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Questions Related to Registered Professional Nurses (RN)

Anesthesia

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

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

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

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

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

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

Anesthetic Agents

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

Reviewed March 2, 2006.

The Board rescinded a portion of its previous position that “a registered professional nurse may, after appropriate documented training based on the facility’s established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

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

Reviewed March 3-4, 2010

Arterial Lines

At its April, 1996 meeting, the Board determined that registered professional nurses with documented training may perform arterial line insertions.

Assessment

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

Cardioversion

At its October, 1993 meeting, the Board determined that it is not within the scope of practice for the registered professional nurse (RN) to independently perform synchronized cardioversion. This is not intended to preclude the RN performing cardioversions in life-threatening emergencies.

C-ARM

At its June 1993 meeting, the Board determined that while positioning a C-arm over a patient is not nursing, it is certainly permissible for a registered nurse to lend in positioning the machine as long as the physician is actually operating the fluoroscopy C-arm and the nurse has been instructed on how to move the C-arm.

Chapter 6 Clarification

At its October 22-23, 1997 meeting, the Board determined that it would maintain Chapter 6 as adopted and provide clarification through the following advisory ruling in situations where care is directed by the consumer:

In consumer-directed care provided by an unlicensed assistive person (UAP), the registered nurse's responsibility is to provide the consumer with appropriate information regarding the task to be performed by the UAP.

Chest Tubes

At its August 2-3, 2000 meeting, the Board reaffirmed that a registered professional nurse may not remove chest tubes.

Defibrillation

RNs do not have to be ACLS certified to use a defibrillator. (1988-89)

In June, 1984, the Board determined that the procedure of defibrillation is not within the usual scope of practice of the LPN, but if the LPN is ACLS certified, s/he may perform defibrillation under the delegation and supervision of the MD or the ACLS certified RN in an emergency situation.

On September 28,1990 the Board stated that a registered professional nurse, who holds a current certificate of completion from an American Heart Association sponsored certificate program for life support, may perform those functions for which s/he has received the required education and training and has been deemed qualified to perform. Policies and procedures should be agreed upon by medical, nursing, administrative and legal staffs before implementation.

Device to Insert Hair

At its June 9-10, 1999 meeting, the Board determined that it is not within the scope of practice for a registered professional nurse to utilize a device which forms needle-like openings in the scalp and inserts hair.

Dextro Stix

At its October 22, 1984 meeting, the Board discussed whether a registered nurse could use Dextrostix for the assessment of blood glucose levels in evaluating diabetic clients without orders from a physician. The Board agreed that because assessment is a nursing function and the responsibility of the RN, the nurse may utilize the best methods available in order to make a proper assessment.

Dispensing Medication

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

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

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

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

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

Electrical Stimulaton for Incontinence

At its October 17 and 18, 2001 meeting, the Board determined that a registered professional nurse with appropriate education and supervision according to defined competencies and established facility/organization policies and procedures, may perform electrical stimulation for the treatment of incontinence.

Endoscope

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

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

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

Endotracheal Intubation

The RN who has had the required educational preparation and supervised clinical practice may perform endotracheal intubation when such function is delegated by a physician, in a health care facility that has written institutional policies and procedures regarding such practice. (1986)

The RN who has had the required educational preparation and supervised clinical practice may perform endotracheal intubation on the neonate when the function is delegated by a physician, in a health care facility that has written institutional policies and procedures regarding this practice. (1989)

Epidural Catheters

At its February, 1987 meeting, the Board was requested to issue an advisory ruling regarding the instillation of medications into epidural catheters for long term pain management. It is the opinion of the Board that it is within the scope of practice of a registered professional nurse to instill analgesics into an epidural catheter as follows:
1. Bolus doses of epidural analgesics may be given by a registered nurse (RN) who has had supervised instruction in the proper method of bolus administration.
2. Nursing responsibilities re: instillation of medications into epidural catheters are as follows:
(a) assessment of medication effectiveness;
(b) assessment and management of side effects related to the epidural administration of narcotics;
(c) maintenance of the integrity and sterility of the epidural line; and
(d) patient/family teaching.

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

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

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

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

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

Extubation

The Board determined that extubation of the patient is within the scope of practice of the RN who has had appropriate education and supervised clinical practice, provided that anesthesia back up is available in the facility, patient criteria are clearly delineated and policies and procedures agreed upon by nursing, medical, legal and administrative staff. October 2, 1991

Fetal Pulse Oximetry

At its December 8-9, 1999 meeting, the Board determined that a registered professional nurse may place a fetal pulse oximetry sensor if he or she has had the appropriate documented training according to protocols established by the health care facility.

Fetal Scalp Electrodes

The registered professional nurse may place fetal scalp electrodes if he or she has been trained to do so.

Halo Traction

At its February, 1995 meeting, the Board determined that a registered professional nurse may tighten the loosened bolts on a halo traction if he or she is properly trained to do so.

Hypnotherapy

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

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

Intrathecal Catheters

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

(a) assessment of medication effectiveness
(b) assessment and management of side effects related to intrathecal administration of drugs
(c) maintenance of the integrity and sterility of the intrathecal line, and
(d) patient/family teaching.

Laryngeal Mask Airway

At its June 9-10, 1999 meeting, the Board determined that it is not within the scope of practice
of a registered professional nurse to intubate and/or place the Laryngeal Mask Airway (LMA) for patient airway management.

