowledge consistent with the prevailing standard for the nursing activity being applied. Accountability also includes acknowledgment of personal limitations in knowledge and skills, and communicating the need for specialized instruction prior to providing any nursing activity.

Thomas, Stone, Harrison, Wedel. (1995). Airway management in the air medical setting. Air Medical Journal. 14 (3). Pg. 129 – 138.

Lowe, Sagehorn, Madsen. (1998). The effect of a rapid sequence induction protocol on intubation success rate in an air medical program. Air Medical Journal. 17 (3). Pg. 101 - 104.

Munford. (1998). Practical pharmacology of neuromuscular blockade. Air Medical Journal. 17 (4). Pg 149 – 155.

 

Air & Surface Transport Nurses Association, “Advanced Airway Management Position Statement”, approved by ASTNA Board of Directors April 2007.  Retrieved October 21, 2009 from: http://www.astna.org/PDF/ASTNA2007AdvancedAirwayMgmntPosition.pdf.

 

Air & Surface Transport Nurses Association, “Rapid Sequence Intubation (RSI)

Consensus Statement”, endorsed by ASTNA posted May 2009.  Retrieved October 21, 2009 from: http://www.astna.org/PDF/RSI-Consensus-Statement.pdf.

 

Arizona Board of Nursing. Advisory Opinion, “Intubation: Endotracheal, Esophageal Obturator Airway, Laryngeal Mask Airway: The Role of The Registered Nurse”, revised July 2007.  Retrieved November 2, 2009 from: http://www.azbn.gov/AdvisoryOpinions.aspx.

Oklahoma Board of Nursing. “Rapid Sequence Intubation Guidelines – Medication Administration by Registered Nurses”. Board Approved May 2006. Retrieved November 2, 2009 from: http://www.ok.gov/nursing/prac1.html.

Kentucky Board of Nursing. “Administration of Etomidate During Rapid Sequence Intubation”. Updated May 2005. Retrieved November 2, 2009 from: http://kbn.ky.gov/NR/rdonlyres/60FE6DFC-CCCC-4913-B0A3-744A0C746B7D/0/aos29.pdf.

Adopted January, 1997
Revised December, 1998
Revised May 2000

Revised December 2009

Top of Page 

Analgesia and Moderate Sedation

This Nebraska Board of Nursing advisory opinion is issued in accordance with PDF File Nebraska Revised Statute 38-2216 (2).  As such, this advisory opinion is for informational purposes only and is non-binding.

Moderate Sedation

Definitions

Minimal Sedation is a drug-induced state during which patients respond normally to verbal commands.  Although cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are unaffected.

Moderate Sedation/Analgesia (formerly referred to as “Conscious Sedation”) is a drug-induced depression of consciousness during which patients respond purposefully* to verbal commands, either alone or accompanied by light tactile stimulation.  No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate.  Cardiovascular function is usually maintained.

Deep Sedation/Analgesia is a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation.  The ability to independently maintain ventilatory function may be impaired.  Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate.  Cardiovascular function is usually maintained.

General Anesthesia is a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation.   The ability to independently maintain ventilatory function is often impaired.   Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function.  Cardiovascular function may be impaired.

*Reflex withdrawal from a painful stimulus is NOT considered a purposeful response.

It is not considered appropriate for an RN to administer drugs labeled by the Food and Drug Administration as Anesthetic Agents for the purpose of moderate sedation. This includes but is not limited to Propofol, Etomidate, Pentothal, Ketamine, or Brevital by any route.

The exception is the administration of these medications by an RN to an intubated, ventilated patient in the critical care setting.

Management and Monitoring of Moderate Sedation using Non-Anesthetic Agents 

It is within the scope of practice of a registered nurse who is not a qualified anesthesia provider to manage and monitor the care of patients receiving IV moderate sedation during therapeutic, diagnostic, or surgical procedures provided the following criteria are met:

  1. Administration of IV moderate sedation medications by non-anesthetist RNs is allowed by institutional policy, procedures, and protocol.    Written protocols which address specific drugs to be used for moderate sedation, the purpose, goals, techniques, desired outcomes of administration, and the recommended dose per kilogram of body weight that may be safely administered by an RN, taking into account the patient’s age and co-morbidities.

  2. A qualified anesthesia provider or licensed practitioner orders the medications to achieve IV moderate sedation.

  3. Guidelines for patient monitoring, drug administration, and protocols for dealing with potential complications or emergency situations are available and have been developed in accordance with accepted standards of anesthesia practice.

  4. The registered nurse managing and monitoring the care of the patient receiving IV moderate sedation shall have no other responsibilities that would leave the patient unattended or compromise continuous patient monitoring.

Qualifications

  1. The registered nurse managing the care of patients receiving IV moderate sedation is accountable to:
    a.  Demonstrate the acquired knowledge of anatomy, physiology, pharmacology, cardiac arrhythmias and complications related to IV moderate sedation and medications.
    b.  Understand the principles of oxygen delivery, respiratory physiology, oxygen transport and uptake, as well as demonstrate the ability to use oxygen delivery devices.
    c.  Anticipate and recognize potential complications of IV moderate sedation in relation to the type of medication being administered.
    d.  Possess the requisite knowledge and skills to assess, diagnose and intervene in the event of complications or undesired outcomes.  The nurse must be able to institute nursing interventions in compliance with orders (including standing orders) or institutional protocols or guidelines.
    e.  Demonstrate competency in airway management and resuscitation appropriate to the age of the patient.  This may be completed by Advanced Cardiac Life Support (ACLS)/Pediatric Advanced Life Support (PALS) certification or appropriate competency assessment.
    f.  Demonstrate knowledge of the legal ramifications of administering IV moderate sedation and/or monitoring patients receiving IV moderate sedation, including the RN's responsibility and liability in the event of an untoward reaction or life-threatening complication.

Additional Guidelines

  1. The institution or practice setting has in place an educational/competency validation mechanism that includes a process for evaluating and documenting the individuals' demonstration of the knowledge, skills, and abilities related to the management of patients receiving IV moderate sedation. Evaluation and documentation of competence occurs on a periodic basis according to institutional policy.

  2. Intravenous access will be continuously maintained for the patient receiving IV moderate sedation and analgesia.

  3. All patients receiving IV moderate sedation will be continuously monitored throughout the procedure as well as the recovery phase by physiologic measurements including, but not limited to, respiratory rate, oxygen saturation, blood pressure, cardiac rate and rhythm, and patient's level of consciousness.

  4. Supplemental oxygen will be immediately available to all patients receiving IV moderate sedation and administered per order (including standing orders).

  5. An emergency cart with a defibrillator must be immediately accessible to every location where IV moderate sedation is administered. Suction and a positive pressure breathing device, oxygen, and appropriate airways must be in each room where IV moderate sedation is administered.

  6. Provisions must be in place for back-up personnel who are experts in airway management, emergency intubation, and advanced cardiopulmonary resuscitation if complications arise during IV moderate sedation.

Analgesia

It is the opinion of the Nebraska Board of Nursing that it is within the scope of practice for a registered nurse to manage the care of non-pregnant patients receiving analgesic medication via catheter techniques (Epidural, Intrathecal, Intrapleural, or Peripheral) for acute or chronic pain. 

Management and Monitoring

The RN will assume responsibility for patient care only after the anesthesia provider has placed the catheter, verified placement of the catheter, administered an initial test dose of pain medication with the patient’s vital signs remaining stable. 

The RN may: 

  1. Monitor the patient's vital signs, mobility, level of consciousness, and perception of pain.

  2. Replace empty infusion syringes or infusion bags with new, pre-prepared solutions according to authorized provider’s orders.

  3. Reinject medication following establishment of appropriate therapeutic range, and adjustment of drug infusion rate in compliance with the authorized provider’s patient-specific written orders.

  4. Administer a bolus dose though the bolus features of a continuous infusion pump, following establishment of appropriate therapeutic range.

  5. Remove the catheter, if educational criteria and institutional policy allow. Removal of the catheter by a RN is contingent upon receipt of a specific order from a qualified anesthesia provider or licensed practitioner.

  6. Decrease or stop the continuous infusion if there is a safety concern

  7. Initiate emergency therapeutic measures according to institutional policy and/or protocol if complications arise.

The following are not considered within the scope of practice for an RN:

  1. The RN may not place the catheter, check placement or give an initial test dose.

  2. The RN may not administer anesthetic medications via catheter for the purposes of anesthesia.

Qualifications 

  1. Only registered nurses with the appropriate education, knowledge, skills and supervised clinical practice are allowed to administer and manage the medications for analgesia by catheter (Epidural, Intrathecal, Intrapleural, or Peripheral).

  2. Education: The registered nurse must receive instructions in and demonstrate competence in the following;

a.  Anatomy and physiology related to the analgesia technique.
b.  Indications and contraindications to analgesia by catheter (Epidural, Intrathecal,
     Intrapleural, or Peripheral).
c.  Potential adverse reactions.
d.  Maintenance of the catheter and or infusion device and related equipment.
e.  Pharmacology and pharmacokinetics of commonly used analgesia medications.
f.  Nursing care responsibilities as defined and approved by institutional policy.

  Additional guidelines 

  1. Written policy and procedures are maintained by the employer/agency. Guidelines for the patient monitoring, drug administration, management, and protocols for dealing with potential complications or emergency situations are available and have been developed in conjunction with the physician or CRNA.  

A licensed nurse is accountable to be competent for all nursing care that he/she provides.   Competence means the ability of the nurse to apply interpersonal, technical and decision-making skills at the level of knowledge consistent with the prevailing standard for the nursing activity being applied.  Accountability also includes acknowledgment of personal limitations in knowledge and skills, and communicating the need for specialized instruction prior to providing any nursing activity.

  References

American Association of Critical-Care Nurses (1996).  Role of the Registered Nurse (RN) in the Management of Patients Receiving Conscious Sedation for Short-Term Therapeutic, Diagnostic or Surgical Procedures.  

American Association of Nurse Anesthetists (2003). Considerations for Policy Guidelines for Registered Nurses Engaged in the Administration of Conscious Sedation.  

American Association of Nurse Anesthetists (2003). Provisions of Pain Relief by Medication Administered via Continuous Epidural, Intrathecal, Intrapleural, Peripheral Nerve Catheters, or Other Pain Relief devices.   

American Association of Nurse Anesthetists and American Society of Anesthesiologists (2004).  Joint Statement Regarding Propofol Administration.

American Association of Operating Room Nurses (2000).  Recommended Practices for Managing the Patient Receiving Conscious Sedation/Analgesia

American Nurses Association (1997). Position Statement on the Role of the Registered Nurse (RN) in the Management of Patients Receiving IV Conscious Sedation for Short-Term Therapeutic, Diagnostic, or Surgical Procedures

American Nurses Association (1997).  Position Statement on the Role of the Registered Nurse (RN) in the Management of Analgesia by Catheter Techniques (Epidural, Intrathecal, Intrapleural, or Peripheral Nerve Catheters)

American Society of Anesthesiologists (2008).   The Role of Registered Nurses in the Management of Continuous Regional Analgesia.  

American Society of Anesthesiologists (2001). Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists

American Society for Pain Management Nursing (2007).  Registered Nurse Management and Monitoring of Analgesia by Catheter Techniques

Institute of Safe Medication Practices (2005). Propofol Sedation: Who Should Administer. Retrieved from http://www.ismp.org August 20, 2012.

