Arizona Board of Nursing Revised Date 03/10; 9/13, 5/20, 7/21
Reviewed by Sedation Certification – December 27, 2023
State Sedation Policy – Yes
Can LPN’s give sedation? – No
Can RN’s give sedation? – Yes
Can RNs give anesthetic medications? – Yes, but only under certain circumstances.
Can RN’s give Ketamine? – Yes, read Advisory Opinion link
Contact the Board of Nursing if you have any questions!
** Ketamine Advisory Opinion Link
Nitrous Oxide Advisory Opinion Link
Sedation Advisory Opinion Link
Doug Ducey – Governor
Joey Ridenour – Executive Director
Arizona State Board of Nursing
1740 W Adams Street, Suite 2000
Phoenix, AZ 85007
Phone (602) 771-7800
E-Mail: arizona@azbn.gov
Home Page: www.azbn.gov
OPINION: SEDATION: DEEP, MODERATE AND PALLIATIVE
DATE APPROVED: 1/07
REVISED DATE: 03/10; 9/13, 5/20, 7/21, 9/23 ORIGINATING COMMITTEE
SCOPE OF PRACTICE COMMITTEE
An advisory opinion adopted by AZBN is an interpretation of what the law requires. While an advisory opinion is not law, it is more than a recommendation. In other words, an advisory opinion is an official opinion of AZBN regarding the practice of nursing as it relates to the functions of nursing. Facility policies may restrict practice further in their setting and/or require additional expectations related to competency, validation, training, and supervision to assure the safety of their patient population and or decrease risk.
Within the Scope of Practice of __X__RN ____LPN
ADVISORY OPINION
SEDATION: DEEP, MODERATE, AND PALLIATIVE
STATEMENT OF SCOPE
Administration of medications for moderate sedation, rapid sequence intubation (RSI), and deep or
palliative sedation, including the administration of anesthetic agents, is NOT within the LPN scope
of practice. The licensed practical nurse (LPN) scope of practice is limited to the administration and
monitoring of medications (e.g., opioids) given for minimal sedation (anxiolysis).
It is NOT within the scope of practice of a registered nurse (RN) who is not a certified registered
nurse anesthetist (CRNA) to provide deep sedation for non-ventilated patients or to administer or
monitor medications given to a general anesthesia level.
It is within the scope of practice of an RN to administer medications to clinical response, when
general requirements are met for the purpose(s) of:
a. Deep sedation of a patient in acute care settings in the following situations: 1)
intubated, 2) mechanically ventilated (including continuous positive airway
pressure [CPAP]), or 3) assisting with RSI.
b. Moderate sedation for diagnostic or therapeutic procedures when a qualified
Licensed Practitioner(LP) is present at the bedside.
c. Palliative (end of life) care.
Medications used for sedation may include opioids, barbiturates, and anesthetic agents.
Anesthetic agents are intended to be administered at sub-anesthetic dosages; however, it should
be noted that sedation exists along a continuum, and RNs who administer moderate sedation or
deep sedation (with a ventilated patient) must be qualified to provide rescue support to patients
who proceed to a deeper level of sedation.
The RN has the right and obligation to refuse to administer and/or continue to administer
medication(s) in amounts/frequency that may produce sedation at a deeper level than desired.
Anesthetic agents administered locally to block sensations of pain in a specific area of the
body and are not injected into the vascular system are not included in this advisory.
See also Definitions section (following Rationale section).
I. GENERAL REQUIREMENTS
A. Written policies and procedures are developed and maintained
by the employer/facility. These policies must include, but are
not limited to:
1. Sedation medications must be prescribed within applicable legal and
policy constraints by a credentialed and privileged licensed (LP).
2. Levels of sedation RNs may assist with at their facility.
3. An interdisciplinary team, that includes RN participation, identifies
approved medications and reversal agents including weight
/age-appropriate dosages, to be utilized for appropriate level of sedation.
4. If titration is used, the RN must have a medication order that contains
specific parameters for the titration based on a validated sedation scale
and/or monitoring device data(This should include reversal agents as well.)
5. Emergency equipment, medications, and supplies must be available
within the immediate work area and appropriate to the age,weight
and size of the patient being sedated.
