201 KAR 20:490. Licensed practical nurse intravenous therapy
scope of practice.
RELATES TO: KRS 314.011(10)(a), (c)
STATUTORY AUTHORITY: KRS 314.011(10)(c),
314.131(1), 314.011(10)(c)
NECESSITY, FUNCTION, AND CONFORMITY: KRS
314.131(1) authorizes the Board of Nursing to promulgate administrative
regulations as may be necessary to enable it to carry into effect the
provisions of KRS Chapter 314. KRS 314.011(10)(c) authorizes the board to
promulgate an administrative regulation to establish the scope of practice for
administering medicine or treatment by a licensed practical nurse. KRS
314.011(10)(a) requires that licensed practical nurses practice under the
direction of a registered nurse, physician, or dentist. This administrative
regulation establishes the scope of that practice as it relates to intravenous
therapy.
Section 1. Definitions. (1)
"Administration" means to initiate and infuse intravenous therapy.
(2) "Antineoplastic agent"
means a medication that prevents the development, growth, or proliferation of
malignant cells.
(3) "Bolus" means a
concentrated medication or solution given rapidly over a short period of time.
(4) "Central venous access
device" means a device that permits access to the central vascular system
and is inserted with the tip residing in the lower one-third of the superior
vena cava or above the level of the diaphragm in the inferior vena cava.
(5) "Direction" means a
communication of a plan of care that is based upon assessment of a patient by
an advanced practice registered nurse, a registered nurse, physician, or dentist
that establishes the parameters for the provision of care or for the
performance of a procedure.
(6) "Discontinuance" means to
stop the infusion of the medication or fluid and does not include removal of
the intravenous access device.
(7) "Fibrinolytic agent" means
a pharmaceutical agent capable of dissolving blood clots.
(8) "Intravenous access device"
means either a peripheral access device or a central venous access device.
(9) "Mix" or "mixing"
means to combine two (2) or more medications or solutions, and includes
reconstituting a powder into a liquid, and diluting a medication or solution.
(10) "Moderate sedation" means
the administration of intravenous medications to produce a state that intentionally
results in a depressed level of consciousness in a patient.
(11) "Peripheral access device"
means a peripherally-inserted intravenous catheter or needle that is less than
or equal to three (3) inches in length.
(12) "Pharmacology" means
information on the classification of intravenous drugs, indications for use,
pharmacological properties, monitoring parameters, contraindications, dosing,
clinical mathematics, anticipated side effects, potential complications,
antidotal therapy, compatibilities, stabilities, specific considerations for
select intravenous drugs, and administration of intravenous medications to pediatric,
adult, and geriatric populations.
(13) "Procedural sedation"
means the administration of intravenous medications to produce a state that
allows a patient to tolerate unpleasant procedures and results in a depressed
level of consciousness.
(14) "Push" means
administration of medication under pressure via a syringe.
(15) "Supervision" means the
provision of guidance by a registered nurse, advanced practice registered
nurse, physician or dentist for the accomplishment of a nursing task with
periodic observation and evaluation of the performance of the task including
validation that the nursing task has been performed in a safe manner.
(16) "Supervisor" means the
registered nurse, advanced practice registered nurse, physician or dentist who
provides supervision of the licensed practical nurse’s practice as defined in
subsection (15) of this section.
(17) "Therapeutic phlebotomy"
means a clinical procedure whereby blood volume is reduced to achieve a
therapeutic outcome.
(18) "Titration" means
adjustment of a medication dosage or rate of solution infusion as prescribed
within a therapeutic range that is based on the assessment of a patient.
(19) "Vesicant" means an agent
capable of causing injury if it escapes from the intended vascular pathway into
surrounding tissue.
Section 2. Education and Training
Standards. (1) Prior to performing intravenous (IV) therapy, the licensed
practical nurse (LPN) shall have completed education and training related to
the scope of IV therapy for an LPN. This education and training shall be
obtained through:
(a) A prelicensure program of nursing for
individuals admitted to the program after September 15, 2004; or
(b) An institution, practice setting, or
continuing education provider that has in place a written instructional program
and a competency validation mechanism that includes a process for evaluation
and documentation of an LPN’s demonstration of the knowledge, skills, and
abilities related to the safe administration of IV therapy. The LPN shall
receive and maintain written documentation of completion of the instructional
program and competency validation.