Society of Gastroenterology Nurses and Associates, Inc. (1998)   Position Statement: Sedation and Analgesia.  Revised 1998.

United States Food and Drug Administration Drug Reference, labeling. Retrieved from http://www.fda.gov/Drugs August 20, 2012

 

Adopted 1989
Updated 1991
Reaffirmed January 1996
Revised December 1998
Revised April 2004
Revised September 2006
Revised May 2007
Revised January 2008
Revised May 2010
Revised October 2010
Revised April 2013

Top of Page 

Arterial Lines

This Nebraska Board of Nursing advisory opinion is issued in accordance with PDF File Neb. Rev. Stat. (NRS) 38-2216(2). As such, this advisory opinion is for informational purposes only and is non-binding.

It is the opinion of the Board that the removal of a femoral arterial catheter sheath is an acceptable practice for the registered nurse who is competent in the procedure.

It is the opinion of the Board that manipulation of a pulmonary artery catheter by an RN competent in the skill is appropriate when necessary to avoid adverse patient consequences. The nurse should use nursing judgement when making a decision to perform this activity.

It is the opinion of the Board that insertion of radial arterial lines is acceptable practice for the registered nurse who is competent and knowledgeable regarding the procedure and potential complications.

It is the opinion of the Board that it is acceptable practice for the RN to discontinue subclavian catheters and internal jugular catheters.

It is the opinion of the Board, that it is not acceptable for the nurse to remove an intra-aortic balloon pump catheter with a femoral artery access.

The decision to provide the various activities associated with arterial lines should be based upon self-assessment of competency, and following an assessment of the client and environment. A licensed nurse is accountable to be competent for all nursing care that he/she provides. Competence means the ability of the nurse to apply interpersonal, technical and decision-making skills at the level of knowledge consistent with the prevailing standard for the nursing activity being applied. Accountability also includes acknowledgment of personal limitations in knowledge and skills, and communicating the need for specialized instruction prior to providing any nursing activity.

Adopted 1992
Revised April, 1996
Revised August, 1997
Reaffirmed May 2000

Top of Page 

 

Cardioversion

This Nebraska Board of Nursing advisory opinion is issued in accordance with PDF File Neb. Rev. Stat. 38-2216(2). As such, this advisory opinion is for informational purposes only and is non-binding.

It is the opinion of the Nebraska Board of Nursing that providing elective cardioversion is not acceptable practice for the registered nurse. Elective cardioversion is a scheduled and planned medical intervention. Due to the elective nature of the procedure and the potential complications, such intervention is appropriately provided by the physician or other qualified practitioner.

Cardioversion in the case of an emergency and life-threatening situation is left to the discretion of the registered nurse. Such decision should be based upon client assessment, self-assessment of competency, employer policies/procedures, availability of qualified care givers etc.

A licensed nurse is accountable to be competent for all nursing care that he/she provides. Competence means the ability of the nurse to apply interpersonal, technical and decision-making skills at the level of knowledge consistent with the prevailing standard for the nursing activity being applied. Accountability also includes acknowledgment of personal limitations in knowledge and skills, and communicating the need for specialized instruction prior to providing any nursing activity.

Adopted January, 1988
Reaffirmed November, 1995
Reaffirmed May 2000

Top of Page

 

Casting

This Nebraska Board of Nursing advisory opinion is issued in accordance with PDF File Neb. Rev. Stat. 38-2216(2). As such, this advisory opinion is for informational purposes only and is non-binding.

It is the opinion of the Board that it is acceptable practice for licensed nurses in the specialty of orthopedics to apply principles of fracture treatment. Such practice may include cast application for simple fractures after a diagnosis has been made by a qualified licensed practitioner.

The decision to apply a cast should be based upon self-assessment of competency, and following an assessment of the client and environment. A licensed nurse is accountable to be competent for all nursing care that he/she provides. Competence means the ability of the nurse to apply interpersonal, technical and decision-making skills at the level of knowledge consistent with the prevailing standard for the nursing activity being applied. Accountability also includes acknowledgment of personal limitations in knowledge and skills, and communicating the need for specialized instruction prior to providing any nursing activity.

Approved October, 1991
Revised April, 1996
Reaffirmed May 2000

Top of Page

 

Chest Tube Removal

This Nebraska Board of Nursing advisory opinion is issued in accordance with PDF File Neb. Rev. Stat. 38-2216(2). As such, this advisory opinion is for informational purposes only and is non-binding.

It is the opinion of the Nebraska Board of Nursing that removal of mediastinal and pleural chest tubes is within the scope of practice for the RN.

The decision to remove a chest tube should be based upon self-assessment of competency, and following an assessment of the client and environment. A licensed registered nurse is accountable to be competent for all nursing care that he/she provides. Competence means the ability of the nurse to apply interpersonal, technical and decision-making skills at the level of knowledge consistent with the prevailing standard for the nursing activity being applied. Accountability also includes acknowledgment of personal limitations in knowledge and skills, and communicating the need for specialized instruction prior to providing any nursing activity.

Adopted May, 1997
Reaffirmed May 2000

Top of Page

 

Chronic Ambulatory Peritoneal Dialysis (CAPD)

This Nebraska Board of Nursing advisory opinion is issued in accordance with PDF File Neb. Rev. Stat. 38-2216(2). As such, this advisory opinion is for informational purposes only and is non-binding.

It is the opinion of the board that it is appropriate for LPNs to provide nursing care relative to chronic ambulatory peritoneal dialysis (CAPD). The principles of aseptic and sterile technique, gravity drainage, and osmotic fluid and electrolyte balance are within the educational background of the practical nurse.

The decision for an LPN to provide CAPD should be based upon self-assessment of competency, and following an assessment of the client and environment. LPNs should participate in CAPD only after he/she has self-assessed his/her level of competence. Competence of the practical nurse means the ability of the LPN to apply interpersonal, technical and decision making skills consistent with the prevailing standards for provision of CAPD. Registered nurses and licensed practitioners should provide direction to the LPN by direct supervision or indirect supervision through the use of employer guidelines, plans of care, and periodic inspection and evaluation.

LPNs may contribute to the assessment, planning of care, and evaluation of patient response to the treatment intervention of peritoneal dialysis. LPNs may provide the procedural interventions necessary to accomplish CAPD including the addition of medication to the dialysate solution.

Issued January, 1988
Reaffirmed November, 1995
Reaffirmed May 2000

Top of Page

 

Cortisone Injection

This Nebraska Board of Nursing advisory opinion is issued in accordance with PDF File Neb. Rev. Stat. 38-2216(2). As such, this advisory opinion is for informational purposes only and is non-binding.

It is the opinion of the Nebraska Board of Nursing that injecting cortisone and similar medications into joints of a patient is not appropriate practice for the RN. An injection of this nature is not an emergency procedure; due to the potential complications such injection is appropriately provided by the physician or other qualified practitioner.

Adopted November, 1993
Reaffirmed January, 1996
Reaffirmed May 2000

Top of Page 

 

CPR: Nurses Accountability to Perform Cardiopulmonary Resuscitation (CPR)

This Nebraska Board of Nursing advisory opinion is issued in accordance with PDF File Neb. Rev. Stat. 38-2216(2).

All licensed nurses, regardless of their practice setting, are accountable in an emergency to resuscitate individuals who are present in the practice setting for the purpose of receiving care, unless the individual has a Do Not Resuscitate (DNR) order or other advanced directive. Nurses should perform resuscitation based on their assessment of the situation and their level of competency. Current CPR certification is not required in order for the nurse to be accountable to assist the individual to the best of his/her ability. However, maintaining current CPR certification is the professional standard for all licensed nurses.

A nurse is not expected to perform resuscitation on an individual when obvious signs of death are present unless facility policy states otherwise.   Obvious signs of death include lividity or pooling of blood in dependent body parts (livor mortis), cooling of the body following death (algor mortis), hardening of muscles or rigidity (rigor mortis), and injuries incompatible with life.

A licensed nurse is accountable to be competent for all nursing care that he/she provides. Competence means the ability of the nurse to apply interpersonal, technical and decision-making skills at the level of knowledge consistent with the prevailing standard for the nursing activity being applied. Accountability also includes acknowledgement of personal limitations in knowledge and skills, and communicating the need for specialized instruction prior to providing any nursing activity.

2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. (2010).   Retrieved September 12, 2012 from http://circ.ahajournals.org/content/122/18_suppl_3/S720.full?sid=ecd77984-9642-48c1-b22e-162a0402cf62  

February 2007
Reaffirmed December 2012

Top of Page

 

HHS R & L Position Statement
Provision of Medication when Pharmacy is Closed

PDF File Neb. Rev. Stat. 71-1,142 (14) Dispense or dispensing means interpreting, evaluating, and implementing a medical order, including preparing and delivering a drug or device to a patient or caregiver in a suitable container appropriately labeled for subsequent administration to, or use by, a patient. The practice of pharmacy includes dispensing; a physician may also dispense incident to the practice of medicine.

It is acceptable that a physician assistant, nurse practitioner or nurse (pursuant to a physician order) may provide a patient with enough multiple single doses of medication for self-administration until such time as the ordered medication can be dispensed by a pharmacist so long as the exact amount to be dispensed and specific instruction on how the medication is to be taken is specified by the licensed practitioner in the medical record.

Top of Page

 

Delegation, Assignment, and/or Direction within the Outpatient Dialysis Unit

  1. The Nebraska Board of Nursing supports the Joint Position Statement of the American Nephrology Nurses Association (ANNA) and the National Association of Nephrology Technicians/Technologists on Use of Unlicensed Personnel in Dialysis and the ANNA Position Statement on Delegation of Nursing Tasks.
  2. The board supports the standard that RN’s use a decision making process, based upon nursing education, a body of nursing knowledge, nursing judgement, and application of the nursing process to delegate and make assignments in a manner that allows for safe, accountable and responsible provision of nursing care related to dialysis services for patients.
  3. The board supports the standard that RNs retain accountability for the adequacy and outcomes of nursing care provided directly and indirectly related to dialysis services.
  4. The board supports the standard that RNs are accountable to assess and verify unlicensed person’s competency to provide auxiliary services in support of the hemodialysis nurse’s practice. The board further supports the standard that RNs are accountable to assess and verify the competency of licensed practical nurses prior to making assignments related to the provision of dialysis services.
  5. The board supports the standards that direct supervision should be provided for all delegated/directed activities. Direct supervision means that the responsible licensed nurse is physically present in the clinical area, and is available to assess, evaluate and respond immediately.
  6. The board recommends the following as appropriate delegation, assignment, and/or direction for patients with chronic renal disease receiving services in an outpatient dialysis unit.
Obtain lab samples
(access the dialysis tubing for withdrawal of blood sample)
LPN or technician
Obtain Site Cultures LPN
Cannulation of access LPN or technician
Initiation of dialysis (connection of dialysis tubing to the access device and administration of normal saline) LPN or technician
Initiating dialysis via a duo-lumen catheter LPN or technician
Determine clotting time LPN or technician
Draw up and inject heparin dose associated with routine dialysis treatment LPN or technician
Monitor and record dialysis LPN or technician
Discontinue dialysis (includes administration of normal saline and discontinuing the cannulation) LPN or technician
Clean/dress fistula graft site LPN or technician
Administration of O2 LPN or technician (only if medication aide)
Subclavian care LPN
Nutrition & medication education LPN
Nutrition & medication information LPN or technician
Routine injection of normal saline LPN or technician
  1. The board also recommends that the following are not appropriate delegation, assignment, and/or direction.

