24 Del. Admin. Code § 1900-7.0 - Standards of Nursing Practice
7.1
Nursing practice encompasses several levels of accountability in order to
ensure safe, competent practice. At the foundation of accountability are
standards of nursing practice developed by general and specialty nursing
professional organizations. A second level of accountability is provided by
statutes, rules and regulations promulgated by individual states, based upon
each state's nurse practice act which defines nursing practice. Nurses are also
accountable to the institution or agency where they are employed through
institutional policies and procedures. A final level of accountability resides
with nurses' self-determination of those aspects of practice they believe
themselves competent to perform.
7.2 Definitions
"Standards of Nursing Practice" are those standards adopted
by the
"Nursing Process" includes assessment, diagnosis, outcome identification, planning, implementation and evaluation.
7.3 Purpose
The purpose of standards is to establish minimal acceptable
levels of safe practice for the
7.3.1 The board will not
rule on for what purpose a drug is given.
7.3.2 Standards of nursing practice and
position statements developed by general and specialty nursing professional
organizations may be used to address scope of practice
accountability.
7.3.3 Nursing
practice occurs where the patient is located.
7.3.4 The scope of practice decision tree
https://dprfiles.delaware.gov/nursing/ScopeofPracticeDecisionTree.pdf
should be used to determine if a task or procedure is within the scope of the
nurse. If all conditions are met, the procedure is within the scope of the
nurse.
7.3.5 The scope of practice
parameters for RNs, LPNs, and UAPs can be found at
https://dprfiles.delaware.gov/nursing/ScopeofPracticeDecisionTree&Duties.pdf
and may also be used to determine if a task or procedure is within the scope of
the nurse or UAP.
7.4
Standards of Practice, Competencies and Responsibilities for the Registered and
Licensed Practical Nurse
7.4.1 Registered and
Licensed Practical Nurses shall:
7.4.1.1 Have
knowledge of and function within the statutes and regulations governing
nursing.
7.4.1.2 Accept
responsibility for competent nursing practice.
7.4.1.3 Function as a member of the health
team through interdisciplinary and/or interagency consultation and
collaboration to provide optimal care, seeking guidance, instruction and
supervision as necessary.
7.4.1.4
Contribute to the formulation, interpretation, implementation and evaluation of
the objectives and policies related to nursing practice within the employment
setting.
7.4.1.5 Participate in
evaluating nurses through peer review.
7.4.1.6 Report unsafe nursing practice to the
Board and unsafe practice conditions to recognized legal authorities.
7.4.1.7 Practice without discrimination as to
age, race, religion, sex, sexual orientation, national origin, gender identity
or expression, or disability.
7.4.1.8 Respect the dignity and rights of
clients regardless of social or economic status, personal attributes or nature
of health problems.
7.4.1.9 Respect
the client's right to privacy by protecting confidentiality unless obligated by
law to disclose the information.
7.4.1.10 Respect the property of clients,
their families and significant others.
7.4.1.11 Teach safe practice to other health
care workers as appropriate.
7.4.1.12 Perform waived and moderately
complex laboratory point of care testing after appropriate education, including
annual competency demonstration and quality control measures for equipment,
which are completed and documented.
7.4.1.13 Nurses who perform any special
procedures should possess specialized knowledge and competent technical skill
in the performance of the procedure, be knowledgeable of the potential
complications and adverse reactions which may result from the performance of
the procedure, possess the knowledge and skill to recognize adverse reactions,
and take appropriate actions.
7.5 Standards related to the Registered
Nurse.
7.5.1 The Registered Nurse shall
conduct and document nursing assessments in accordance with the nursing
process. The registered nurse shall assess the health status of individuals and
groups by:
7.5.1.1 Collecting objective and
subjective data from observations, examinations, interviews, in person or by
electronic communication and written records in an accurate and timely manner.
The data include but are not limited to:
7.5.1.1.1 Biophysical and emotional status
and observed changes;
7.5.1.1.2
Growth and development;
7.5.1.1.3
Ethno-cultural, spiritual, socio-economic and ecological background;
7.5.1.1.4 Family health history;
7.5.1.1.5 Information collected by other
health team members;
7.5.1.1.6
Ability to perform activities of daily living;
7.5.1.1.7 Consideration of client's health
goals;
7.5.1.1.8 Client knowledge
and perception about health status and potential, or maintaining health
status;
7.5.1.1.9 Available and
accessible human and material resources;
7.5.1.1.10 Patterns of coping and
interaction.