6. Guidelines and equipment for patient monitoring, drug
administration, and addressing potential complications.
7. Documentation and monitoring requirements for level of sedation,
vital signs and physiologic measurements (e.g., blood pressure,
respiratory rate, oxygen saturation, capnography, heart rate, and
cardiac rhythm).
8. Venous access will be maintained for all patients having moderate sedation,
RSI, or deep sedation.
9. Documentation of basic life support (BLS) is required for palliative sedation.
10. Documentation of age appropriate advanced life support (ACLS,
NRP, PALS) is required for moderate to deep sedation.
11. Only RNs who have completed an instructional program and have
had supervised clinical practice can administer and manage deep,
moderate, and palliative sedation.
B. Specific requirements related to individual sedation levels:
1. Deep sedation:
a. Identification of which medications and/or anesthetic agents can be
given by the RN as a continuous administration (non-bolus), IV
bolus or push (intermittent dose), or titration to clinical response for
patients who are intubated and mechanically ventilated.
b. The RN provides and documents ongoing monitoring,
including blood pressure, respiratory rate, oxygen saturation,
capnography, heart rate, and cardiac rhythm.
c. Functioning equipment for suctioning and maintaining the
airway/resuscitation is available.
2. Rapid sequence intubation (RSI) or drug assisted intubation (DAI):
a. Identification of which medications, reversal agents and/or
anesthetic agents can be given by IV bolus or push by the RN
assisting the LP during an intubation.
b. Functioning equipment for suctioning and maintaining the
airway/resuscitation is available
c. Note: This does not apply to prehospital or transport personnel
providing emergency care while in direct communication with their
medical director or while following approved medical protocols.
3. Moderate sedation (procedural or conscious sedation):
a. Identification of which medications, reversal agents and/or
anesthetic agents can be given by the RN as a continuous
administration (non-bolus), IV push (intermittent dose), or titration
to clinical response.
b. The LP ordering the medication and performing procedures for
moderate sedation must be credentialed for such medications and
must be at the bedside from the time the medication is initiated
through the completion of the procedure.
c. A LP capable of managing complications must be immediately
available in the facility during the post-procedure period and must
remain in the facility until the patient is medically discharged from
the post-procedure area.
d. The RN administering medications and monitoring the patient
receiving moderate sedation will have NO other duties that would
interfere with primary responsibility of monitoring the patient
during the procedure, must remain at bedside during procedure.
e. A pre-sedation assessment and collaborative sedation plan must be
performed for each patient by the LP and administering RN to
determine that the patient is a candidate for moderate sedation.
f. Supplemental oxygen must be available during and throughout the
recovery period.
g. Documentation and monitoring of physiologic measurements
including, but not limited to blood pressure, respiratory rate, oxygen
saturation, capnography, heart rate, and cardiac rhythm via approved
scale is recorded per facility guidelines during the procedure and
throughout the recovery period. Documentation of adequate
ventilation using continuous capnography is strongly recommended.
4. Palliative care sedation:
a. Identification of which medications and/or anesthetic agents can be
administered as a continuous infusion, IV bolus, or IV push
(intermittent dose) for the purpose of palliative sedation without the
presence of an LP.
b. Pre- and post-sedation symptom assessments and ongoing
assessments are performed by the RN to maintain sedation at the
ordered level. Monitoring may or may not include electronic
physiological monitoring modalities.
II. COURSE OF INSTRUCTION
A. Only RNs who have the knowledge and have demonstrated competency may
administer deep, moderate, or palliative sedation. The instructional program
includes, but not limited to:
1. Anatomy and physiology of the respiratory system including
principles of oxygen delivery, gas exchange, transport, and uptake.
2. Physiology of levels of sedation including minimal
sedation, moderate sedation, deep sedation and
anesthesia.
3. Indications and contraindications for the sedation level to be
provided and potential adverse consequences including over or
under sedation.
4. Legal implications, responsibility, and documentation
associated with sedation.
5. Pharmacology of drugs used singularly or in combination for
sedation, reversal agents and anesthesia including drug
implementation and discontinuation, action, onset, peak,
duration, side effects, contraindications, and adverse reactions.