    Decision to adjust heparin dose
    Final accountability for staff and patient education
    Administration of IV medications*
    Case management of the home dialysis client

    *Administration of IV medications is a complex nursing intervention and is within the scope of practice of a Registered Nurse. An LPN-C may also administer limited IV medications as defined in 172 NAC 102, the Regulations Governing the Practice of Licensed Practical Nurse-Certified.

  1. The Mediation Aide Act requires any unlicensed person providing medications in any licensed facility to be on the Medication Aide Registry.

A licensed nurse is accountable to be competent for all nursing care that he/she provides. Competence means the ability of the nurse to apply interpersonal, technical and decision-making skills at the level of knowledge consistent with the prevailing standard for the nursing activity being applied. Accountability also includes acknowledgement of personal limitations in knowledge and skills, and communicating the need for specialized instruction prior to providing any nursing activity.

References:

Joint Position Statement of the American Nephrology Nurses’ Association (ANNA) and the National Association of Nephrology Technicians/Technologists (NANT) on Unlicensed Personnel in Dialysis. ANNA Board of Directors and NANT Board of Directors. 2003.

The Role of Unlicensed Assistive Personnel in Dialysis Therapy. ANNA Board of Directors. 2003.

Delegation of Nursing Care Activities. ANNA Board of Directors. 2003.

Title 172 Chapter 95; State of Nebraska Regulations Governing the Provision of Medications by Medication Aides and Other Unlicensed Persons. 2003.

Opinion Issued per April 24, 1991 Board of Nursing meeting.
Revised January, 1996
Reaffirmed May 2000
Revised July 2003
Revised March 2005

Top of Page

 

Epicardial Pacing Wires

This Nebraska Board of Nursing advisory opinion is issued in accordance with PDF File Neb. Rev. Stat. 38-2216(2). As such, this advisory opinion is for informational purposes only and is non-binding.

It is the opinion of the Nebraska Board of Nursing that removal of epicardial pacing wires is an acceptable activity for RNs.

The decision to remove epicardial pacing wires should be based upon self-assessment of competency, and following an assessment of the client and environment. A licensed nurse is accountable to be competent for all nursing care that he/she provides. Competence means the ability of the nurse to apply interpersonal, technical and decision-making skills at the level of knowledge consistent with the prevailing standard for the nursing activity being applied. Accountability also includes acknowledgment of personal limitations in knowledge and skills, and communicating the need for specialized instruction prior to providing any nursing activity.

Adopted January, 1990
Reaffirmed January, 1996
Reaffirmed May 2000

Top of Page

"Extra-Pair of Hands" Concept

This Nebraska Board of Nursing advisory opinion is issued in accordance with PDF File Neb. Rev. Stat. 38-2216(2). As such, this advisory opinion is for informational purposes only and is non-binding.

RNs/LPNs cannot expand their legal scopes of practice based upon physician direction/supervision. However, there are non-routine occasions of an emergent nature in the provision of health care in which a licensed practitioner may be involved in an uninterruptable procedure, and may need to use the services of a RN or LPN to assist in providing an "extra pair of hands" to perform a mechanical task. Similar situations may occur in which a RN may need to utilize the services of an unlicensed assistive person. The extra pair of hands concept requires the physical presence in the same proximity of the licensed practitioner with the RN/LPN, or the RN and the unlicensed assistive person. It is not intended for routine situations or facility policy. Licensed practitioner is defined in the nurse practice act as "a person lawfully authorized to prescribe medications or treatments," Neb. Rev. Stat. 38-2209

By way of example, in an Emergency Department a licensed nurse may actually "perform the task of injecting the drug for anesthesia into the IV tubing." The licensed practitioner must make all the necessary decisions and assume total responsibility, accountability for determining the drug and dosage, and for the care of the client during the anesthesia phase, and has the ultimate responsibility for the interventions related to the potentially threatening responses. The nurse is solely "injecting" the drug as directed and making no determinations.

Another example may be the use of an unlicensed assistive person to assist the RN in the tub/debridement room of a burn unit. The unlicensed person assumes no responsibility for the decision to perform the act, or for intervention regarding patient response or adverse reaction. The RN is responsible to ensure the unlicensed person has the necessary skill to assist.

In contrast, delegation means that the RN has transferred to the unlicensed person the authority to provide a specific intervention. Along with the delegated transfer of authority, the RN transfers the responsibility and accountability for performance of the activity, and a limited level of decision making related to the activity to the unlicensed person. While delegation requires the provision of supervision, delegation does not require that the RN be in the same physical proximity as the unlicensed person, as does direct supervision.

Adopted 1990
Updated January, 1996
Reaffirmed May 2000
Revised October 2010
Revised April 2011
Revised October 2011

Top of Page

 

Internal Fetal Scalp Electrodes

This Nebraska Board of Nursing advisory opinion is issued in accordance with PDF File Nebraska Revised Statute (NRS) 71-1,132.11(2). As such, this advisory opinion is for informational purposes only and is non-binding.

It is the opinion of the Board that it is acceptable practice for a registered nurse to apply internal fetal scalp electrodes for fetal heart rate monitoring when membranes are not intact. It is not appropriate for a registered nurse to apply internal fetal scalp electrodes when membranes are intact. However, if external methods of monitoring appear non-reassuring, amniotomy by the registered nurse to place a fetal scalp electrode to assess fetal well-being may be indicated in the absence of the physician or certified nurse-midwife.

The decision to provide internal fetal scalp electrodes and, in emergencies to perform amniotomy to apply such electrodes, should be based upon self-assessment of competency, and following an assessment of the client and environment. A licensed nurse is accountable to be competent for all nursing care that he/she provides. Competence means the ability of the nurse to apply interpersonal, technical and decision-making skills at the level of knowledge consistent with the prevailing standard for the nursing activity being applied. Accountability also includes acknowledgment of personal limitations in knowledge and skills, and communicating the need for specialized instruction prior to providing any nursing activity.

Approved, 1986
Updated April, 1996
Reaffirmed 2000

Top of Page

Gastric Band Adjustments

This Nebraska Board of Nursing advisory opinion is issued in accordance with Nebraska Revised Statute § 38-2216 (2). As such, this advisory opinion is for informational purposes only and is non-binding.

It is the opinion of the Nebraska Board of Nursing that Gastric Band adjustments are within the scope of the Registered Nurse.  The RN may perform this procedure provided:
 
1.     The RN has completed additional education and training and has demonstrated competence in performing the procedure.
2.    A licensed independent practitioner competent in bariatric medicine has assessed the patient and determined the amount of solution to add or remove from the band prior to the trained RN performing the procedure.

 A licensed nurse is accountable to be competent for all nursing care that he/she provides. Competence means the ability of the nurse to apply interpersonal, technical and decision-making skills at the level of knowledge consistent with the prevailing standard for the nursing activity being applied. Accountability also includes acknowledgment of personal limitations in in knowledge and skills, and communicating the need for specialized instruction prior to providing any nursing activity.
 
References:
 
Arizona State Board of Nursing Advisory Opinion Laparoscopic Adjustable Gastric Band Fill
 
“All About Gastric Band Adjustment” http://www.lap-band-surgery-site.com/lap-band-fill.html
 
The Art of Adjustments with the LAP-BAND AP System, Allergan Web site.  www.lapbandcentral.com.
 
Approved by the Nebraska Board of Nursing 10/11/12.

 

Gastric Tube Insertion: Selection of Insertion Site and Type of Tube

Advisory Opinion: Nebraska Board of Nursing

 Gastric Tube Insertion: Selection of insertion Site and Type of Tube

This Nebraska Board of Nursing advisory opinion is issued in accordance with Nebraska Revised Statute (Neb. Rev. Stat.) 71-132.11. As such, this advisory opinion is for informational purposes only and is non-binding.  

When a licensed nurse receives an order to insert a gastric tube, the insertion site (nasal or oral) and type of tube may not be specified in the order.   The process of determining type of tube and insertion site is similar to determining size of Foley catheter tube to use or the needle type, size and injection site.   Therefore, the selection of insertion site and type of tube for gastric tube insertion is within the scope of practice for licensed nurses who are competent to make this determination.   It is the opinion of the Nebraska Board of Nursing that it is acceptable practice for licensed nurses licensed in Nebraska to make such determinations

A licensed nurse is accountable to be competent for all nursing care that he/she provides.    Competence means the ability of the nurse to apply interpersonal, technical and decision-making skills at the level of knowledge consistent with the prevailing standard for the nursing activity being applied.   Accountability also includes acknowledgment of personal limitations in knowledge and skills, and   communicating the need for specialized instruction prior to providing any nursing activity.

January, 2007

Top of Page

Gastroenterology

This Nebraska Board of Nursing advisory opinion is issued in accordance with PDF File Neb. Rev. Stat. 38-2216(2). As such, this advisory opinion is for informational purposes only and is non-binding.

The Board of Nursing supports the following positions published by the Society of Gastroenterology Nurses and Associates, Inc (SGNA).

Statement on the Use of Sedation & Analgesia in the Gastrointestinal Endoscopy Setting (2007).  It is the opinion of the Nebraska Board of Nursing that acceptable RN practice includes administering medications for the purposes of conscious sedation. Conscious sedation means the patient is calmed but remains awake and has perception. Please refer to the board's advisory opinion on Analgesia/Conscious Sedation (January 2008).

Manipulation of Endoscopes During Endoscopic Procedures.  It is the opinion of the Nebraska Board of Nursing that acceptable licensed nurse practice includes providing assistance to the licensed practitioner by manipulating the endoscope to facilitate an endoscopic procedure.  Manipulation is defined as “only the act of advancing or withdrawing the endoscope under the direct supervision of the endoscopist”.  Please refer to the board's advisory opinion on "extra-pair of hands" concept (May 2000).

Performance of Gastrointestinal Manometry Studies and Provocative Testing.  (2006).  Nursing care of the patient undergoing these studies involves a nursing assessment and documentation, administering topical anesthetics inserting a manometry probe, and performing the study (SGNA, 2003; SGNA, 2004). Pediatric patients undergoing manometric procedures also require a nurse or associate familiar with the special development and behavioral needs of this population.

The role of the gastroenterology registered nurse has expanded to include provocative testing. Nursing care of the patient undergoing these studies involves nursing assessment, documentation and administration of intravenous drugs used in provocative testing.  SGNA supports the position that the licensed practical nurse experienced in gastroenterology and/or manometry studies may be given the responsibility of preparing the patient, performing the study under the direction of the registered nurse and/or physician. The licensed practical nurse may document events during the procedure on the tracing that correspond to patient activity for interpretation by the physician.

It is our belief that licensed practical nurse responsible for manometry must have the education, knowledge of medications, and technical skills specific to manometry. The licensed practical nurse must also be prepared to identify untoward reactions, including but not limited to epistaxis, vaso-vagal reactions and syncope.