7.5.1.2
Sorting, selecting, reporting, and recording the data.
7.5.1.3 Analyzing data.
7.5.1.4 Validating, refining and modifying
the data by using available resources including interactions with the client,
family, significant others, and health team members.
7.5.1.5 Evaluating data.
7.5.2 Registered Nurses shall establish and
document nursing diagnoses that serve as the basis for the strategy of
care.
7.5.3 Registered Nurses shall
develop strategies of care based on the nursing process. This includes:
7.5.3.1 Prescribing nursing
interventions.
7.5.3.2 Initiating
nursing interventions through giving, assisting and/or delegating
care.
7.5.3.3 Identifying
priorities in the plan of care.
7.5.3.4 Setting realistic and measurable
goals for implementation.
7.5.3.5
Identifying measures to maintain comfort, to support human functions and
responses, to maintain an environment conducive to well being, and to provide
health teaching and counseling.
7.5.4 Registered Nurses shall participate in
the implementation of the strategy of care by:
7.5.4.1 Providing care for clients whose
conditions are stabilized or predictable.
7.5.4.2 Providing care for clients whose
conditions are critical and/or fluctuating, under the direction and supervision
of a recognized licensed authority.
7.5.4.3 Providing an environment conducive to
safety and health.
7.5.4.4
Documenting nursing interventions and client outcomes.
7.5.4.5 Communicating nursing interventions
and client outcomes to appropriate health team members.
7.5.5 Registered Nurses shall evaluate
outcomes, which may include the client, family, significant others and health
team members.
7.5.5.1 Evaluation data shall be
documented and communicated appropriately;
7.5.5.2 Evaluation data shall be used as a
basis for modifying health care strategies including but not limited to
reassessing client health status, modifying nursing diagnoses, or prescribing
changes in nursing interventions.
7.5.6 Delegation
7.5.6.1 Definitions
"Accountability" - The state of being accountable, answerable, or legally liable for actions and decisions, including supervision.
"Delegation" - Entrusting the performance of selected
nursing duties to individuals qualified, competent and legally able to perform
such duties while retaining the accountability for such
"Supervision" - The guidance by a
"Unlicensed Assistive Personnel" - Individuals not
licensed to perform nursing tasks that are employed to assist in the delivery
of client care. The term "unlicensed assistive personnel" does not include
members of the client's immediate family, guardians, or friends; these
individuals may perform incidental care of the sick in private homes without
specific authority from a licensed nurse (as established in 24
7.5.6.2 Conditions. The following conditions
are relevant to delegation:
7.5.6.2.1 RNs, not
LPNs, may delegate.
7.5.6.2.2 The
RN must be knowledgeable regarding the unlicensed assistive personnel's
education and training and have opportunity to periodically verify the
individual's ability to perform the specific tasks.
7.5.6.2.3 The RN maintains accountability for
determining the appropriateness of all delegated nursing duties and
responsibility for the delivery of safe and competent care. The RN is
accountable for decisions made and actions taken in the course of that
delegation. Unlicensed assistive personnel may not reassign a delegated
act .
7.5.6.3 Criteria
7.5.6.3.1 The RN may delegate only tasks that
are within the scope of sound professional nursing judgment to delegate.
Nursing judgments and actions include decisions made when delegating nursing
tasks to others and providing supervision for those activities.
7.5.6.3.2 Determination of appropriate
factors include, but are not limited to:
7.5.6.3.2.1 Stability of the client's
condition
7.5.6.3.2.2 Educational
background, skill level, or preparation of the individual
7.5.6.3.2.3 Nature of the nursing act that
meets the following:
7.5.6.3.2.3.1 Task is
performed frequently in the daily care of a client
7.5.6.3.2.3.2 Task is performed according to
an established sequence of steps
7.5.6.3.2.3.3 Task may be performed with a
predictable outcome
7.5.6.3.2.3.4
Task does not involve ongoing assessment, interpretation or decision making
that cannot be logically separated from the task
itself.