6. Required nursing interventions in the event of
complications or adverse outcomes.
7. Assessment of patients receiving deep, moderate, or
palliative sedation.
8. Use of appropriate monitoring devices and sedation scales.
9. Education specific for different types of sedation or specific agents:
a. If providing deep sedation: instruction in mechanical
ventilation including mode of ventilation.
b. For palliative-specific sedation, knowledge of the
process of dying and death, and end of life symptom
assessment and management of care.
III. RATIONALE
Because medicine is ever evolving, this advisory opinion is NOT intended to delineate what
medications can or cannot be given but rather to focus the nurse on providing safe care at
the desired level of sedation.
The administration of anesthetics for the purpose of general anesthesia is outside of the
scope of practice for RNs or advanced practice nurses who are not a CRNA. However, it is
within the scope of practice of the RN to safely provide sedation, including the use of an
anesthetic agent, provided the conditions set in this advisory opinion are met. The ultimate
responsibility of the RN is to assure patient safety and this independent obligation under his
or her licensure supersedes any LP order or facility policy.
IV. DEFINITIONS
Anesthetic agents are medications which cause partial or complete loss of sensation with
or without loss of consciousness.
Immediately available is defined as being present in the facility and not otherwise engaged
in any other uninterruptible procedure or task.
IV bolus is a small volume of medication or large volume solution that is given rapidly
intravenously (IV) to hasten or magnify the response.
IV push is the direct injection of medication via an IV. The rate of injection is determined
by the type of the medication being given and the patient’s response.
Licensed Practitioner (LP) is a physician, dentist, nurse practitioner, nurse midwife,
certified nurse anesthetists, or any individual permitted by law and the organization to
provide care and services without direction or supervision within the scope of the
individual’s license.
Minimal sedation (anxiolysis) is a drug-induced state during which patients respond
normally to verbal commands, may have impaired cognitive function or coordination but
respiratory and cardiovascular functions remain stable.
Moderate sedation (procedural or conscious sedation) is defined as “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. Centers for Medicare and Medicaid Services
(CMS) consistent with American Society of Anesthesiologist (ASA) guidelines, does not
define moderate or conscious sedation as anesthesia” (CMS, 2011).
Deep sedation is a drug-induced depression of consciousness during, which patient cannot
be easily aroused but responds purposefully, following repeated or painful stimulation.
While, cardiovascular function is usually maintained, the ability to independently maintain
respiratory function may be impaired. Patients may require assistance in maintaining a
patent airway, and spontaneous ventilation may be inadequate, therefore the patient must be
intubated and mechanically ventilated.
*Reflex withdrawal from a painful stimulus is NOT considered a purposeful response.
General anesthesia is a drug-induced loss of consciousness during which patients are not
arousable, even by painful stimulation. General anesthesia affects the patient’s ability to
maintain an adequate airway and respiratory function and may impair cardiovascular
function.
Palliative sedation is the monitored use of medications at end of life intended to provide
relief of intolerable and refractory symptoms but not to intentionally hasten death. This
distinction separates it from euthanasia and/or assisted suicide where the intent is solely to
end life. A refractory symptom is one that cannot be controlled in a tolerable time frame
despite use of therapies and seems unlikely to be controlled by further therapies without
excessive or intolerable acute or chronic side effects/complications.
Rapid sequence intubation (RSI) or drug assisted intubation (DAI) is an airway
management technique in which a powerful sedative or anesthetic induction agent is
administered virtually simultaneously with a paralytic agent.
V. REFERENCES
American Association of Nurse Anesthetists. (2022). Non-anesthesia provider procedural
sedation and analgesia: position statement an d policy considerations.
https://www.aana.com/docs/default-source/practice-aana-com-webdocuments-(all)/non-anesthesia-provider
-procedural-sedation-andanalgesia.pdf?sfvrsn=670049b1_2
American College of Emergency Physicians. (2017). Procedural sedation in the
emergency department. ACEP: Dallas.
American Heart Association. (2020). 2020 American Heart Association Guidelines for CPR and
ECC. https://cpr.heart.org/en/resucitation-science/cpr-and-ecc-guidelines
American Society of Anesthesiologists Ambulatory Surgical Care Committee. (2019, October 23).