The Role of the Nurse/Associate in the Placement of Percutaneous Endoscopic Gastrostomy (PEG) Tube. (October 2005).  It is the opinion of the Nebraska Board of Nursing that it is acceptable practice for RNs to provide "direct nursing care" and "technical support" and that LPNs be limited to provide "technical support" as stated in the position paper.  RNs educated and experienced in gastroenterology nursing and endoscopy can be given the responsibility for performing additional duties in the presence of and under the direct supervision of a physician endoscopist.  The RN is required to maintain current knowledge, competency and experience in PEG tube placement to fill this role (as defined in the position statement).

A licensed nurse is accountable to be competent for all nursing care that he/she provides. Competence means the ability of the nurse to apply interpersonal, technical and decision-making skills at the level of knowledge consistent with the prevailing standard for the nursing activity being applied. Accountability also includes acknowledgment of personal limitations in knowledge and skills, and communicating the need for specialized instruction prior to providing any nursing activity.

Adopted January, 1986
Updated January, 1996
Reaffirmed May 2000

Revised July 2008

 

http://www.sgna.org/Resources/position.cfm

Top of Page

 

Intraosseous Cannulation

This Nebraska Board of Nursing advisory opinion is issued in accordance with PDF File Neb. Rev. Stat. 38-2216(2). As such, this advisory opinion is for informational purposes only and is non-binding.

It is within the Scope of Practice of a Registered Nurse (RN) to place intra-osseous devices if the following requirements are met: 

I. General Requirements

 a.       A written policy and procedures are maintained by the agency/employer. Appropriate policies, procedures, and standing orders should be developed which specify qualifications, special education and training to include didactic and clinical competency verification components, and emergent conditions/patient situations wherein the RN is authorized to administer intraosseous therapy.

b.       Only RNs who have satisfactorily completed an instructional program and have had supervised clinical practice are allowed to insert intra-osseous devices.

c.       Documentation of satisfactory completion of an instructional program, supervised clinical practice, and clinical competency verification is on file with the employer.

 II    Course of Instruction is to include but not be limited to:

a.       Anatomy and physiology of the bone and circulation

b.       Indications and contraindications for the procedure

c.       Complications and management techniques to include potential adverse reactions

d.       Selection of appropriate site and preparation of site

e.       Technique of intra-osseous device insertion and removal

f.         Nursing responsibilities

RATIONALE

The guiding principle for this opinion is that Intraosseous Cannulation insertion/removal can be safely performed by a registered nurse with specialized training, skills, and knowledge.

A licensed nurse is accountable to be competent for all nursing care that he/she provides. Competence means the ability of the nurse to apply interpersonal, technical and decision-making skills at the level of knowledge consistent with the prevailing standard for the nursing activity being applied. Accountability also includes acknowledgment of personal limitations in knowledge and skills, and communicating the need for specialized instruction prior to providing any nursing activity.

REFERENCES

PALS provider manual, American Academy of Pediatrics, American Heart Association, 2012

Henretig, FM, King, C, Textbook of Pediatric Emergency Procedures. Philadelphia, PA, Lippincott. 1997, 289-298

Lark, S, Macnab, A, (2000). “Early report on Emergency Sternal Intraosseous Infusion in Adults,” Prehospital Disaster Medicine, 15(3); 51

Day, M, (1999). “Using a Sternal Intraosseous device in adults,” Nursing 99, 29(12)

Emergency Nurses Association (2000). Trauma nursing core course (provider) manual, 5th Ed. Des Plaines, IL: Author

Semonin-Holleran, R (1996). “Flight Nursing: Principles & Practices.” 2nd Ed. St. Louis, MO. Mosby

Arizona Board of Nursing, Advisory Opinion, Intra-osseous Cannulation, March 2009

South Carolina Board of Nursing, Advisory Opinion, July 2007

Approve October, 1989
Reaffirmed October, 1996
Reaffirmed May, 2000
Revised May, 2008
Reaffirmed December 2012

Top of Page

 

Intra-Uterine Pressure Catheters

This Nebraska Board of Nursing advisory opinion is issued in accordance with PDF File Neb. Rev. Stat. 38-2216(2). As such, this advisory opinion is for informational purposes only and is non-binding.

It is the opinion of the Nebraska Board of Nursing that it is acceptable practice for registered nurses to insert the various intrauterine pressure devices. Such nurses should have knowledge of anatomy and physiology of the pregnant uterus, and of the potential complications of the various devices.

The decision to insert intrauterine pressure devices should be based upon self-assessment of competency, and following an assessment of the client and environment. A licensed nurse is accountable to be competent for all nursing care that he/she provides. Competence means the ability of the nurse to apply interpersonal, technical and decision-making skills at the level of knowledge consistent with the prevailing standard for the nursing activity being applied. Accountability also includes acknowledgment of personal limitations in knowledge and skills, and communicating the need for specialized instruction prior to providing any nursing activity.

Adopted October, 1988
Reaffirmed April, 1996
Reaffirmed May 2000
Reaffirmed Feb 2013

Top of Page

 

LPN and Gynecological Services

This Nebraska Board of Nursing advisory opinion is issued in accordance with PDF File Neb. Rev. Stat. 38-2216(2). As such, this advisory opinion is for informational purposes only and is non-binding.

It is the opinion of the Board of Nursing that it is appropriate practice for LPNs practicing in the area of Women’s Health to take a gynecological health history, obtain pap smears, and perform screening pelvic examinations under the direction of a registered nurse or licensed practitioner. It is expected that the LPN recognize abnormal findings and seek additional direction as appropriate.

The decision to provide gynecological services by an LPN should be based upon self-assessment of competence, and following an assessment of the client and environment. A licensed nurse is accountable to be competent for all nursing care that he/she provides. Competence means the ability of the nurse to apply interpersonal, technical and decision-making skills at the level of knowledge consistent with the prevailing standard for the nursing activity being applied. Accountability also includes acknowledgment of personal limitations in knowledge and skills, and communicating the need for specialized instruction prior to providing any nursing activity.

Adopted January, 1986
Updated August, 1996
Reaffirmed May 2000

Top of Page

 

LPN and Laboring Obstetrical Patients

This Nebraska Board of Nursing advisory opinion is issued in accordance with PDF File Neb. Rev. Stat. 38-2216(2). As such, this advisory opinion is for informational purposes only and is non-binding.

PDF File Title 172 Chapter 99 Regulations Governing the Provision of Client Care, PDF File Section 003 define the LPN’s responsibilities within the framework of the nursing process while under the direction of a RN or licensed practitioner. As identified in those regulations and within the realm of nursing needs related to the laboring obstetrical patient, the following appropriate LPN activity is identified:

Assessing: LPNs may collect basic objective and subjective data from observations, examinations, interviews and written records. The scope and depth of data collection must be consistent with the educational preparation and experience of the LPN. Objective data includes that related to physical status.

Nursing LPNs are accountable to identify signs and symptoms of deviations Diagnosis from normal health status.

Planning: LPNs participate in planning by providing data and determining priorities; further, LPNs assist in identification of measures to maintain comfort and support human function and response.

Implementing: LPNs provide care for clients whose conditions are stabilized and/or predictable. Under direct supervision of the RN (or in some situations, the licensed practitioner) LPNs assist with interventions whose conditions are not stable and/or predictable.

Evaluating: LPNs contribute to the evaluation of client response to nursing interventions.

It is the opinion of the Board of Nursing that LPNs may utilize subjective client data along with observation and physical data to assist in identification of beginning labor, labor progression, and signs and symptoms of deviations from the normal progression of labor; included may be the performance of a vaginal examination. In the case of a laboring obstetrical patient, under the direct supervision of a RN or licensed practitioner, LPNs may participate in assessment of the laboring patient through the collection of data by observation and examination.

LPNs are accountable to immediately report to the directing RN or licensed practitioner any deviations from normal for the laboring patient. The RN or licensed practitioner directing the LPN is accountable to determine that the laboring obstetrical patient status is predictable and therefore, participation by the LPN in the nursing care is an appropriate assignment.

The decision by an LPN to participate in the care of a laboring patient should be based upon self-assessment of competency, and following assessment of the client and environment. A licensed nurse is accountable to be competent for all nursing care that he/she provides. Competence means the ability of the nurse to apply interpersonal, technical and decision-making skills at the level of knowledge consistent with the prevailing standard for the nursing activity being applied. Accountability also includes acknowledgment of personal limitations in knowledge and skills, and communicating the need for specialized instruction prior to providing any nursing activity.

Adopted January, 1997
Reaffirmed May 2000

Top of Page

 

LPNs and Respiratory Care

This Nebraska Board of Nursing advisory opinion is issued in accordance with PDF FileNeb. Rev. Stat. 38-2216(2). As such, this advisory opinion is for informational purposes only and is non-binding.

It is the opinion of the Board the it is acceptable practice for LPNs to provide chest percussion, aerosol treatment and IPPB therapy. Additionally, it is appropriate practice for LPNs to perform naso-pharyngeal and oral pharyngeal suctioning. LPN practice may include tracheal suctioning for purposes of maintaining an open airway; it is not appropriate practice for LPNs to provide bronchial tree suctioning.

LPNs may assist with ventilator care by making observations, and by recording and reporting such observations. It is not appropriate for LPNs to independently implement nursing actions based upon conclusions or assessments drawn from their observations, ie., make ventilator adjustments.

The decision for an LPN to provide respiratory care should be based upon self-assessment of competency, and following an assessment of the client and environment. A licensed nurse is accountable to be competent for all nursing care that he/she provides. Competence means the ability of the nurse to apply interpersonal, technical and decision-making skills at the level of knowledge consistent with the prevailing standard for the nursing activity being applied. Accountability also includes acknowledgment of personal limitations in knowledge and skills, and communicating the need for specialized instruction prior to providing any nursing activity.

Approved January, 1988
Reaffirmed April, 1996
Reaffirmed May 2000

Top of Page

 

Verbal and Telephone Orders

There is nothing in the Nurse Practice Act, nursing regulations, or Board opinion that restricts or prohibits LPNs and other persons from taking and recording orders from licensed practitioners. Any restrictions on such practice are at the discretion of the organization.

Top of Page

 

HHS R & L Position Statement
Obtaining Blood Specimens

PDF File Nebraska Revised Statutes 71-1,103 of the Statutes Pertaining to the Practice of Medicine and Surgery identify who shall not be construed to be engaged in the unauthorized practice of medicine. Included is:

(18) Persons obtaining blood specimens while working under an order of or protocols and procedures approved by a physician, registered nurse, or other independent health care practitioner licensed to practice by the state if the scope of practice of that practitioner permits the practitioner to obtain blood specimens; and

(19) Any other trained person employed by a licensed health care facility or health care service defined in the Health Care Facility Licensure Act or clinical laboratory certified pursuant to the federal Clinical Laboratories Improvement Act of 1967, as amended, or Title XVIII or XIX of the federal Social Security Act to withdraw human blood for scientific or medical purposes.

Based upon the above, it is the responsibility of the physician, registered nurse, or other independent health care practitioner... to establish protocols defining who may obtain specimens including qualifications, defining what particular specimens may be obtained, and defining the methods and procedures to be used to obtain specimens. There are no specific limitations defined in statute; therefore, limits to the protocol would be as defined by the licensed person and should be congruent with prevailing professional standards.