7.5.6.3.3 Variables in each service setting
include, but are not limited to:
7.5.6.3.3.1
Complexity and frequency of care needed by a given patient population
7.5.6.3.3.2 Proximity of patients to
staff
7.5.6.3.3.3 Number and
qualifications of staff
7.5.6.3.4 The RN must be readily available in
person or by telecommunication.
7.5.6.4 Exclusions
7.5.6.4.1 The following activities require
nursing knowledge, judgment, and skill and may not be delegated by the RN to an
unlicensed assistive person.
7.5.6.4.2 Physical, psychological, and social
assessment which requires professional nursing judgment, intervention,
referral, or follow-up;
7.5.6.4.3
Development of nursing diagnoses and/or care goals;
7.5.6.4.4 Formulation of the plan of nursing
care and evaluation of the effectiveness of the nursing care
provided;
7.5.6.4.5 Specific tasks
involved in the implementation of the plan of care which require nursing
judgment, skill, or intervention, that include, but are not limited to:
performance of sterile invasive procedures involving a wound or anatomical
site; nasogastric, newly established gastrostomy and jejunostomy tube feeding;
nasogastric, jejunostomy and gastrostomy tube insertion or removal; suprapubic
catheter insertion and removal; (phlebotomy is not considered a sterile,
invasive procedure);
7.5.6.4.6
Administration of medications, including prescription topical medications;
and
7.5.6.4.7 Receiving or
transmitting verbal orders.
7.6 Standards of Practice for the Licensed
Practical Nurse
7.6.1 Standards related to the
Licensed Practical Nurse's contributions to the nursing process.
7.6.1.1 At the direction and under the
supervision of a recognized licensed authority, the Licensed Practical Nurse
shall contribute to the nursing process and document nursing assessments of
individuals and groups by:
7.6.1.1.1
Collecting objective and subjective data from observations, examinations,
interview and written records in an accurate and timely manner. The data
include but are not limited to:
7.6.1.1.1.1
Biophysical and emotional status and observed changes;
7.6.1.1.1.2 Growth and development;
7.6.1.1.1.3 Ethno-cultural, spiritual,
socio-economic, and ecological background;
7.6.1.1.1.4 Family health history;
7.6.1.1.1.5 Information collected by other
health team members;
7.6.1.1.1.6
Ability to perform activities of daily living;
7.6.1.1.1.7 Consideration of client's health
goals;
7.6.1.1.1.8 Client knowledge
and perception about health status and potential, or maintaining health
status;
7.6.1.1.1.9 Available and
accessible human and material resources;
7.6.1.1.1.10 Patterns of coping and
interaction.
7.6.1.1.2
Sorting, selecting, reporting, and recording the data.
7.6.1.1.3 Analyzing data.
7.6.1.1.4 Validating, refining and modifying
the data by using available resources including interactions with the client,
family, significant others, and health team members.
7.6.1.2 Licensed Practical Nurses shall
participate in establishing and documenting nursing diagnoses that serve as the
basis for the strategy of care.
7.6.1.3 Licensed Practical Nurses shall
participate in developing strategies of care based on assessment and nursing
diagnoses.
7.6.1.3.1 Contributing to setting
realistic and measurable goals for implementation.
7.6.1.3.2 Participating in identifying
measures to maintain comfort, to support human functions and responses to
maintain an environment conducive to well-being, and to provide health teaching
and counseling.
7.6.1.3.3
Contributing to setting client priorities.
7.6.1.4 Licensed Practical Nurses shall
participate in the implementation of the strategy of care by:
7.6.1.4.1 Providing care for clients whose
conditions are stabilized or predictable.
7.6.1.4.2 Providing care for clients whose
conditions are critical and/or fluctuating, under the directions and
supervision of a recognized licensed authority.
7.6.1.4.3 Providing an environment conducive
to safety and health.
7.6.1.4.4
Documenting nursing interventions and outcomes.
7.6.1.4.5 Communicating nursing interventions
and outcomes to appropriate health team members.
7.6.1.5 Licensed Practical Nurses shall
contribute to evaluating outcomes through appropriate documentation and
communication.
