Subchapter D. INTERPRETATIONS

§ 21.401. Interpretations: scope of practice.

 (a)  The Board may, upon request of a licensed nurse, nursing association, health care facility or licensed health care professional, or upon its own motion, issue interpretations of this chapter as they apply to the question of whether the execution of specific practices are within the scope of professional or practical nursing.

 (b)  Interpretations issued by the Board will not conflict with this chapter, or enlarge or restrict this chapter, but will solely address the matter of applying principles set forth in this chapter to specific practices.

 (c)  Interpretations issued under this section do not constitute an exercise of delegated legislative power by the Board and will be expressly subject to modification by the Board in an adjudicative proceeding based upon the particular facts and circumstances relevant to a proceeding. Interpretations are not intended to be legally enforceable against a licensed person by the Board. In issuing adjudications, the Board may consider, but is not bound by, interpretations.

 (d)  Prior to issuing interpretations, the Board will submit to the Legislative Reference Bureau for recommended publication in the Pennsylvania Bulletin a notice indicating its intent to adopt interpretations, and making available upon request to interested persons copies of proposed or draft interpretations. The notice shall also indicate the date and place for the conduct of hearings proposed regarding the interpretations. The notice shall contain the full statement of policy or a description of the substance of the statement of policy.

 (e)  The Board will not adopt statements of policy until the time for public comment has elapsed. A minimum of 60 days from publication in the Pennsylvania Bulletin of notice of intention to adopt shall be provided for public comment. Following a review and consideration of comments received concerning a proposed interpretation, the Board may adopt interpretations by a majority vote taken at a scheduled public meeting of the Board.

 (f)  Interpretations adopted by the Board under this chapter will be reviewed for form and legality under Chapter 3 of the Commonwealth Attorneys Act (71 P. S. § §  732-301—732-303) and, upon approval, will be submitted to the Legislative Reference Bureau for recommended publication in the Pennsylvania Bulletin and Pennsylvania Code as a statement of policy of the Board as a part of this subchapter.

 (g)  If a nurse executes a practice which the Board has interpreted to be within the scope of nursing practice, the nurse shall only undertake the practice if the nurse has the necessary preparation, experience and knowledge to properly execute the practice. The execution of the procedures shall include the identification and discrimination of expected and unexpected human responses and the effective management of nursing actions.

 (h)  Interpretations of the Board will not be deemed to impose requirements upon educational institutions to include the teaching of practices within their curricula.

 (i)  The procedure for issuing interpretations will not prohibit the Board from answering specific inquiries involving individual factual situations, which answers will be limited in application to the individual factual situation involved in the inquiry.

   The provisions of this §  21.401 adopted February 20, 1987, effective February 21, 1987, 17 Pa.B. 811.

STATEMENT OF POLICY

§ 21.411. Interpretations regarding the general functions of registered nurses—statement of policy.

 The following nursing practices fall within the scope of registered nurse practice under §  21.11 (relating to general functions):

   (1)  Collection of arterial and venous blood samples.

   (2)  Collection of arterial and venous blood samples from indwelling arterial/venous catheters.

   (3)  Arterial puncture for blood samples in infant intensive care units.

   (4)  Vaginal examination using a speculum to include:

     (i)   Testing for ruptured membranes.

     (ii)   Doing Pap smears.

     (iii)   Doing cervical smears.

   (5)  Application of intraocular pressure reducer.

   (6)  Internal fetal monitoring including the application of leads.

   (7)  Insertion of nasogastric tubes.

   (8)  Insertion and removal of enteric double or multilumen tubes with or without mercury bags.

   (9)  The changing of an outer tracheostomy tube after stoma is healed.

   (10)  The change of an cystostomy tubes.

   (11)  The changing of a gastrostomy tube when stoma is healed.

   (12)  Removal of sutures.

   (13)  Use of hypnosis.

   (14)  Surgical debridement of decubiti.

   (15)  The programming of permanent pacemakers.

   (16)  Documenting the fact that a patient has died.

 The following nursing practices fall within the scope of registered nursing practice under § §  21.11 and 21.12 (relating to general functions; and venipuncture; intravenous fluids):

   (1)  Introduction of percutaneous catheters for intravascular infusion of infant intensive care unit.

   (2)  Insertion of angiocath into an A-V Fistula.

   (3)  Changing a subclavian catheter over guidewire after it had been placed by a physician.

   (4)  Removal of central venous line.

   (5)  Teaching patients and families the administration of intravenous medications in the home.

 (a)  The following nursing practices fall within the scope of registered nursing practice under § §  21.11, 21.12 and 21.14 (relating to general functions; venipuncture; intravenous fluids; and administration of drugs):

   (1)  Intravenous administration of Pavulon to a patient maintained on a mechanical ventillator.