Top of Page

 

Peripherally Inserted Central Catheters (PICC)

This Nebraska Board of Nursing advisory opinion is issued in accordance with PDF File Neb. Rev. Stat. 38-2216(2).  As such, this advisory opinion is for informational purposes only and is non-binding.

It is the opinion of the Nebraska Board of Nursing that it is acceptable practice for RNs to insert Peripherally Inserted Central Catheters (PICC).

The use of ultrasound is a non-invasive procedure that should improve the outcome for the placement of PICC lines. The Board of Nursing also supports the use of ultrasound for this procedure based on demonstrated competency and utilization of manufacturer’s guidelines for the procedure.

A decision to insert a PICC should be based upon self-assessment of competency, and following an assessment of the client and environment.

A licensed nurse is accountable to be competent for all nursing care that he/she provides. Competence means the ability of the nurse to apply interpersonal, technical and decision-making skills at the level of knowledge consistent with the prevailing standard for the nursing activity being applied. Accountability also includes acknowledgment of personal limitations in knowledge and skills, and communicating the need for specialized instruction prior to providing any nursing activity.

Approved January, 1989
Reaffirmed January, 1996
Reaffirmed May 2000
Revised July 2005

Top of Page

 

Pronouncement of Death

The statutes of the State of Nebraska are silent upon the specific issue of pronouncement of death. There is no Nebraska statute that states that only a physician may pronounce a person dead.

PDF File Nebr. Rev. Stat. 71-605 requires that the physician shall have the responsibility and duty to complete and sign in his or her own handwriting, within twenty-four hours, the death certificate. The law also requires that if a physician was not in attendance, the funeral director shall refer the case to the county attorney for a death certificate.

Because the statutes are silent on the issue of "pronouncement of death", there is no specific state requirement for such a specific declaration and it is unclear as to the exact meaning of pronouncement of death. It is acceptable for a nurse, including the LPN, to recognize and record that vital signs are absent, respirations ceased etc. An Attorney General opinion dated May 25, 1984 identifies that the certification of the cause of death on a death certificate of a person dying in a nursing home, who has been under the care or charge of a particular physician, may be signed by that physician even though that physician was not physically present at the time the person died. Notification of the physician that life has ceased could appropriately be done by a RN or LPN.

Top of Page

 

Accountability for Professional Conduct of Nurses

Professional Conduct for nurses is nursing behavior (acts, decisions and practices) which through professional experience, have become established by the consensus of the expert opinion of practicing nurses as conduct which is reasonably necessary for the protection of the public interest. Nursing behaviors that reflect professional conduct include the following:

Provision of nursing care with respect for human dignity and the uniqueness of the patient unrestricted by considerations of social or economic status, personal attributes, or the nature of the health problems. Respect is demonstrated by ensuring that patient welfare prevails, and empowerment of patients to participate in health care decisions and outcomes. Nurses should:

  1. Consider patient decisions regarding treatment. Patient self-determination requires that patients be given accurate and all necessary information; be assisted with determination of options; be able to accept, refuse, or terminate treatment without coercion; and be given emotional support.
  2. Understand, consider, and respect individual patient attributes in tailoring care to personal needs and in maintaining the individual's self-respect and dignity.
  3. Provide nursing care irrespective of the nature of the health problem. If ethically opposed to treatment methods, the nurse should make any refusal to participate in care known in advance and in time for other appropriate arrangements to be made.
  4. Provide an environment for nursing care in which the behavior, language, gestures, acts and/or communication styles between health care providers and between health care providers and patients is indicative of mutual respect and consideration, non-offensive, and respectful of individual patient attributes.
  5. Establish and maintain boundaries for the expected and accepted psychological and social distance in the nurse/patient relationship to allow the patient to build trust and the nurse to build credibility. Maintaining boundaries provides for a balance between patient vulnerability and influence of the nurse who possesses special knowledge, expertise and authority.

Safeguarding the patient's right of privacy and confidentiality

  1. By protecting the patients right to personal privacy to the reasonable extent desired.
  1. Provide private space for visitation or meetings with whomever the patient wishes to be private, including full visual privacy;
  2. Provide auditory privacy and privacy for telephone communication; and
  3. Provide nursing care and personal hygiene in a manner that maintains the privacy of the patient's body.

  1. By judiciously protecting information of a confidential nature.

  1. Sharing relevant data and with members of the health care team. Only information pertinent to a patient's treatment and welfare should be disclosed. Such disclosure should be made only to those directly concerned with the patient's care.

  2. Sharing information necessary for peer review, third-party payment, and other quality assurance mechanisms only when disclosed under defined policies, mandates, or protocols which assure that the rights, well-being, and safety of the patient are maintained.

Safeguarding the patient and the public when health care and safety are affected by incompetent, unethical, or illegal practice by any person. Safeguarding behaviors include:

  1. Reporting within organizational structures and according to the policies and procedures of the organization, concerns regarding questionable practice of any health care team member and the potential detrimental effect such practice may have upon patient welfare.
  2. Reporting those things required by law:
  1. To the Department any first hand knowledge of practice by another licensed nurse indicating gross incompetence, pattern of negligent conduct, unprofessional conduct, practice while impaired by alcohol/drugs or physical, mental, or emotional disability.
  2. To the Department any first hand knowledge of practice by another health care professional indicating gross incompetence and/or practice while impaired by alcohol/drugs or physical, mental, or emotional disability.
  3. To the Department of self if any of the following actions occur due to alleged incompetence, negligence, unethical or unprofessional conduct, or physical, mental, or chemical impairment:
  1. any loss of employment in lieu of termination;
  2. resignation; licensure denial;
  3. loss or voluntary limitation of privileges;
  4. loss of membership in a professional organization;
  5. adverse action pertaining to professional liability coverage;
  6. licensure discipline, settlement, voluntary surrender, or limitation in another State or jurisdiction; or
  7. conviction of felony or misdemeanor in this or any other State or jurisdiction.
  1. To the Department any first hand knowledge of practice of any licensed profession by a person without a license to practice that profession.
  2. To the appropriate authorities if reasonable cause exists to believe that a vulnerable adult has been subjected to abuse or conditions or circumstances that would result in abuse in accordance with PDF File Neb. Rev. Stat. 28-372.
  3. To the appropriate authorities if reasonable cause exists to believe that a child has been subjected to abuse or neglect or observes a child being subjected to conditions or circumstances which reasonably would result in abuse or neglect in accordance with PDF File Neb. Rev. Stat. 28-711.
  1. Providing an environment for nursing care in which the behavior, acts, and communication style promotes a sense of safety and security for patients and free from creating a threatening and/or assaultive atmosphere.

Assuming responsibility and accountability for individual actions, practice, and decisions at the level for which the nurse is licensed by critically reviewing self, knowing what he/she needs to know, knowing what he/she does not know, recognizing when it matters to know, and seeking appropriate assistance, supervision and/or counsel. Neither physician’s orders nor agency policies relieve the nurse of accountability for actions taken and judgments made. The nurse demonstrates responsibility by:

  1. Applying the nursing process to all patients in a manner that recognizes patient rights, the collaborative relationship between the nurse and the patient, and assists the patient in maximizing his or her health capabilities and participating in the evaluation of the effectiveness of the nursing care.
  2. Knowing the legal, ethical, and prevailing accepted parameters of practice;
  3. Acknowledging himself/herself in behaviors, actions and decisions, and learning to build on the positive experience or learning from the negative experiences;
  4. Differentiating between positive and negative accountability; positive accountability is triggered by concerns for patient and negative accountability is triggered by fear for reputation and self;
  5. Acknowledging when a decision or action has not been in the best interest of a patient while taking corrective action in the patient's behalf.
  6. Being open to receiving other perceptions, new knowledge, and feedback;
  7. Identifying his/her role within the community of the group as evidenced by communicating information to appropriate health team members;
  8. Recognizing that he/she is not the only accountable member of the health care team, and trusts appropriately including consulting with other nurses and other health care team members;
  9. Advocating for patients;
  10. Intervening as a response to an unexpected outcome;
  11. If a RN, recognize individual responsibility and accountability to delegate in a manner that protects public health, welfare and safety by assessing patient(s) and resources, developing a delegation plan, implementing the delegation plan including the provision of direction and supervision, and evaluating the delegation plan;
  12. If a LPN, practice nursing only under circumstances in which direction is provided by a RN or licensed practitioner;
  13. When supervising, provide oversight to assure whether nursing care is adequate and delivered appropriately, and assessing the competency of the care giver; and
  14. If a nursing manager, establishing policies and guidelines reflective of legal and prevailing accepted standards, and if a staff nurse, working within the identified parameters of agency policies and guidelines.

Demonstrating honesty and integrity as is reflected in the fundamental values needed by the nurse that permeates all aspects of nursing practice. Imperative to promoting nursing behaviors that encourage demonstration of honesty and integrity is creating an environment where admitting mistakes or errors of omission is seen as constructive, as an opportunity for systems improvement, as a method to identify potential educational/staff development needs, and as an opportunity to assist individuals to identify areas needing competency improvements. Expert and seasoned nurses should create an atmosphere that encourages novices or the inexperienced to seek consultation and collaboration with colleagues; seasoned nurses should role model professional behaviors.

The nurse demonstrates honesty and integrity in practice by:

  1. Documenting accurately, completely and in a timely manner;
  2. Presenting reports congruent with current patient condition (allowing for clinical instability);
  3. Having what is documented and reported by himself/herself correspond to what is observed by others;
  4. Respecting property and belonging of patients and agencies;
  5. Willingly participate and cooperate with organizations, with the department and other appropriate agencies seeking to determine whether health care standards and safety of patients may have been compromised;
  6. Admitting mistakes;
  7. Maintaining an active nursing license in good standing;
  8. Providing employers or prospective employers with accurate and complete information regarding qualifications, skills and abilities, and employment history; and
  9. Providing accurate and complete information in both oral and written communications connected with the practice of nursing.

Knowing and incorporating prevailing accepted standards into nursing practice at the level for which the nurse is licensed as reflected in the need for the nurse to achieve the necessary knowledge, skills and abilities, and make professional decisions based on that knowledge and the expectations delineated in the prevailing accepted standards. The nurse demonstrates knowledge and incorporation of prevailing accepted standards into practice by:

  1. Exhibiting behavior consistent with prevailing accepted standards; and
  2. Knowing limitations and understanding the framework provided by prevailing accepted standards.