Statement on the safe use of Propofol.
https://www.asahq.org/standards-and-guidelines/statement-on-safe-use-of-propofol
American Society of Anesthesiologists, Committee on Standards and Practice
Parameters. (2018). Practice guidelines for moderate procedural sedation and
analgesia.
https://pubs.asahq.org/anesthesiology/article/128/3/437/18818/Practice-Guidelines-fo
r-Moderate-Procedural?_ga=2.165697662.1993695634.1673892441-71640081.16738
92441
American Society of Anesthesiologists Quality Management and Departmental
Administration Committee. (2019, October 23). Continuum of depth of sedation: Definition
of general anesthesia and levels of sedation/analgesia.
https://www.asahq.org/standards-and-guidelines/continuum-of-depth-of-sedation-definition
-of-general-anesthesia-and-levels-of-sedationanalgesia
Arizona State Legislature. (2017). Arizona revised statute § 32-1634.03:
Qualifications for certified registered nurse anesthetist; temporary certificate.
https://www.azleg.gov/
viewdocument/?docName=https://www.azleg.gov/ars/32/01634-03.htm
Centers for Medicare & Medicaid Services. (2011). State operations provider
certification: Transmittal 74 (CMS Manual System Publication No. 100-07). U.S.
Department of Health and Human Services.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R74
SOMA.pdf
Eberson C.P., Hsu R.Y., Borenstein T.R. Procedural sedation in the emergency department. (2015) The
Journal of the American Academy of Orthopaedic Surgeons 23(4):233-42. doi:
10.5435/JAAOS-D-14-00236. Epub 2015 Feb 25. PMID: 25715648.
Emergency Nurses Association. (2019). Clinical practice guideline: The use of capnography
during procedural sedation/analgesia.
http://preview.ena.org/docs/default-source/resource-library/practice-resources/cpg/capnographycpg.pdf?sfv
rsn=2acee418_26
Gao, M., Rejaei, D., & Liu, H. (2016). Ketamine use in current clinical practice.
Acta Pharmacologica Sinica, 37(1), 865-872.
Kurdi, M.S., Kaushic, A.T., & Deva, R.S. (2014). Ketamine: Current applications
in anesthesia, pain, and critical care. Anesthesia Essays and Researches, 8(3), 283-
290.
Manzi, J. E., Jones, M. R., Cornett, E. M., & Kaye, A. D. (2021). Moderate and deep
procedural sedation-the role of proper monitoring and safe techniques in clinical
practice. Current Opinion in Anaesthesiology, 34(4), 497–501.
https://doi.org/10.1097/ACO.0000000000001011Miller, K.A., Andolfatto, G., Miner,
J.R., Burton, J.H., & Krauss, B.S. (2019). Clinical practice guideline for emergency
department procedural sedation with Propofol: 2018 update. Annals of Emergency
Medicine, 73(5), 470-480.
STATE BOARDS OF NURSING ADVISORY OPINIONS
Alabama Board of Nursing. (2016). Standards of nursing practice: Standards for moderate
sedation. http://www.alabamaadministrativecode.state.al.us/docs/nurs/610-X-6.pdf
Alaska Board of Nursing. (2009). Advisory opinion: Registered nurse administration of
sedating and anesthetic agents.
https://www.commerce.alaska.gov/web/portals/5/pub/nur1809.pdf
Arkansas State Board of Nursing. (2017). Role of the registered nurse in the management of
patients receiving moderate sedation, anesthetic agents or neuromuscular blocking
(paralytic)agents for therapeutic or diagnostic procedures.
https://www.arsbn.org/Websites/arsbn/images/PositionStatement 94-1Moderate
Sedation.5.2017.pdf
California Board of Registered Nursing. (2013). Conscious sedation/moderate sedation.
https://www.rn.ca.gov/pdfs/regulations/npr-b-06.pdf
Connecticut Board of Examiners for Nursing. (n.d.). Guidance offered on Propofol
administration.