(2) The education and training programs
recognized in subsection (1) of this section shall be based on "Policies
and Procedures for Infusion Nursing" and "Infusion Nursing: Standards
of Practice" and shall include the following components:
(a) Technology and clinical applications;
(b) Fluid and electrolyte balance;
(c) Pharmacology and vesicants;
(d) Infection control;
(e) Transfusion therapy;
(f) Parenteral nutrition; and
(g) Legal aspects based on KRS Chapter
314 and this administrative regulation.
Section 3. Supervision Requirements. (1)
An LPN performing IV therapy procedures shall be under the direction and supervision
of a registered nurse (RN), advanced practice registered nurse (APRN),
physician, or dentist.
(2) For a patient whose condition is
determined by the LPN’s supervisor to be stable and predictable, and rapid
change is not anticipated, the supervisor may provide supervision of the LPN’s
provision of IV therapy without being physically present in the immediate
vicinity of the LPN, but shall be readily available.
(3) In the following cases, for the LPN
to provide IV therapy, the LPN’s supervisor shall be physically present in the
immediate vicinity of the LPN and immediately available to intervene in the
care of the patient:
(a) If a patient’s condition is or
becomes critical, fluctuating, unstable, or unpredictable;
(b) If IV medications or fluids are
administered by push or bolus administration, except for saline or heparinized
saline to maintain patency of an IV access device;
(c) If a patient has developed signs and
symptoms of an IV catheter-related infection, venous thrombosis, or central
line catheter occlusion;
(d) If a patient is receiving blood,
blood components, or plasma volume expanders; or
(e) If a patient is receiving peritoneal
dialysis or hemodialysis.
Section 4. Standards of Practice. (1) An
LPN shall perform only those IV therapy acts for which the LPN possesses the
knowledge, skill, and ability to perform in a safe manner, except as limited by
Section 6 of this administrative regulation and under supervision as required
by Section 3 of this administrative regulation.
(2) An LPN shall consult with an RN or
physician, physician assistant, dentist, or advanced practice registered nurse
and seek guidance as needed if:
(a) The patient’s care needs exceed the
licensed practical nursing scope of practice;
(b) The patient’s care needs surpass the
LPN’s knowledge, skill, or ability; or
(c) The patient’s condition becomes
unstable or imminent assistance is needed.
(3) An LPN shall obtain instruction and supervision
as necessary if implementing new or unfamiliar nursing practices or procedures.
(4) An LPN shall follow the written,
established policies and procedures of the facility that are consistent with
KRS Chapter 314.
Section 5. Functions That May Be
Performed. An LPN who has met the education and training requirements of
Section 2 of this administrative regulation may perform the following IV
therapy functions, except as limited by Section 6 of this administrative
regulation and under supervision as required by Section 3 of this
administrative regulation:
(1) Calculation and adjustment of the
flow rate on all IV infusions;
(2) Observation and reporting of
subjective and objective signs of adverse reactions to any IV administration
and initiate appropriate interventions;
(3) For all IV access devices:
(a) Administration of IV fluids and
medications via central venous and peripheral access devices as permitted by
this section and not prohibited by Section 6 of this administrative regulation;
(b) Performance of site care and
maintenance that includes:
1. Monitor access site and infusion
equipment;
2. Change administration set, including
add-on device and tubing;
3. Flushing; and
4. Change site dressing;
(c) Discontinuance of a medication or
fluid infusion; and
(d) Conversion of a continuous infusion
to an intermittent infusion;
(4) Insertion or removal of a peripheral
access device;
(5) Administration, monitoring, and
discontinuance of blood, blood components, and plasma volume expanders;
(6) Administration of IV medications and
fluids that are mixed and labeled by an RN, APRN, physician, dentist, or
pharmacist or are commercially prepared;
(7) Mixing and administration via push or
bolus route of any of the following classifications of medications:
(a) Analgesics;
(b) Antiemetics;
(c) The antagonistic agents for