Maintaining competency in nursing

  1. Elements of a professionally competent nurse are a specific knowledge base, awareness of and adherence to prevailing accepted practice standards, psychomotor skills, decision-making skills, communication skills, experience and attitude at the level for which the nurse is licensed. Each of these elements is essential in determining nurse competency:
  1. Knowledge base. The nurse must have a knowledge base of sufficient breadth and depth for safe and effective nursing practice, and which provides the nurse with the fundamental information necessary to make sound decisions. The knowledge base includes nursing, behavioral, and biological and physical sciences.
  2. Adherence to standards of practice including accepted prevailing standards of practice, specialty standards, institutional standards, as well as ethical codes and legal standards.
  3. Psychomotor skills. The nurse must have the psychomotor skills needed to collect information about a particular patient and to perform the interventions required for a particular nursing situation, and which along with a knowledge base enable the nurse to gather the information necessary to make nursing decisions about nursing problems and desired patient outcomes.
  4. Decision Making. The nurse must have the ability to process information prudently to determine a logical, deliberate and well-grounded conclusion. The information used must be accurate and collected appropriately. The outcome of decision-making is choosing the right action, at the right time, using the right resources.
  5. Communication is the ability to interact therapeutically and exchange accurate, appropriate, and timely information with patients, families and other health care professionals.
  6. Previous experience is an essential element of a nurse's knowledge base, skills and decision-making. Experience is the transference of learning from previous nursing situations where the nurse had direct observation and participation. Experience assists the nurse to make astute observations and judgments, learn new skills more quickly and process new information more easily.
  7. Professional attitude, which is the manner in which the nurse interacts and attaches to responsibility and the standards of behavior for the profession. It is also the integrity of the nurse to acknowledge personal limitations in knowledge and skills.
  1. Self-behaviors which reflect actions on behalf of the nurse to maintain continued competency include:
  1. Assessing self, using the Nurse Practice Act and prevailing accepted standards of practice as guides;
  2. Planning and initiating the necessary strategies to maintain and advance competence, and evaluating their effectiveness;
  3. Keeping abreast of current nursing literature and nursing research as appropriate to level of licensure; and
  4. D. Providing learning opportunities for others as appropriate for level of licensure.
  1. Demonstration of competency in practice is reflected by exercising informed judgment and use of individual competency and qualifications as criteria in providing nursing care, seeking consultation, accepting responsibilities, and assigning/delegating and supervision nursing activities to others who provide nursing care. Behaviors include:
  1. Applying knowledge and skills at the level for which the nurse is licensed and at the level required for a particular practice situation
  2. Applying the nursing process to all patients in accordance with N.A.C. PDF File 172 Chapter 99 Regulations Governing the Provision of Nursing Care, PDF File Section 003. The nurse must know what information is needed to make sound nursing judgments and how to gather that information. Nursing decisions are made regarding nursing interventions and outcomes that are appropriate to the particular patient situation. Nursing decisions are also made after an analysis of the effectiveness and efficiency of the interventions in relation to the desired outcome.
  3. Accepting only those assignments for which the nurse has the knowledge, skills and abilities, including all of the competency elements, to provide safe and appropriate care for patients. When making a decision to accept or refuse an assignment, the nurse should recognize his/her individual responsibility to perform a self assessment for any of the competency elements.
  1. Knowledge and experience in general nursing vs. specialty nursing varies greatly based upon education and background. A novice or generalist nurse may be able to perform parts of a specialty assignment, or a specialty nurse may be able to provide parts of an assignment in another specialty area or generalist area.
  2. Acknowledging that experience, education and background may also affect the nurse’s knowledge of the prevailing accepted standards for a specific assignment. The nurse may need to seek additional consultation, direction etc. as appropriate for the specific assignment.
  3. The nurse must consider affective abilities such as decision making and attitude when accepting assignments for which he/she would normally consider himself/herself competent but such assignment involves long shifts, double shifts, multiple jobs, unfamiliar environment etc.
  4. The nurse should give sufficient notice of intent to accept a partial assignment or refuse an assignment so as to allow for alternative arrangements to me made.
  1. Assigning nursing cares to others only under circumstances for which the nurse making the assignment has reason to believe the nurse accepting the assignment has the knowledge, skills and abilities, including all of the competency elements, to provide safe and appropriate care for patients. When making assignment decisions, the nurse should recognize his/her individual responsibility to assess the competency of the nurse expected to accept the assignment relative to the specific assignment request.
  1. Nursing service administrators should consider each of the competency elements when making assignment requests for nursing practice roles.
  2. Nursing service administrators must consider adequacy of available resources when requesting licensed nurses to accept assignments. Such resources should include consideration of human resources as well as support resources for nurses needing additional consultation, direction etc.
  3. Nursing service administrators and nursing managers must consider affective abilities such as decision making and attitude when requesting nurses to accept assignments for which he/she would normally consider the nurse to be competent but such assignment request involves long shifts, double shifts, multiple jobs, unfamiliar environments etc.
  1. Contributing accurate, complete and timely information that will assist the health care team to plan and provide comprehensive care to patients. The nurse must be aware of the services available to patients and obtain the services required or make the proper referrals.
  2. Asking for assistance appropriately and seeking consultation as warranted.
  3. Providing supervision, either as part of the delegation process or when assigned such responsibilities by his/her employer, in such a manner to assure the adequacy of nursing care and the competency of the care givers.
  4. If a registered nurse, delegating using a systematic delegation decision making process that allows for safe, accountable, and responsible provision of nursing care in congruence with NAC PDF File Title 172 Chapter 99 Regulations Governing the Provision of Nursing Care, PDF File Section 004.01.

Approved May 30, 1996
Reaffirmed May 2000

Top of Page

 

RN First Assistants

This Nebraska Board of Nursing advisory opinion is issued in accordance with PDF File Neb. Rev. Stat. 38-2216(2). As such, this advisory opinion is for informational purposes only and is non-binding.

The Nebraska Board of Nursing supports the AORN Official Statement on RN First Assistants. The board supports the Scope of Practice statement that includes the intraoperative nursing behaviors of a) handling tissue, b) providing exposure, c) using instruments, d) suturing, and e) providing hemostasis. The board also encourages the Qualifications of the RN First Assistant statement and Preparation For the RN First Assistant statement as one method for attaining competency to practice in the RN First Assistant role.

A licensed nurse is accountable to be competent for all nursing care that he/she provides. Competence means the ability of the nurse to apply interpersonal, technical and decision-making skills at the level of knowledge consistent with the prevailing standard for the nursing activity being applied. Accountability also includes acknowledgment of personal limitations in knowledge and skills, and communicating the need for specialized instruction prior to providing any nursing activity.

Approved January, 1989
Reaffirmed January, 1996
Reaffirmed 2000

Top of Page

Safety to Practice: Functional Ability

This Nebraska Board of Nursing advisory opinion is issued in accordance with PDF File Neb. Rev. Stat. 38-2216(2). As such, this advisory opinion is for informational purposes only and is non-binding.

Licensed nurses are accountable for assuring that their actions and behaviors meet all applicable standards at all times.  This requires constant awareness of the demands of the job and a continual process of evaluation and assessment in order to make sure that the nurse is fit to practice and competent to safely perform those functions that fall within the defined scope of nursing practice and for which the nurse has accepted responsibility.  Nurses who practice while not fit to do so, may be subject to disciplinary action. 

One essential element of safe nursing practice is a nurse’s functional ability:  the competence and reliability with which a nurse is able to practice at any given time.

The board is aware that nurses sometimes experience situations that may compromise their ability to safely practice for either the short or long term.   Some of these situations involve personal or job-related stress, sleep deprivation, mandatory overtime, extra shifts, the normal effects of aging, and episodic or persistent health conditions, some of which may require pain management or the use of maintenance-level prescribed medication. The list is not all-inclusive.

Whether a nurse should continue active nursing practice in these situations depends upon the nurse’s ability to function safely and effectively.   The assessment of functional ability is an individualized process that does not lend itself to application of a set format based on select elements.  Rather, assessment of functional ability requires active consideration of all relevant factors, such as diagnosis, prescribed treatment and situational events, as well as an evaluation of the impact of those factors on the individual being assessed.

Constant evaluation of one’s ability to safely and competently practice nursing is the responsibility of each individual nurse.  In some instances, it may be necessary for the board to require objective physical and/or functional assessment, using reliable psychometric instruments and methods administered by qualified licensed professionals in order to determine if any limitation of the nurse’s practice is needed to ensure public protection.  When evidence indicates that the nurse’s functional ability is impaired, action by the board may be warranted.

References:

Idaho Board of Nursing Position Statement: Position on Safety to Practice.
North Dakota Board of Nursing Position Statement: Safety to Practice.
American Nurses Association Position Statement: Registered Nurses Responsibility in All Roles and Settings to Guard Against Working When Fatigued, December 2006.
North Carolina Board of Nursing Position Statement: Extended Work Hours and Patient Safety.
Texas Board of Nursing Position Statement: Duty of a Nurse in any Practice Setting.

Adopted January 2008

Top of Page

 

Safety to Practice: Temporary Reassignments, Floating

This Nebraska Board of Nursing advisory opinion is issued in accordance with PDF File Neb. Rev. Stat. 38-2216(2). As such, this advisory opinion is for informational purposes only and is non-binding.  

Licensed nurses are accountable for the care they provide and must have the appropriate knowledge and skills before accepting assignments or responsibilities.  The Nebraska Nurse Practice Act states each nurse is directly accountable and responsible to the patient/client for the quality of nursing care rendered.  Accepting an assignment and providing care without the appropriate knowledge and skills places both the recipient of the care and the licensed nurse in jeopardy.

It is the nurse’s responsibility to determine whether she/he is clinically competent to perform the nursing care required on a new unit or with a new patient population. If the nurse is not clinically competent to perform the care, she/he should not accept the patient care assignment. The nurse may accept a limited assignment of nursing care duties, which utilizes his/her currently existing clinical competence.   The nurse’s license may be subject to discipline for accepting an assignment for which he/she is not competent to safely perform the intervention required by the assignment.

Nursing administrators, supervisors, and managers are responsible to assure appropriate and competent nursing care to patients/clients. Nursing administrators, supervisors, and managers are required to assign patient care only to nurses who are clinically competent. Nursing administrators, supervisors and managers are subject to discipline if they do not ensure assignment of clinically competent nursing staff. 

The Board of Nursing encourages employers to take steps to provide adequate orientation and cross-training before reassigning licensed nurses to areas outside of their usual work assignment.  Such orientation and cross-training must occur prior to the expected reassignment.  If census problems require that nurses “float” to unfamiliar clinical settings, the nurse should be assigned to work with another licensed nurse who has the requisite knowledge and skills to provide the specialized care.

References:

North Dakota Board of Nursing Practice Statement: Temporary Reassignments.
California RN Board of Nursing Position Statement: RN Responsibility When Floating to a New Patient Care Unit or Assigned to a New Patient Population.
Wyoming Board of Nursing Advisory Opinion: Refusing Patient Care Assignments.
Texas Board of Nursing Position Statement: The Duty of a Nurse in Any Practice Setting.
American Nurses Association Position Statement: The Right to Accept or Reject an Assignment, July 1995.

Adopted January 2008

Top of Page

 

This Nebraska Board of Nursing advisory opinion is issued in accordance with PDF File Neb. Rev. Stat. 38-2216(2).  As such, this advisory opinion is for informational purposes only and is non-binding.   

It is the opinion of the Nebraska Board of Nursing that it is acceptable practice for licensed nurses to replace gastrostomy tubes, jejunostomy tubes and suprapubic catheters for those clients whose stoma conditions are stable and well established.  LPNs must do so under the direction of a licensed practitioner or RN.

The decision to provide tube replacement should be based upon self-assessment of competency, and following an assessment of the client and environment.   A licensed nurse is accountable to be competent for all nursing care that he/she provides. Competence means the ability of the nurse to apply interpersonal, technical and decision-making skills at the level of knowledge consistent with the prevailing standard for the nursing activity being applied.  Accountability also includes acknowledgment of  personal limitations in knowledge and skills, and  communicating the need for specialized instruction prior to providing any nursing activity.

