Nebraska Board of Nursing Review – July 2016
Reviewed by Sedation Certification – Jan. 8, 2019
State Sedation Policy – Yes
Can RN’s give sedation? – Yes
Can RN’s give Propofol/Ketamine? – Under Certain Circumstances – Intubated/Ventilated
Nebraska Board of Nursing Advisory opinion
This Nebraska Board of Nursing advisory opinion is issued in accordance with the Nebraska Nurse Practice Act, Neb. Rev. Stat. 38-2216 (2). As such, this advisory opinion is for informational purposes only and is nonbinding. The advisory opinions define acts, which in the opinion of the board, are or are not permitted in the practice of nursing.
“Minimal Sedation is a drug-induced state during which patients respond normally to verbal commands. Although cognitive function and coordination may be impaired, airway reflexes, and ventilatory and cardiovascular functions are unaffected” (American Society of Anesthesiologists [ASA], 2009).
It is within the scope of practice of a non-CRNA registered nurse to provide minimal sedation as prescribed.
Nitrous oxide may be administered by the registered nurse, for the purposes of moderate sedation. Nitrous Oxide should be administered by the RN as a single agent, not concurrently with any other sedative or depressant.
“Moderate Sedation (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. *Reflex withdrawal from a painful stimulus is NOT considered a purposeful response” (ASA, 2009).
Loss of consciousness should not be the goal for patients undergoing moderate sedation. Thus, pharmacologic agents used for the purposes of moderate sedation should render loss of consciousness unlikely.
Use of Anesthetic Agents for the Purposes of Moderate Sedation
The Nebraska Nurse Practice Act does not specifically address procedures which each nurse may or may not perform, all nurses should take into account evidence-based nursing guidelines put forth by professional organizations with specialized clinical expertise. A number of specialty and professional organizations have well-defined standards and recommendations for non-CRNA RNs regarding the practice of administration of anesthetic drugs for the purposes of moderate sedation.
Using anesthetic agents for the purposes of moderate sedation presents serious risks to the patient, including loss of protective reflexes and airway, no matter who is administering the drug. Personnel with expertise in airway management and emergency intubation must be readily available. Advanced Cardiac Life Support certification alone does not ensure ongoing expertise in airway management and emergency intubation.
A non-CRNA registered nurse may administer propofol to intubated, ventilated patients, or those patients who are being prepared for intubation. According to the manufacturer’s product information (2012), Propofol is intended for use as an anesthetic agent or for the purpose of maintaining sedation of an intubated, mechanically ventilated patient (United States Food and Drug Administration [FDA]). This information also includes a warning, “only persons trained to administer general anesthesia should administer Propofol for purposes of general anesthesia or for monitored anesthesia care/sedation” (FDA, 2012). The clinical effects for patients receiving Propofol may vary widely within a negligible dose range (ASA, 2009). Though Propofol is “short-acting,” it also should be noted there are no reversal agents. While the physician or other health care provider performing the procedure may possess the necessary knowledge, skills and abilities to rescue a patient from deep sedation and general anesthesia, it is not prudent to presume this physician will be able to leave the surgical site or abandon the procedure to assist in rescuing the patient.
Other Anesthetic Medications
Other medications labeled as anesthetics may be administered by the non-CRNA registered nurse for the purposes of moderate sedation. The following must be carefully considered by the nurse:
o Risks and benefits of the drug(s) to be used;
o Patient and environment;
o Ongoing competency and training;
o Knowledge of and availability of reversal agents;
o Established institutional policy, procedures, and protocols;
o Accountability for nursing practice; and
o Availability of physician or other health care provider possessing the necessary knowledge, skills and abilities to rescue patient from deep sedation or anesthesia AND the availability of this provider to abandon any procedure(s) to rescue or intubate the patient.
From the Nebraska Nurse Practice Act, Neb. Rev. Stat. §38-2210, “Each nurse is directly accountable and responsible to the consumer for the quality of nursing care rendered (2012).” This includes maintaining safe and effective nursing care rendered directly or indirectly, which supersedes any physician order.
Moderate Sedation Using Non-Anesthetic Agents
It is within the scope of practice of a registered nurse to administer, manage, and monitor the care of patients receiving IV moderate sedation during therapeutic, diagnostic, or surgical procedures. 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. Institutional policy, procedures, and protocol should be established for moderate sedation.
“Deep Sedation 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” (ASA, 2009).
It is not in the scope of practice for a non-CRNA RN to provide deep sedation. Deep sedation in a patient who is not appropriately monitored and/or who does not have appropriate airway support may result in a life-threatening emergency for the patient.
“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” (ASA, 2009).
General Anesthesia may only be provided by those qualified to administer anesthesia.
Pursuant to the Nebraska Nurse Practice Act (2012), 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 of nursing practice. Accountability also includes acknowledgment of personal limitations in knowledge and skills, and communicating the need for specialized instruction prior to providing any nursing activity.
The decision to provide any nursing care should be based upon self-assessment of competency, 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 communication of the need for specialized instruction prior to providing any nursing activity.
The Nebraska Board of Nursing may choose to issue advisory opinions in accordance with the Nebraska Nurse Practice Act, Neb. Rev. Stat. 38-2216 (2). As such, advisory opinions are for informational purposes only and are non-binding. The advisory opinions may define acts, which in the opinion of the board, are or are not permitted in the practice of nursing. Nursing practice, however, is constantly evolving and advisory opinions can become outdated. Ultimately, Nebraska law and Board regulations require the licensee to provide nursing care services within parameters consistent with education, skills, experience, and current competence. Application of the Decision-Making Model is encouraged.
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