7.7 Dispensing
7.7.1 Definitions
7.7.1.1 "Dispensing " means providing
medication according to an order of a practitioner duly licensed to prescribe
medication. The term shall include both the repackaging and labeling of
medication from bulk to individual doses.
7.7.1.2 "Prescription Label" - a label
affixed to every prescription or drug order which contains the following
information at a minimum.
7.7.1.2.1 A unique
number for that specific drug order.
7.7.1.2.2 The date the drug was
dispensed.
7.7.1.2.3 The patient's
full name.
7.7.1.2.4 The brand or
established name and manufacturer and the strength of the drug to the extent it
can be measured.
7.7.1.2.5 The
practitioner 's directions as found on the prescription order.
7.7.1.2.6 The practitioner 's name.
7.7.1.2.7 The initials of the dispensing
nurse.
7.7.1.2.8 The name and
address of the facility or practitioner from which the drug is
dispensed.
7.7.1.2.9 Expiration
date.
7.7.1.3 "Standing
order" - An order written by the practitioner which authorizes a designated
registered nurse or nurses to dispense prescription drugs to the practitioner 's
patients according to the standards listed below.
7.7.2 Authority to Dispense
7.7.2.1 Registered Nurses may assume the
responsibility of dispensing as defined in the Nurse Practice Act .
7.7.2.2 Licensed Practical Nurses may assume
the responsibility of dispensing as authorized by the Nurse Practice Act and
defined in these Regulations, subsections 7.7.2.2.1, 7.7.2.2.2, and 7.7.2.2.3.
7.7.2.2.1 Licensed Practical Nurses may
provide to a patient pre-packaged medications in accordance with the order of a
practitioner duly licensed to prescribe medication where such medications have
been pre-packaged by a person with lawful authority to dispense
drugs .
7.7.2.2.2 Licensed Practical
Nurses, per written order of a physician, dentist, podiatrist, advanced
practice nurse, or other practitioner duly licensed to prescribe medication,
may add the name of the client to a preprinted label on a pre-packaged
medication.
7.7.2.2.3 Licensed
Practical Nurses in a licensed methadone clinic may apply a preprinted label to
a pre-packaged medication.
7.7.3 Standards for Dispensing
7.7.3.1 All licensed nurses engaged in
dispensing shall adhere to these standards.
7.7.3.1.1 The medication must be prepackaged
by a pharmaceutical company or prepared by a registered pharmacist .
7.7.3.1.2 The nurse shall be responsible for
proper drug storage of the medication prior to dispensing .
7.7.3.1.3 The practitioner who originated the
prescription or drug order must be on the premises or the practitioner 's
designated coverage shall be available by telephone during the act of
dispensing .
7.7.3.1.4 Once a drug
has been dispensed it shall not be returned for reuse by another or the same
patient in an institutional setting.
7.7.3.1.5 The nurse may not delegate any part
of the dispensing function to any other individual who is not licensed to
dispense .
7.7.3.1.6 The dispensing
nurse must assure compliance to the state generic substitution laws when
selecting the product to be dispensed.
7.7.3.1.7 The nurse-dispensed prescription
may not be refillable; it requires the authority of the prescriber with each
dispensing .
7.7.3.1.8 A usage
review process must be established for the medicines dispensed to assure proper
patient usage.
7.7.3.1.9 All
dispensed drugs must be labeled as defined above and dispensed in proper safety
closure containers that meet the standards established by the United States
Pharmacopoeia for stability.
7.7.3.1.10 Record keeping must include the
maintenance of the original written prescription of drug order for at least
three years, allow retrospective review of accountability, and provide an audit
trail. All dispensing records must be maintained on site, and available for
inspection by authorized agents of the Board of Health, Pharmacy, and
Nursing.
7.7.3.1.11 The dispensing
nurse shall assume the responsibility of patient counseling of drug effects,
side-effects, desired outcome, precautions, proper storage, unique dosing
criteria, drug interactions, and other pertinent data, and record evidence of
patient education.
7.7.3.1.12
Conformance to subsection 7.7.3.1.6 through 7.7.3.1.11 are not necessary if the
original prescription was dispensed by a pharmacist for that specific
patient.