At its February 14-15, 2001 meeting, the Board revisited the issue based on changes in national standards and determined that a registered professional nurse, who is educationally prepared
according to the organization/facility's established policies and procedures, may intubate and/or place the Laryngeal Mask Airway (LMA) for patient airway management.

Lumbar Punctures

On June 25,1984 the Board determined that the performance of lumbar punctures by registered professional nurses in advanced roles is not considered to be within the scope of nursing practice in Maine.

Neuromuscular Blockers

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

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

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

Operating Room (O.R.) Circulating Nurse

In December, 1984, the Board stated that it believed that the registered professional nurse is the appropriate person to be the circulating nurse in the operating room and that this function should not be delegated to the licensed practical nurse.

Again in September, 1990, the Board determined that the registered professional nurse circulating in the operating room cannot be replaced by the licensed practical nurse or an unlicensed technician.

In 1989 the Board determined that the Law Regulating the Practice of Nursing does not govern scrub technicians.

Paracentesis

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

PICCs - Peripherally Inserted Central Catheters

At its April, 1992 meeting, the Board determined that it is within the scope of practice for a registered professional nurse to insert a biocompatible, flexible venous catheter via a peripheral vein under the following circumstances:
1. The registered nurse has substantial experience in intravenous therapy and a solid understanding of central lines
2. The registered nurse has undergone a specialized educational program which includes but is not limited to:
(a) anatomy and physiology of the insertion site and venous and arterial systems
(b) patient screening
(c) equipment
(d) sterile insertion technique
(e) supervised clinical experience
(f) complication identification management
(g) catheter care, and
(h) a mechanism for quality assurance and periodic review for competency
3. The peripheral catheter insertion site is the antecubital area or the optimal vessel in one of the extremities.
4. The catheter length for each patient is measured using specified anatomical landmarks for the tip location intended. The catheter tip destination may be the axillary, subclavian or brachiocephalic vein or the superior vena cava.
5. The catheter location is confirmed radiographically prior to administration of any solutions when the tip is advanced beyond the axilliary vein.

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

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

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

Phlebotomy

The Board determined that the performance of phlebotomy is not considered the practice of nursing; therefore, it is not necessary for the registered nurse to be physically present in the facility when the LPN performs phlebotomy. September 28, 1990

Prostaglandin Suppositories

At its October 11-12, 1996 meeting, the Board revisited its previous ruling re: registered professional nurses inserting prostaglandin suppositories. The Board determined that procedurally a registered professional nurse could insert a vaginal suppository but with respect to this particular drug, the facility must have policy and procedural safeguards, sufficient documented education and training of the registered professional nurse and agreement among medical, nursing and administrative staff.

Scabies Scrapings

At its December 8-9, 1999 meeting, the Board determined that skin scraping with subsequent microscopic examination for the purpose of identifying the presence or absence of a scabies infestation is within the scope of practice of a registered professional nurse providing he or she receives the appropriate, documented training based on the following diagnostic procedure:

1. apply mineral oil to the skin in an area which is not excoriated but where papules appear to be present
2. with a #15 blade or curette, scrape the area
3. apply scale to slide
4. view the slide under a low magnification microscope and observe for mites, or eggs.

Skin Anesthetic

In 1988-1989, the Board determined that a registered professional nurse who has had appropriate instruction and supervision, may inject an anesthetic medication prior to the insertion of a peripheral intravenous line for the purpose of providing comfort to the patient, providing that the procedure has been delegated to the nurse by a physician

Spiral Electrodes

Registered professional nurses licensed in Maine may apply internal spiral electrodes if the following conditions are met:

(a) the nurse has had appropriate education and supervised clinical practice following NAACOG certification guidelines
(b) the above is documented and
(c) the health care facility has established policies and procedures regarding such application which are agreed upon by nursing, medical, administrative and legal staff. (
April 12, 1990)

Subfascial Catheter

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

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

Sutures

At its October 13-14, 1983 meeting, the Board ruled that simple suturing, although the practice of medicine, can be delegated by a physician to a registered nurse who has the required knowledge, skill and competence and when policies have been developed by the health care agency or facility regarding the matter.

In June 1983 the Board ruled that the removal of sutures is not within the scope of nursing practice. This has led to inquiries from RNs who are being delegated this function in the health care facilities in which they are employed. The Board has responded that the removal of sutures is medical practice, but it may be delegated by the physician to the nurse who has the knowledge, skill and competence to carry out the order.

Tracheostomy

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

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

Transfusions

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

Unna Boots

At its December 13-14, 1983 meeting, the Board ruled that the application of Unna Boots is within the scope of practice of the registered nurse under the following conditions:

1) the nurse has received the necessary education and supervised clinical practice and such training is documented

2) the nursing, medical and administrative staffs have established policies and procedures for such a procedure; and

3) the physician who delegates the application of Unna Boots knows that the nurse is capable of carrying out this function and understands the possible complications.

Vaginal Exam

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

1. General Requirements

A. Written policy and procedures are maintained by the employer.
B. The registered professional nurse performing the procedure must have satisfactorily completed an instructional program that included supervised clinical practice.
C. Documentation of satisfactory completion of the course of instruction and supervised practice is on file with the employer.

2. Course of Instruction

The course of instruction shall include, but not be limited to, the following:
A. anatomy and physiology of the female reproductive system
B. indications and contraindications for performing speculum examinations
C. proper methods of specimen collection
D. intervention for potential side effects
E. nursing care responsibilities

Vagus Nerve Stimulator

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

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

Wound Debridement

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