Approve October, 1988
Reaffirmed January, 1999
Reaffirmed May 2000
Reaffirmed July 2005

Top of Page

Standing Orders & Protocols

This Nebraska Board of Nursing advisory opinion is issued in accordance with  Nebraska Revised Statute 38-2216 (2). As such, this advisory opinion is for informational purposes only and is non-binding.

The practice of nursing is defined in the Nebraska Nurse Practice Act: “Practice of nursing means the performance for compensation or gratuitously of any act expressing judgment or skill based upon a systematized body of nursing knowledge. Such acts include the identification of and intervention in actual or potential health problems of individuals, families, or groups, which acts are directed toward maintaining health status, preventing illness, injury, or infirmity, improving health status, and providing care supportive to or restorative of life and well-being through nursing assessment and through the execution of nursing care and of diagnostic or therapeutic regimens prescribed by any person lawfully authorized to prescribe. Each nurse is directly accountable and responsible to the consumer for the quality of nursing care rendered. Licensed nurses may use the services of unlicensed individuals to provide assistance with personal care and activities of daily living”. Neb. Rev. Stat. 38-2210

The scope of practice for both the RN and LPN does not include making a medical diagnosis or prescribing medical treatments or medications.  The RN and LPN practice does include the execution of diagnostic or therapeutic regimens ordered by a licensed practitioner, defined in the act as “a person lawfully authorized to prescribe medications or treatments.” Neb. Rev. Stat. 38-2209  An RN may only make a nursing assessment, nursing diagnosis and implement nursing interventions.  The LPN may contribute to the nursing assessment, nursing diagnosis, and may implement nursing interventions.  A nurse may not practice under standing orders or protocols that require the nurse to make medical judgments outside the nurse’s scope of practice.  The Nurse Practice Act confers no authority to practice medicine or surgery. Neb. Rev. Stat. 38-2218
Standing orders: means medical treatment orders generated by a licensed practitioner who identifies an action or medication that must be implemented or administered. The use of standing orders must be documented as an order in the patient’s medical record and signed by the licensed practitioner responsible for the care of the patient, but the timing of such documentation should not be a barrier to effective emergency response, timely and necessary care, or other patient safety advances.
 
While there is significant merit to the use of standing orders, there is also the potential for harm to patients if agencies use such orders so nurses are routinely expected to make clinical decisions outside their scope of practice. This is a complex issue that requires careful consideration by agencies, physicians, nurses and other licensed health care professionals, experts in patient safety and quality improvement, and patients.
 
Standing orders should be clearly written to include the signs and symptoms, rather than a medical diagnosis and should include parameters for the nurse to refer and consult with the licensed practitioner. They should include the parameters under which the nurse may act in specified situations and outline the assessment, testing, and treatment a nurse may perform on behalf of the licensed practitioner.  The standing orders must be in writing, dated and signed by the medical director or licensed practitioner, and reviewed and updated periodically.
 
Protocol: means a series of actions (which may include a number of medications) that may be implemented to manage a patient’s clinical status. A protocol allows the application of specific interventions to be decided by the nurse based on the patient meeting certain criteria outlined in the protocol as long as the intervention is within the scope of practice of the nurse. A protocol includes alternative actions or “exceptions” to the prescriptive orders which allow for individual patient circumstance as assessed by the nurse. These “exceptions” are addressed by application of an algorithm that is a step-by-step procedure for solving a problem or accomplishing the intervention. An agency may, if it chooses, have protocols which are developed by licensed practitioners and are designed to standardize and optimize patient care in accordance with current clinical guidelines or standards of practice.
 
Registered nurses may implement a protocol issued by a licensed practitioner for a specific group of patients when a patient meets the criteria for initiating the protocol.  Protocols may include both independent nursing activities and nursing activities requiring a health care provider order and collaboration.  Nursing protocols should include the following content:
          1. Title
          2. Definition or Purpose
          3. Specific population to whom the protocol applies
          4. Assessment data to be obtained
          5. Collaboration parameters when appropriate
          6. Interventions to be implemented
          7. Anticipated outcome
          8. Signature of the licensed authorized prescriber who authorized implementation of the guideline
The nurse is responsible for documenting the implementation of the protocol and the nursing care provided under the protocol.
 
Preprinted order set: refers to a tool generally designed to assist licensed practitioners as they write orders. Order sets may include computerized programs that are the functional equivalent of hard copy preprinted order sets. Such tools may include a menu of medications or actions from which the authorized prescriber makes selections to be applied to a particular patient. They sometimes include a standard combination of medications and actions to be followed without amendment whenever the practitioner selects that order. All orders, preprinted or otherwise, in the medical record must be dated, timed, and authenticated by the person responsible for providing or evaluating the service provided.

A licensed nurse is accountable to be competent for all nursing care that he/she provides.  Competence means the ability of the nurse to apply interpersonal, technical and decision-making skills at the level of knowledge consistent with the prevailing standard for the nursing activity being applied. Accountability also includes acknowledgment of personal limitations in in knowledge and skills, and communicating the need for specialized instruction prior to providing any nursing activity.

Adopted Dec. 2012
References
DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
Memorandum, October 24, 2008
Nevada BON Advisory Opinion
Update:  In June 2004, the Board approved revisions to Advisory Opinion Statement #14
Alabama Board of Nursing
Kentucky BON Roles of Nurses in the Implementation of Patient Care Orders [PDF Format - 35k] to include information on the use of protocols and standing/routine orders.   KY
New Hampshire BON Clinical Care Guidelines
Alabama 610-X-6-.09 Patient Care Orders History: Filed March 20, 2003. Effective April 24, 2003.
North Carolina BON Advisory Opinion
Agency for health Care Policy and Research
Ohio Joint Regulatory Statement, 2003
North Dakota Board of Nursing practice statements
 

Suturing

This Nebraska Board of Nursing advisory opinion is issued in accordance with  Nebraska Revised Statute 38-2216 (2). As such, this advisory opinion is for informational purposes only and is non-binding.
 
The performance of simple stapling, suturing or application of tissue adhesive for anchoring catheter devices or superficial wound closure is within the scope of the licensed registered nurse.  The RN performing simple suturing should be properly trained and possesses the required knowledge, skill and competence.  The wound must be evaluated by a licensed practitioner and should consist of subcutaneous tissue only.  NO muscle, nerve, tendon, or blood vessels should be sutured by the RN unless the RN meets the definition and competency of a Registered Nurse First Assist (RNFA).
  
A licensed nurse is accountable to be competent for all nursing care that he/she provides. Competence means the ability of the nurse to apply interpersonal, technical and decision-making skills at the level of knowledge consistent with the prevailing standard for the nursing activity being applied. Accountability also includes acknowledgment of personal limitations in knowledge and skills, and communicating the need for specialized instruction prior to providing any nursing activity.
 
Arkansas Board of Nursing (2001). The Performance of Stapling, Suturing, or Application of Tissue Adhesive, for Superficial Wound Closure by Nurses in the Operating Room. Position Statement. Retrieved from http://www.arsbn.arkansas.gov/lawsRules/Documents/97_1.pdf.

Maine State Board of Nursing (n.d.) Suturing Practice Questions Related to the Registered Professional Nurse.  Retrieved from: http://www.maine.gov/boardofnursing/questions/questions_rn.html#sutures
New Hampshire Board of Nursing (n.d.) Lidocaine and Suturing. Clinical Practice Questions.  Retrieved from: http://www.nh.gov/nursing/faq/lidocaine-liposuction.htm

Clark, A. (2004). Understanding the Principles of Suturing Minor Skin Lesions. Nursing Times.net Retrieved from: http://www.nursingtimes.net/nursing-practice/clinical-zones/dermatology/understanding-the-principles-of-suturing-minor-skin-lesions/204195.article

Bonadio, W.A., Carney, M., & Gustafson, D. (1994). Efficacy of Nurses Suturing Pediatric Dermal Lacerations in an Emergency Department [Abstract]. Annals of Emergency Medicine, 24(6), 1144-1146.
 

Umbilical Catheters

This Nebraska Board of Nursing advisory opinion is issued in accordance with PDF File Neb. Rev. Stat. 38-2216(2). As such, this advisory opinion is for informational purposes only and is non-binding.

It is the opinion of the Board that placement of umbilical catheter lines is not appropriate practice for the registered nurse. In an emergency situation and the unavailability of a qualified licensed practitioner, it is appropriate for the RN to perform any procedure which may be considered a life-saving measure until a qualified practitioner is available

It is also the opinion of the Board that removal of umbilical catheters by registered nurses is acceptable practice. Competency is a critical component. Such decisions should be based upon experience, education, frequency of exposure, the environment and any other applicable considerations.

A licensed nurse is accountable to be competent for all nursing care that he/she provides. Competence means the ability of the nurse to apply interpersonal, technical and decision-making skills at the level of knowledge consistent with the prevailing standard for the nursing activity being applied. Accountability also includes acknowledgment of personal limitations in knowledge and skills, and communicating the need for specialized instruction prior to providing any nursing activity.

Approved April 1989
Reaffirmed April, 1996
Reaffirmed March 2000

Top of Page

 

Unna Boot

This Nebraska Board of Nursing advisory opinion is issued in accordance with PDF File Neb. Rev. Stat. 38-2216(2). As such, this advisory opinion is for informational purposes only and is non-binding.

It is the opinion of the Nebraska Board of Nursing that it is acceptable practice for licensed nurses to apply Unna Boots based upon a physician prescription. LPNs may apply Unna Boots only after having received advanced specialized training. The registered nurse or licensed practitioner remains accountable for assessment whenever the LPN is providing such care.

The decision to apply an Unna Boot should be based upon self-assessment of competency, and following an assessment of the client and environment. A licensed nurse is accountable to be competent for all nursing care that he/she provides. Competence means the ability of the nurse to apply interpersonal, technical and decision-making skills at the level of knowledge consistent with the prevailing standard for the nursing activity being applied. Accountability also includes acknowledgment of personal limitations in knowledge and skills, and communicating the need for specialized instruction prior to providing any nursing activity.

Approved October, 1989
Reaffirmed January, 1996
Reaffirmed May 2000

Top of Page


Wound Debridement

This Nebraska Board of Nursing advisory opinion is issued in accordance with PDF File Neb. Rev. Stat. 38-2216(2). As such, this advisory opinion is for informational purposes only and is non-binding.

As reference, the Board of Nursing has used the Pressure Ulcer Treatment: Quick Reference Guide for Clinicians and Treatment of Pressure Ulcers: Clinical Practice Guideline published by the U.S. Department of Health and Human Services, Agency for Health Care Policy and Research (1994), publication numbers 95-0653 and 95-0652 respectively.

The Board accepts the following definitions of wounds:

Stage I: Non-blanchable erythema of intact skin, the heralding lesions of skin ulceration. In individuals with darker skin, discoloration of the skin, warmth, edema, induration, or hardness may also be indicators.

Stage II: Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.

Stage III: Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.

Stage IV: Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, join capsule). Undermining and sinus tracts also may be associated with Stage IV pressure ulcers.

Sharp, mechanical, enzymatic, and/or autolytic debridement techniques may be used for devitalized tissue. It is appropriate practice for the RN and LPN to apply any of the techniques providing the nurse has the necessary clinical skills. LPNs may provide sharp debridement only under direct supervision of a registered nurse or licensed practitioner. The registered nurse or licensed practitioner remains accountable for wound assessment whenever the LPN is providing debridement techniques. Extensive Stage IV wounds require debridement by a surgeon or other qualified provider.