https://portal.ct.gov/-/media/Departments-and-Agencies/DPH/dph/phho/Nursing_Board/Guideli
nes/PROPOFOLGUIDANCEpdf.pdf?la=en
Georgia Board of Nursing. (2015). Position statement: Administration of Propofol, Etomidate
and neuromuscular blocking agents. https://sos.ga.gov/PLB/acrobat/Forms/38 Reference
Position Statement – Administration of Propofol, Etomidate and Neuromuscular Blocking
Agents.pdf
Illinois Department of Financial and Professional Regulation. (n.d.). Provision of conscious
sedation by registered nurses in ambulatory surgical treatment centers.
http://www.ilga.gov/commission/jcar/admincode/068/068013000C03700R.html
Kansas State Board of Nursing. (2014). Position statement: Administration of IV
conscious sedation (moderate sedation/analgesia) by the registered professional nurse.
https://ksbn.kansas.gov/wp-content/uploads/Resources/Position_Statements/Approved-IV
-Conc-Sed-Draft-3-2014.pdf
Kentucky Board of Nursing. (2019, June). Advisory opinion statement: Procedural sedation and
analgesia. https://kbn.ky.gov/practice/Documents/aos32.pdf
Louisiana State Board of Nursing. (2015, April 9). Declaratory statement on the role and scope
of practice of the registered nurse in the administration of medication and monitoring of
patients during the levels of intravenous procedural/conscious sedation (minimal, moderate,
deep, and anesthesia).
http://www.lsbn.state.la.us/Portals/1/Documents/DeclaratoryStatements/Declerat18.pdf
Minnesota Board of Nursing. (2016, October). Statement of accountability by the
registered nurse for administration of medications classified as anesthetics.
https://mn.gov/boards/assets/Stmt_Accountblty_RN_Admin_Anesthetics_%20
2
010 _10-11-18_tcm21-37484.pdf
Mississippi Board of Nursing. (2016). Administration and management of intravenous
(IV) moderate sedation.
https://www.msbn.ms.gov/sites/default/files/documents/IVModerateSedationasam
mended.pdf
New York State Board of Nursing. (2013). Administration of IV anesthetic agents by
non-anesthetist registered nurses for the purpose of sedation and anesthesia.
http://www.op.nysed.gov/prof/nurse/nurse-ivsedation.htm
North Carolina Board of Nursing. (2018). Palliative sedation for end-of-life care
position statement for RN and LPN practice.
https://www.ncbon.com/vdownloads/position-statements-decision-trees/ps-
palliative-sedation.pdf
North Carolina Board of Nursing. (2018). Procedural sedation/analgesia position
statement for RN practice. https://www.ncbon.com/vdownloads/position-
statements-decision-trees/procedural-sedation.pdf
North Carolina Board of Nursing. (2018). Rapid sequence intubation (RSI) position
statement for RN practice. https://www.ncbon.com/vdownloads/position-
statements-decision-trees/rapid-sequence-intubation.pdf
North Dakota Board of Nursing. (2013). Role of the RN in administration of anesthetic
agents.
https://www.ndbon.org/RegulationsPractice/PracticeStatements/AdminAnestheticA
gents.asp
Oklahoma Board of Nursing. (2019). Moderate (conscious) sedation guidelines for registered
nurse managing and monitoring patients. https://nursing.ok.gov/prac-rnguid.pdf
Oklahoma Board of Nursing. (2018). Rapid sequence intubation guidelines:
Medication administration by registered nurses.
https://nursing.ok.gov/rapseqint.pdf
Oregon State Board of Nursing. (2018). The registered nurse (RN) who administers a
pharmacologic agent to a client to achieve moderate or deep sedation.
https://www.oregon.gov/osbn/documents/IS_Sedation.pdf
Rhode Island Board of Nurse Registration and Nursing Education. (2017). Scope of
practice guide to the administration of anesthetic agents by registered nurses.
http://www.health.ri.gov/publications/policies/scopeofpractice/AdministrationOfA
nestheticAgentsByRegisteredNurses.pdf
Texas Board of Nursing. (2020). Position statement 15.8: Role of the nurse in moderate
sedation. http://www.bne.state.tx.us/practice_bon_position_statements_content.asp#15.8