7.8 Intravascular Therapy by Licensed Nurses.
Intravascular therapy encompasses several components, some of which require
primarily skill proficiency with a minimum of critical judgment. Other aspects
of intravascular therapy require skill proficiency and more importantly a high
degree of knowledge, critical judgement and decision making to perform the
function safely.
7.8.1 Definition of Terms.
7.8.1.1 Intravascular therapy (IV) - is the
broad term including the administration of fluids and medications, blood and
blood derivatives into an individual's vascular system .
7.8.1.2 Intravascular therapy maintenance -
Monitoring of the therapy for changes in patient's condition, appropriate flow
rate, equipment function, the hanging of additional fluid containers and the
implementation of site care.
7.8.1.3 Intravenous and intra-arterial
medications - are drugs administered into an individual's vascular system by
any one of the following methods:
7.8.1.3.1
By way of infusion diluted in solution or suspended in fluid and administered
over a specified time at a specified rate.
7.8.1.3.2 Through an established
intra-vascular needle or catheter (referred to as "IV push").
7.8.1.3.3 By venipuncture carried out for the
sole purpose of administering the medication. This method is referred to as
direct medication injection (direct IV push).
7.8.1.4 Intravenous fluids - include
solutions, vitamins, nutrient preparations, and commercial blood fractions
designed to be administered into an individual's vascular system . Whole blood
and blood components, which are administered in the same manner, are considered
intravenous fluids in this definition.
7.8.1.5 Subcutaneous Infusion- Continuous
infusion or intermittent injection of medication into the layer of fatty tissue
between the skin and muscle using a subcutaneous needle.
7.8.1.6 Supervision - a registered nurse,
licensed physician or dentist is physically present in the unit where the
patient is being provided care, or within immediate electronic/telephone
contact.
7.8.1.7 Termination of
intravascular therapy - Cessation of the therapy either by withdrawing a needle
or catheter from an individual's vascular system or by discontinuing the
infusion and maintaining the device as a reservoir.
7.8.1.8 Vascular access - Utilization of an
established device or the introduction of a needle or catheter into an
individual's vascular system .
7.8.1.9 Vascular system - is composed of all
peripheral and central veins and arteries.
7.8.1.10 Venipuncture - Introduction of a
needle or catheter into an individual's peripheral vein for the purposes of
withdrawing blood or establishing an infusion or administering
medications.
7.8.2
Conditions of Performing Intravascular Therapy Procedures by Licensed Nurses
7.8.2.1 Intravascular therapy must be
authorized by a written order from a state licensed and authorized
prescriber .
7.8.2.2 The performance
of any procedures of intravascular therapy by a licensed practical nurse will
be done under the supervision of a registered nurse, APRN, or person licensed
to practice medicine, surgery, or podiatry.
7.8.2.3 Admixed intravascular solutions
documented and instituted by one licensed nurse and subsequently interrupted
may be re-instituted by another licensed nurse after confirmation with the
state licensed and authorized prescriber 's order.
7.8.2.4 Admixed intravascular solutions
documented and prepared by one licensed nurse may be initiated or continued by
another licensed nurse after confirmation with the state licensed and
authorized prescriber 's order.
7.8.2.5 Intradermal or topical anesthetics
may be used by the RN or LPN when initiating vascular access therapy in various
situations or settings, provided there is an authorized prescriber 's order and
organizational policy/procedure to support use of these medications. All RNs
and LPNs must have documented educational preparation according to the
employing agency's policies and procedures. Documented evidence must include
both theoretical instruction including anatomy and physiology, pharmacology,
nursing management and education of patients and demonstration of clinical
proficiency in performance of the task.
7.8.3 Functional Scope of Responsibility for
Intravascular Therapy Procedures
7.8.3.1
Registered Nurses bear the responsibility and accountability for their nursing
practice under the license granted by the Board of Nursing and are permitted to
perform the following:
7.8.3.1.1 Assessment of
the patient and the prescribed intravascular therapy before, during and after
the therapy is carried out.
7.8.3.1.2 Acceptance and confirmation of
intravascular therapy orders.
7.8.3.1.3 Calculation of medication dosage
and infusion rate for intravascular therapy administration .
7.8.3.1.4 Confirmation of medication dosage
and infusion rate for intravascular therapy administration .