The decision to provide wound debridement should be based upon self-assessment of competency, and following an assessment of client and environment. A licensed nurse is accountable to be competent for all nursing care that he/she provides. Competence means the ability of the nurse to apply interpersonal, technical and decision-making skills at the level of knowledge consistent with the prevailing standard for the nursing activity being applied. Accountability also includes acknowledgment of personal limitations in knowledge and skills, and communicating the need for specialized instruction prior to providing any nursing activity.

Adopted January, 1985
Updated January, 1996
Reaffirmed May 2000

Top of Page

 

Wound Drains

This Nebraska Board of Nursing advisory opinion is issued in accordance with PDF File Neb. Rev. Stat. 38-2216(2). As such, this advisory opinion is for informational purposes only and is non-binding.

It is the opinion of the Nebraska Board of Nursing that removal of wound drains is acceptable practice for licensed nurses.

The decision to remove a drain should be based upon self-assessment of competency, and following an assessment of the client and environment. A licensed nurse is accountable to be competent for all nursing care that he/she provides. Competence means the ability of the nurse to apply interpersonal, technical and decision-making skills at the level of knowledge consistent with the prevailing standard for the nursing activity being applied. Accountability also includes acknowledgment of personal limitations in knowledge and skills, and communicating the need for specialized instruction prior to providing any nursing activity.

Adopted January, 1985
Updated January, 1996
Reaffirmed May 2000

Top of Page

 

OB Patients Receiving Analgesia-Anesthesia by Catheter

The Nebraska Board of Nursing supports the following Clinical Position Statement from the Association of Women’s Health, Obstetric and Neonatal Nurses ( AWHONN).

The Role of the Registered Nurse (RN) in the Care of Pregnant Women Receiving Analgesia/Anesthesia by Catheter Techniques (Epidural, Intrathecal, Spinal, PCEA Catheters).

Registered nurses who are not licensed anesthesia care providers should monitor, not manage, the care of pregnant patients receiving analgesia/anesthesia by catheter techniques. Safe anesthesia administration is a complex and specialized practice that relies on the education, experience, competence and attentiveness of those responsible for its initiation and management. The requisite education and clinical skill acquisition necessary to provide safe management of regional analgesia/anesthesia for the pregnant woman are not included in basic education programs for entry into practice as a registered nurse; therefore such analgesia/anesthesia management should be reserved exclusively for licensed, credentialed anesthesia care providers. Whenever regional analgesia/anesthesia is administered, a qualified, credentialed, licensed anesthesia care provider should be readily available as defined by institutional policy.

Only qualified, credentialed, licensed anesthesia care providers as described by the American Society of Anesthesiologists and the American Association of Nurse Anesthetists, and/or as authorized by state law should perform the following procedures:

  • Insertion, initial injection, bolus injection, rebolus injection or initiation of a continuous infusion of catheters for analgesia/anesthesia
  • Verification of correct catheter placement
  • Increasing or decreasing the rate of the continuous infusion

Following stabilization of vital signs after either initial insertion, initial injection, bolus injection, rebolus injection, or initiation of continuous infusion by a licensed, credentialed anesthesia care provider, non-anesthetist registered nurses, in communication with the obstetric and anesthesia care providers, may:

  • Monitor the patient's vital signs, mobility, level of consciousness, and perception of pain
  • Monitor the status of the fetus
  • Replace empty infusion syringes or infusion bags with new, pre-prepared solutions containing the same medication and concentration, according to standing orders provided by the anesthesia care provider
  • Stop the continuous infusion if there is a safety concern or the woman has given birth
  • Remove the catheter, if educational criteria have been met and institutional policy and law allow. Removal of the catheter by a RN is contingent upon receipt of a specific order from a qualified anesthesia or physician provider.
  • Initiate emergency therapeutic measures according to institutional policy and/or protocol if complications arise

Nonanesthetist registered nurses should not:

  • Rebolus an epidural either by injecting medication into the catheter or increasing the rate of a continuous infusion
  • Increase/decrease the rate of a continuous infusion
  • Re-initiate an infusion once it has been stopped
  • Manipulate PCEA doses or dosage intervals
  • Be responsible for obtaining informed consent for analgesia/anesthesia procedures; however, the nurse may witness the patient signature for informed consent prior to analgesia/anesthesia administration.

The non-anesthetist registered nurse, as a member of the multi-disciplinary health care team monitoring the pregnant woman receiving analgesia/anesthesia by catheter techniques, should communicate any nursing assessments or changes in patient status to the obstetric and anesthesia care providers as indicated by institutional policy.

Background: In order to protect the well being of all patients; in this case, the mother-baby dyad, there should ideally be a substantial and compelling amount of clinical evidence before any changes in practice recommendations are made. AWHONN maintains that there is no such body of research or evidence available to support the management of regional labor analgesia by non-anesthetist registered nurses as a safe practice.

Physiologic and anatomic changes of pregnancy increase the risk of regional analgesia/anesthesia complications. Pregnant women are especially susceptible to cardiovascular and central nervous system disturbances as a result of local anesthetics. Analgesia/anesthesia complications not only impact the mother, but the fetus as well. The fetus is dependent on maternal physiology and can suffer the effects of maternal physiologic changes first. Fetal effects may be significant with only minimal maternal compromise. Clinicians responsible for managing regional labor analgesia/anesthesia must be prepared to handle both patients' complications, some of which may be life-threatening. Qualified, credentialed, licensed anesthesia care providers are trained to manage all anesthesia-related complications; non-anesthetist registered nurses are not.

Patients receiving regional analgesia/anesthesia should have a specific pain management plan developed in consultation with an anesthesia care provider. This plan is ongoing and dependent on thorough assessments of the appropriateness of regional analgesia/anesthesia. These assessments, based on a patient's medical history, physiologic condition, and her desire for pain management options, determine the optimal type and amount of medication to use in each individual circumstance. A multitude of anesthetic medications are used during labor and birth, each with specific indications, possible side effects, and potential adverse reactions. Because of the complexity of providing regional analgesia/anesthesia, only professionals specifically trained in anesthesia administration and management should alter the course of a patient's regional analgesia/anesthesia in any way, including rebolusing a catheter or changing the rate of a continuous infusion. AWHONN maintains that these responsibilities are outside the proper scope of practice for non-anesthetist registered nurses.

AWHONN recognizes that providing continuously available analgesia/anesthesia care to laboring patients can be a challenge for some institutions. AWHONN supports the increased use of certified registered nurse anesthetists (CRNAs) to meet this challenge. CRNAs provide safe and effective anesthesia services for millions of patients each year. They are already the sole anesthesia providers in more than 65% of rural hospitals in the United States1. CRNAs have the professional education and specialty training needed to manage the care of the patient receiving analgesia/anesthesia by catheter techniques.

This statement reflects AWHONN's position on optimal conditions for promoting the health of women and newborns. The statement was developed in conjunction with AWHONN's new Evidence-based Clinical Practice Guideline: Nursing Care of the Woman Receiving Analgesia/Anesthesia in Labor (2001).

1American Association of Nurse Anesthetists. Nurse Anesthesia in Rural Hospitals: a fact sheet on sole anesthesia providers. 1997.

A licensed nurse is accountable to be competent for all nursing care that s/he provides. Competence means the ability of the nurse to apply interpersonal, technical and decision-making skills at the level of knowledge consistent with the prevailing standard for the nursing activity being applied. Accountability also includes acknowledgment of personal limitations in knowledge and skills, and communicating the need for specialized instruction prior to providing any nursing activity.

Approved March 2004

Top of Page


Use of Dermabond® and Other Topical Skin Adhesives

This Nebraska Board of Nursing advisory opinion is issued in accordance with PDF File Neb. Rev. Stat. 38-2216(2).  As such, this advisory opinion is for informational purposes only and is non-binding.

Topical Skin Adhesives such as Dermabond® and similar products, can be applied by the RN with a physician order, following manufacturer’s indications and instructions for use and with demonstrated competencies specific to use.  A licensed nurse is accountable to be competent for all nursing care that s/he provides.  Competence means the ability of the nurse to apply interpersonal, technical and decision-making skills at the level of knowledge consistent with the prevailing standard for the nursing activity being applied.  Accountability also includes acknowledgement of personal limitations in knowledge and skills, and communicating the need for specialized instruction prior to providing any nursing activity. 

Approved July 2005

 

Top of Page

RN and EMTALA Medical Screening Exam (MSE)

The Center for Medicare/Medicaid Services (CMS) Emergency Medical Treatment and Labor Act (EMTALA) rules II.A state, "Medical screening exams (MSE) must be conducted by qualified personnel, which may include physicians, nurse practitioners, physician assistants or RNs trained to perform MSEs and acting within the scope of their State Practice Act."  

It is the opinion of the Nebraska Board of Nursing that it is within the scope of an RN to perform a medical screening exam (MSE).   The RN may perform an MSE if:
  1.  allowed by individual facility bylaw/policy

  2.  the facility has approved protocols or algorithms for the RN to utilize in performing the MSE
  3.  an authorized provider is available for consultation
  4.  the individual RN has the necessary knowledge, skills and abilities and has demonstrated
       competency to perform the MSE
 

It also is the Board’s position that the RN completing the MSE is establishing the presence or absence of an emergency medical condition, and is not engaged in making an independent medical diagnosis or developing a medical treatment plan.  

It is not within the scope of an LPN to perform an MSE however the LPN may contribute to the assessment by “Collecting basic objective and subjective data from observations, examinations, interviews, and written records. The scope and depth of data collection is consistent with the educational preparation of the LPN”. (172 NAC 99.003) 

The scope of practice for a licensed nurse is the same regardless of practice setting.   The role of the LPN in the emergency department is in accordance with their scope of practice.   The LPN practices dependently at the direction of an RN or licensed practitioner through the application of the nursing process and the execution of diagnostic or therapeutic regimens prescribed by licensed practitioners. LPN practice includes the assumption of responsibilities and accountabilities for the performance of acts within their educational background and utilizing procedures leading to predictable outcomes.   

A licensed nurse is accountable to be competent for all nursing care that he/she provides.     Competence means the ability of the nurse to apply interpersonal, technical and decision-making skills at the level of knowledge consistent with the prevailing standard for the nursing activity being applied.  Accountability also includes acknowledgment of personal limitations in knowledge and skills, and communicating the need for specialized instruction prior to providing any nursing activity.    

References

Oregon Board of Nursing. Policy Statement, “Registered Nurse Role in the EMTALA Medical Screening Examination”, Adopted February 2005. 

South Dakota Board of Nursing.   Advisory Opinion, “Performance of Medical Screening Examinations by Registered Nurses”.   Adopted November 1999.

42 US Code § 1395dd.

  42 CFR § 489.24.

Centers for Medicare and Medicaid Services (CMS) “Clarifying Policies Related to the Responsibilities of Medicare-Participating Hospitals in Treating Individuals With Emergency Medical Conditions,” September 9, 2003.

42 CFR § 485.618 (d).

Approved: June 2010

Top of Page

Documents in PDF format require the use of Adobe Acrobat Reader which can be downloaded for free from Adobe Systems, Inc.  Get Adobe Acrobat Reader

Registered Nurse/Licensed Practical Nurse Page