   (2)  Use of lidocaine as an analgesic prior to venipuncture.

   (3)  Use of lidocaine or xylocaine for analgesia prior to use of a vascular access device of an implantable infusion pump.

 (b)  The following nursing practices fall within the scope of registered nursing practice under § §  21.11 and 21.14:

   (1)  The addition of medications to peritoneal dialysate.

   (2)  The administration of chemotherapy.

   (3)  The refilling of implantable drug delivery systems following placement by a physician in the proper anatomical site.

   (4)  The administration of intrathecal medications by an externalized ventriculoperitoneal shunt.

   (5)  Monitoring and administering medications by epidural catheter or other pain relief devices to be used as analgesia for pain control. Administration of medications as used in this paragraph does not include initiation of the medication.

   (6)  When a physician writes a prescription order for a patient for a specific medication with a range of dosage, the registered nurse shall use professional judgment to determine the amount of medication within the range to be given to the patient.

 (c)  The following nursing practices fall within the scope of registered nursing practice under §  21.11 and §  21.15 (relating to monitoring, defibrillating and resuscitating):

   (1)  Measurement of a cardiac output by thermodilution method.

   (2)  Inflation of a Swan-Ganz catheter balloon for the purpose of obtaining intermittent pulmonary capillary wedge pressure readings.

   (3)  Establishment of arterial lines with or without a cannula.

   (4)  Analysis of rhythm strips of patients with permanent programmable pacemakers.

   (5)  Endotrachael intubation and extubation.

   (6)  Endotracheal intubation in infant intensive care unit.

   (7)  Needle aspiration of pneumothorax in infant intensive care unit.

   (8)  Performance of cardioversion in the presence or absence of a physician.

   (9)  Umbilical vessel catheterization in infant intensive care units.

   (10)  Pulling back on Swan-Ganz catheter when it is wedged.

 (d)  As used in this subsection, ‘‘conscious sedation’’ is defined as a minimally depressed level of consciousness in which the patient retains the ability to independently and continuously maintain an airway and respond appropriately to physical stimulation and verbal commands. The registered nurse who is not a certified registered nurse anesthetist may administer intravenous conscious sedation medications, under §  21.14, during minor therapeutic and diagnostic procedures, when the following conditions exist:

   (1)  The specific amount of intravenous conscious sedation medications has been ordered in writing by a licensed physician and a licensed physician is physically present in the room during administration.

   (2)  Written guidelines specifying the intravenous medications that the registered nurse may administer in a particular setting are available to the registered nurse.

   (3)  Electrocardiogram, blood pressure and oximetry equipment are used for both monitoring and emergency resuscitation purposes pursuant to written guidelines which are provided for minimum patient monitoring. Additional emergency resuscitation equipment is immediately available.

   (4)  The patient has a patent intravenous access.

   (5)  The registered nurse involved in direct patient care is certified in advanced cardiac life support (ACLS). Provisions shall be in place for back-up personnel who are experts in airway management, emergency intubation and advanced life support if complications arise.

   (6)  The registered nurse possesses the knowledge, skills and abilities related to the management of patients receiving intravenous conscious sedation with evaluation of competence on a periodic basis. This includes, but is not limited to, arrhythmia detection, airway management and pharmacologic action of drugs administered. This includes emergency drugs.

   (7)  The registered nurse managing the care of the patient receiving intravenous conscious sedation medication may not have other responsibilities during the procedure. The registered nurse may not leave the patient unattended or engage in tasks which would compromise continuous monitoring.

   (8)  The registered nurse monitors the patient until the patient is discharged by a qualified professional authorized to discharge the patient in accordance with established criteria of the facility.

 (a)  Collection of venous blood samples fall within the scope of Licensed Practical Nurse (LPN) practice under §  21.145(a) (relating to functions of the LPN).

 (b)  The following nursing practices fall within the scope of LPN practice under §  21.145(b):

   (1)  Changing cystostomy tubes after the stoma heals.

   (2)  Changing gastrostomy tube when stoma is healed.

 (c)  The following nursing practices fall within the scope of LPN practice under §  21.145(a) and (b):

   (1)  Insertion of nasogastric tubes.

   (2)  Changing outer tracheostomy tube after stoma is healed.

   (3)  Addition of medications to peritoneal dialysate in the care of those patients with chronic renal disease.

   (4)  Removal of sutures of a simple and uncomplicated nature.

   The provisions of this §  21.414 adopted February 20, 1987, effective February 21, 1987, 17 Pa.B. 811.