7.8.3.1.5 Addition of prescribed medications
in intravascular solution, labeling and documenting appropriately.
7.8.3.1.6 Start initial solution or add
replacement fluids to an existing infusion as prescribed.
7.8.3.1.7 Vascular access for establishing an
infusion or administering medications.
7.8.3.1.8 Administration of medications by
"IV push".
7.8.3.1.9 Intravascular
therapy maintenance.
7.8.3.1.10
Termination of intravascular therapy, including the removal of subclavian and
PICC lines.
7.8.3.1.11 Access the
vascular system for the purpose of the withdrawal of blood and to monitor the
patient's condition before, during, and after the withdrawal of
blood.
7.8.3.2 Licensed
Practical Nurses bear the responsibility and accountability for their nursing
practice under the license granted by the Board of Nursing and are permitted to
perform the following for peripheral lines:
7.8.3.2.1 Acceptance and confirmation of
intravascular therapy orders.
7.8.3.2.2 Calculation of medication dosage
and infusion rate of intravascular medications prescribed. This does not
include titration.
7.8.3.2.3
Confirmation of medication dosage and infusion rate for intravascular therapy
administration .
7.8.3.2.4 Addition
of medications in intravascular solutions, label and document
appropriately.
7.8.3.2.5
Venipuncture with needle device to establish access to the peripheral vascular
system .
7.8.3.2.6 Start initial
solution or add replacement fluids to an existing infusion as
prescribed.
7.8.3.2.7 Intravascular
therapy maintenance including the flushing of peripheral lines with Heparin
and/or saline solution.
7.8.3.2.8
Termination of peripheral intravascular therapy.
7.8.3.2.9 Performance of venipuncture for the
purpose of the withdrawal of blood and to monitor the patient's condition
before, during and after the withdrawal of blood.
7.8.3.2.10 Perform therapeutic phlebotomy
under RN supervision using the scope of practice decision tree as a
guide.
7.8.3.3 The
Licensed Practical Nurse is permitted to perform the following procedures for
central lines:
7.8.3.3.1 Acceptance of
intravascular therapy orders.
7.8.3.3.2 Calculation of medication dosage
and infusion rate of intravascular medications prescribed. This does not
include titration.
7.8.3.3.3
Confirmation of medication dosage and infusion rate for intravascular therapy
administration .
7.8.3.3.4 Addition
of medications in intravascular solutions, label and document
appropriately.
7.8.3.3.5
Intravascular therapy maintenance, including the flushing of central lines with
Heparin and/or saline solution.
7.8.3.3.6 Dressing and tubing changes,
including PICC lines.
7.8.3.3.7
Addition of replacement fluids to an existing infusion as
prescribed.
7.8.3.4 The
Licensed Practical Nurse is permitted to perform the following procedures for
subcutaneous infusions after documented instruction and competency
demonstration:
7.8.3.4.1 Accept subcutaneous
infusion therapy orders.
7.8.3.4.2
Insert and remove subcutaneous needle or catheter to initiate/discontinue
therapy or rotate sites.
7.8.3.4.3
Confirm medication dosage and infusion rate.
7.8.3.4.4 Calculate and adjust flow rates on
subcutaneous infusion including pumps. This does not include titration nor
administration of medications via the "push" route.
7.8.3.4.5 Perform dressing and tubing
changes.
7.8.3.4.6 Maintain
subcutaneous infusion therapy.
7.8.3.4.7 Change the administration set and
convert a continuous infusion to an intermittent infusion and vice
versa.
7.8.3.4.8 Observe, document,
and report on insertion site and signs of complications such as infection,
phlebitis, etc.
7.8.4 Special Infusion Therapy Procedures by
Registered Nurses
7.8.4.1 Chemotherapy - Only
intravascular routes are addressed in these rules. Review of the Oncology
Nursing Society's current guidelines is recommended before the administration
of anti-neoplastic agents.
7.8.4.1.1
Definition of Terms
7.8.4.1.1.1 Cancer
Chemotherapy - is the broad term including the administration of
anti-neoplastic agents into an individual's vascular system .
7.8.4.1.1.2 Anti-neoplastic agents - are
those drugs which are administered with the intent to control neoplastic cell
growth.
