Nurse Reporter Fall 2008 - Wyoming State Board of Nursing

S c o p e o f Pr a c t i c e Is s u e s• Advisory Opinion: 04-143, FNP PracticingPsych/Mental Health Setting-APNAlthough members of the Board acknowledgethe barriers to obtaining adequate care forchildren with mental health issues, they reaffirmedAdvisory Opinion Number 04-143 (FNPPracticing Psych/Mental Health Setting-APN).This decision is based upon documents describingthe scope of practice and core competenciesidentified by the National Association of ClinicalNurse Specialists and the National Organizationof Nurse Practitioners. This opinion, drafted July14, 2004, is written as follows: “It is not withina Family Nurse Practitioner’s (FNP) scope topractice as a Clinical Specialist (CS) or NursePractitioner (NP) in Psychiatric/Mental Health(P/MH) nursing. The FNP may only practicewithin the standards of practice promulgated bythe national accreditation agencies representingFNPs. If the FNP wishes to practice as a CS orNP in Psych/Mental Health, they must have theeducational preparation (degree/post graduatecertificate in psych/mental health nursing). Ifthe FNP is appropriately certified by the ANCCfor practice as an Advance Practice Nurse in P/MH nursing, there is no reason that the individualcan not practice in P/MH setting, as certificationis highly recommended.”• Advisory Opinion: 08-186, Procedural Sedationand Analgesia in the Emergency DepartmentFollowing the presentation of the informationfrom the Emergency Nurses Association, thearticle from the American Family Physician(2005) as well as the consensus statement on thistopic, the Board of Nursing made the followingdecisions:1. Rescind Advisory Opinion Number 06-163(Administration of Anesthetic Agents such asPropofol, Etomidate and Ketamine by Rns for IVConscious Sedation).2. Adopt the Procedural Sedation and Analgesiain the Emergency Department Consensus Statementas endorsed by the following organizations:Air and Surface Transport Nurses Association,American Academy of Emergency Medicine,American Association of Critical Care Nurses,American College of Emergency Physicians,American Radiological Nurses Association,American Society for Pain Management Nursing,Emergency Nurses Association, NationalAssociation of Children’s Hospitals and RelatedInstitutions.The Procedural Sedation and Analgesia in theEmergency Department advisory opinion iswritten as follows: “The Wyoming State Boardof Nursing adopted the Procedural Sedation ConsensusStatement as endorsed by the followingorganizations: Air and Surface Transport NursesAssociation, American Academy of EmergencyMedicine, American Association of Critical CareNurses, American College of Emergency Physicians,American Nurses Association, AmericanRadiological Nurses Association, AmericanSociety for Pain Management Nursing, EmergencyNurses Association, National Associationof Children’s Hospitals and Related Institutions.Procedural Sedation Consensus StatementThe immediate availability of interventionsincluding procedural sedation is critical to servingthe needs of our patients. Preserving life,restoring health, and alleviating suffering havebeen fundamental to the practice of nursing andmedicine for centuries. We are challenged ashealth care professionals to provide this care in amanner that meets the Institute of Medicine’s SixQuality Aims of safe, effective, timely, efficient,equitable, and patient centered care. Patientswith emergency medical conditions frequentlyexperience significant treatable pain and anxiety.There is ample evidence to support the routineuse of procedural sedation by appropriatelytrained and credentialed emergency nurses andphysicians.PRINCIPLES FOR PROCEDURAL SEDA-TION IN EMERGENCY CARE SETTINGS➢Patients have a right to expect that:o their survival and recovery will always be toppriorities;o their care will be provided in a safe and patientcentered manner;o their comfort will be assessed and pain managedin an equitable, timely, and efficient manner;o their care in emergency care settings will beconsistent with current medical knowledge andpractice;o their emergency caregivers will be appropriatelytrained and credentialed; ando they will be provided sufficient information,when possible, to allow them to participate intherapeutic decisions and provide informedconsent.➢ The primary goal of procedural sedation forpatients in emergency care settings is to managepain and anxiety while facilitating immediateinterventional procedures.➢ The response to sedating medications followsa broad continuum that varies from patient topatient. Care must be customized to both thepatient and the clinical situation, and caregiversmust be able to recognize and manage potentialcomplications.➢ Procedural sedation is safe and effective whenperformed by appropriately trained, credentialed,and supported emergency nurses and physicians.We, the undersigned organizations, agree:1. Medications including, but not limited to,etomidate, propofol, ketamine, fentanyl, andmidazolam are utilized by healthcare professionalsto facilitate management of a continuum ofpainful conditions. These extend from simplepain management and maintenance sedation tomoderate to deep sedation for painful procedures.Because of the myriad ways these medicationsmight be used, it is best to focus on the goalof the intervention rather than the medicationitself.2. Procedural sedation is defined as a techniqueof administering sedatives or dissociative agentswith or without analgesics to induce a state thatallows the patients to tolerate an unpleasantprocedure while maintaining cardiorespiratoryfunction. (American College of EmergencyPhysicians [ACEP] Clinical Policy for ProceduralSedation and Analgesia in the Emergency Department,Annals of Emergency Medicine 2005)3. Procedural sedation medications may beadministered by a registered nurse (RN) in thepresence of a physician, an advanced practiceregistered nurse, or other health care professionalcredentialed and privileged for procedural sedation.RNs administering such medications mustpossess the training and competencies describedin item four below.4. Administration of medications for proceduralsedation by a RN is a specialized skill thatrequires specific knowledge and competenciesincluding, but not limited to:a. An understanding of the principles of oxygendelivery, transport and uptake, and respiratoryphysiology.b. Demonstrated competency in airway managementappropriate to the age of the patientincluding monitoring patient oxygenation andventilation (e.g. skin color, respiratory rate, pulseoximetry, secondary confirmation of endotrachealtube placement), initiation of resuscitative measures,and utilization of oxygen delivery devices(e.g. nasal cannula, mask, basic airway techniques,oral/nasal airways, bag valve mask).c. Demonstrated knowledge of anatomy, physiology,pharmacology, cardiac dysrhythmia recognition,and complications related to proceduralsedation and analgesia.d. Ability to initiate cardiac resuscitation procedures(e.g. CPR, cardioversion, defibrillation).e. Identification and differentiation of the variouslevels of sedation.f. Demonstrated competence in pre-procedural,procedural, and post-procedural nursing care fromthe initial patient evaluation to patient discharge(e.g. patient assessment and monitoring, IV fluidadministration, medication administration).g. The ability to recognize complications andintervene appropriately.h. Knowledge of the legal/liability ramificationsassociated with an independently licensed RNadministering procedural sedation.5. Procedural sedation requires the presenceof two licensed professionals at the bedside.One licensed professional must be a RN whosecompetency in procedural sedation has been verified.This RN may administer the medication ormonitor the patient and must not be involved inperforming the procedure.Health care professionals monitoring the patientundergoing procedural sedation must not haveother responsibilities that would compromisetheir ability to adequately monitor the patientbefore, during, and after the procedure.6. Resuscitation equipment and supplies must beage appropriate and readily available for the patientundergoing any procedure. At a minimum,equipment should include oxygen and oxygen deliverydevices, suction devices and suction source,cardiac and pulse oximetry monitoring devices,defibrillator, oral/nasal airways, intubation equipment,alternative airways, bag-valve mask device,equipment to allow secondary confirmation ofendotracheal tube placement, reversal agents andACLS medications. (ACEP