7.8.4.1.2 The
Registered Nurse who administers cancer chemotherapy by the intravascular route
must have documented educational preparation according to the employing
agency's policies and procedures.
7.8.4.1.3 The Registered Nurse must have
documented evidence of knowledge and skill in the following:
7.8.4.1.3.1 Pharmacology of anti-neoplastic
agents
7.8.4.1.3.2 Principles of
drug handling and preparation
7.8.4.1.3.3 Principles of
administration
7.8.4.1.3.4 Vascular
access
7.8.4.1.3.5 Side effects of
chemotherapy on the nurse, patient, and family
7.8.4.2 Central Venous Access Via Peripheral
Veins
7.8.4.2.1 Definition of Terms
7.8.4.2.1.1 Central venous access - is that
entry into an individual's vascular system via the insertion of a catheter into
a peripheral vein threaded through to the superior vena cava with placement
confirmed by x-ray.
7.8.4.2.2 The Registered Nurse who performs
central venous access via peripheral veins must have documented educational
preparation according to the employing agency's policies and
procedures.
7.8.4.2.3 Documented
evidence must include, but is not limited to, evidence of both theoretical
instruction and clinical proficiency in performance of the task.
7.8.4.2.3.1 Theoretical instruction must
include, but is not limited to, anatomy and physiology, pharmacology, nursing
management, and education of patients as they relate to central venous access
via peripheral veins.
7.8.4.2.3.2 A
preceptor must supervise the learning experience and must document the
Registered Nurse's competency in the performance of the
procedure.
7.8.4.2.4
Specially trained PICC nurses may determine the location of the distal tip of a
peripherally inserted central catheter by initial or repeat chest radiograph
studies prior to administration of the prescribed therapy.
7.8.4.3 Pain Management via Epidural Catheter
7.8.4.3.1 It is within the scope of practice
of a Registered Nurse to instill analgesics (opiates)/low dose anesthetics at
analgesic levels into an existing catheter under the following
conditions/exceptions:
7.8.4.3.1.1 The
epidural catheter is in place.
7.8.4.3.1.2 The position of the epidural
catheter was verified as correct by a physician or CRNA at the time of
insertion.
7.8.4.3.1.3 Bolus doses
and/or continuous infusions, as pre-mixed by anesthesiologists, C.R.N.A.s, or
pharmacists, of epidural analgesics/low does anesthetics at analgesic levels
can be administered by the Registered Nurse only after the initial dose has
been administered. Changes in medication and/or dosage of the same medication
are not defined as the initial dose.
7.8.4.3.1.4 Only analgesics (opiates)/low
dose anesthetics at analgesic levels will be administered via this route for
acute and chronic pain management.
7.8.4.3.1.5 The Registered Nurse must
complete a course that includes:
7.8.4.3.1.5.1 Anatomy, physiology,
pharmacology, nursing management, assessment, and education of patients as they
relate to epidural administration of opiates/low dose anesthetics at analgesic
levels;
7.8.4.3.1.5.2 A
credentialed preceptor must supervise the learning experience and must document
the Registered Nurse's clinical competency in the performance of the
procedure.
7.8.4.3.1.6
The Registered Nurse may not insert epidural
catheters.
7.8.4.4 Vascular Access via the Intraosseous
Route
7.8.4.4.1 Definition of Terms
7.8.4.4.1.1 Intraosseous- within the bone
marrow.
7.8.4.4.1.2 Intraosseous
infusions- a method of obtaining immediate vascular access, especially in
children, by percutaneous insertion of an intraosseous needle into the bone
marrow cavity of a long bone where substances may be injected or infused and
are readily absorbed into the general circulation.
7.8.4.4.2 The Registered Nurse who performs
intraosseous access, infusions, or removal must have documented educational
preparation according to the employing agency's policies and
procedures.
7.8.4.4.3 Documented
evidence must include, but is not limited to, evidence of both theoretical
instruction and clinical proficiency in performance of the task.
7.8.4.4.3.1 Theoretical instruction must
include, but is not limited to, anatomy and physiology, pharmacology, nursing
management, and education of patients as they relate to intraosseous access,
infusions, or removal.
7.8.4.4.3.2
A preceptor must supervise the learning experience and must document the
Registered Nurse's competency in the performance of the
procedures.
7.8.4.5 The Registered Nurse may perform the
following procedures for subcutaneous infusions after documented instruction
and competency demonstration:
7.8.4.5.1 Accept
subcutaneous infusion therapy orders.
7.8.4.5.2 Insert and remove subcutaneous
needle or catheter to initiate/discontinue therapy or rotate sites.
7.8.4.5.3 Confirm medication dosage and
infusion rate.
7.8.4.5.4 Calculate
and adjust flow rates on subcutaneous infusion including pumps, including
titration and administration of medications via the "push" route.
7.8.4.5.5 Perform dressing and tubing
changes.
7.8.4.5.6 Maintain
subcutaneous infusion therapy.
7.8.4.5.7 Change the administration set and
convert a continuous infusion to an intermittent infusion and vice
versa.
7.8.4.5.8 Assess insertion
site for signs of complications, document, and perform appropriate
interventions as ordered.
7.8.4.6 Pain Management Via Perineural Route
7.8.4.6.1 It is within the role of the RN to
manage care for patients receiving analgesia by catheter techniques by the
perineural route of administration to alleviate pain. This does not include the
epidural route.
7.8.4.6.2 A RN who
has received the proper additional education and training may re-inject
medication (bolus dose) following establishment of an appropriate therapeutic
range and adjust drug infusion rate, intervene with side effects and
complications, replace empty drug reservoirs, refill implanted drug reservoirs,
trouble shoot infusion devices, change infusion device batteries, tubings, and
dressings, discontinue therapy, and remove catheters in compliance with a
licensed healthcare provider's orders.
7.8.4.6.3 The RN must:
7.8.4.6.3.1 Demonstrate the acquired
knowledge of anatomy, physiology, pharmacology, side effects, and complications
related to the analgesia technique and medications being
administered.
7.8.4.6.3.2 Assess
the patient's total care needs (physiological, emotional) while receiving
analgesia
7.8.4.6.3.3 Utilize
monitoring modalities, interpret physiological responses, and initiate nursing
interventions to ensure optimal patient care.
7.8.4.6.3.4 Anticipate and recognize
potential complications of the analgesia technique in relation to the type of
catheter, infusion device, and medications being utilized.
7.8.4.6.3.5 Recognize emergency situations
and institute nursing interventions in compliance with established
institution/healthcare facility policies, procedures, and guidelines and
licensed healthcare provider orders.
7.8.4.6.3.6 Demonstrate the cognitive and
psychomotor skills necessary for use and removal of the analgesic catheter and
infusion device when analgesia is delivered by such a device.
7.8.4.6.3.7 Demonstrate knowledge of the
legal ramifications of the management and monitoring of analgesia by catheter
techniques, including the RN's responsibility and liability in the event of
untoward reactions or life-threatening complications.
7.8.4.6.3.8 Identify patient/family
educational needs and limitations and provide the patient/family with
patient-focused information/education regarding the specific catheter
analgesia/infusion device using appropriate teaching
methods.
7.9 Exclusions of Health Care Acts pursuant
to 24 Del.C . §
1921(a)(15)
7.9.1 Health care acts that shall not be
delegated by a competent individual who does not reside in a medical facility
or a facility regulated pursuant to Chapter 11 of Title 16 include the
following:
7.9.1.1 Original intravenous
insertion.
7.9.1.2 Original
suprapubic catheter insertion or removal.
7.9.1.3 Newly established gastrostomy or
jejunostomy tube feeding.
7.9.1.4
Original nasogastric and gastrostomy tube insertion or removal.
7.9.1.5 Any jejunostomy tube insertion or
removal.
7.9.1.6 Sterile invasive
procedures not normally taught to patients and caregivers by licensed health
care professionals.
Notes
6 DE Reg. 1195 (03/01/03)
8 DE Reg. 864 (12/01/04)
8 DE Reg. 1683 (06/01/05)
15 DE Reg. 685 (11/01/11)
15 DE Reg. 1622 (05/01/12)
17 DE Reg.
21 DE Reg.
23 DE Reg.
24 DE Reg.
25 DE Reg.
26 DE Reg.
27 DE Reg.
27 DE Reg.
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.