analgesics;
(d) Diuretics;
(e) Corticosteroids; and
(f) Saline, heparinized saline, or
Heplock solution to maintain patency of an IV access device;
(8) Administration of glucose to patients
fourteen (14) years of age or older via direct push or bolus route;
(9) Administration, monitoring, and
discontinuance of IV medications and fluids given via a patient controlled administration
system;
(10) Administration, monitoring, and discontinuance
of parenteral nutrition and fat emulsion solutions;
(11) Performance of dialysis treatment,
including:
(a) Administering Heparin 1:1000 units or
less concentration either to prime the pump, initiate treatment, or for
administration throughout the treatment, in an amount prescribed by a
physician, physician’s assistant, or advanced practice registered nurse. The
licensed practical nurse shall not administer Heparin in concentrations greater
than 1:1000; and
(b) Administering normal saline via the
dialysis machine to correct dialysis-induced hypotension based on the
facility’s medical protocol. Amounts beyond that established in the facility’s
medical protocol shall not be administered without direction from a registered
nurse or a physician;
(12) Collection of blood specimens from a
peripheral IV access device only at the time of initial insertion;
(13) Removal of a noncoring needle from
an implanted venous port;
(14) Titration of intravenous analgesic
medications for hospice patients;
(15) Administration of peripheral
intravenous medications via a volumetric control device;
(16) Administration of intravenous
medications or solutions via a ready-to-mix intravenous solution infusion
system;
(17) Aspiration of a central venous
catheter to confirm patency via positive blood return; and
(18) Administration of medications or
fluids via:
(a) Peripherally inserted central
catheters; or
(b) Implanted or tunneled central venous
catheters.
Section 6. Functions that Shall Not be
Performed. An LPN shall not perform the following IV therapy functions:
(1) Administration of tissue plasminogen
activators, immunoglobulins, antineoplastic agents, or investigational drugs;
(2) Accessing of a central venous access
device used for hemodynamic monitoring;
(3) Administration of medications or
fluids via arterial lines or implanted arterial ports;
(4) Administration of medications via
push or bolus route except as permitted by Section 5(7) or (8) of this
administrative regulation;
(5) Administration of a fibrinolytic
agent to declot any IV access device;
(6) Administration of medications
requiring titration, except as permitted by Section 5(14) of this
administrative regulation;
(7) Insertion or removal of any IV access
device, except as permitted by Section 5(4) or (13) of this administrative
regulation;
(8) Accessing or programming an implanted
IV infusion pump;
(9) Administration of IV medications for
the purpose of procedural sedation, moderate sedation, or anesthesia;
(10) Administration of fluids or
medications via an epidural, intrathecal, intraosseous, or umbilical route, or
via a ventricular reservoir;
(11) Administration of medications or
fluids via an arteriovenous fistula or graft, except for dialysis;
(12) Performance of the repair of a central
venous access device;
(13) Mixing of any medications other than
those listed in Section 5(7) of this administrative regulation;
(14) Insertion of noncoring needles into
an implanted port;
(15) Performance of therapeutic
phlebotomy;
(16) Administration of medications or
fluids via a nontunneled, nonimplanted central venous catheter;
(17) Aspiration of an arterial line;
(18) Withdrawal of blood specimens via a
central venous catheter; or
(19) Initiation and removal of a
peripherally inserted central, midclavicular, or midline catheter.
Section 7. Incorporation by Reference.
(1) The following material is incorporated by reference:
(a) "Policies and Procedures for
Infusion Nursing", Fourth Edition, 2011; and
(b) "Infusion Nursing: Standards of Practice",
2011.
(2) This material may be inspected,
copied, or obtained, subject to applicable copyright law, at the Board of
Nursing, 312 Whittington Parkway, Suite 300, Louisville, Kentucky, Monday
through Friday, 8 a.m. to 4:30 p.m. (30 Ky.R. 2585; Am. 31 Ky.R. 369; 546; eff.
9-15-2004; 32 Ky.R. 2324; 33 Ky.R. 382; eff. 9-1-2006; 36 Ky.R. 2073-A; 2312;
eff. 6-15-2010; TAm eff. 7-15-2010; 37 Ky.R. 2446; 2830; eff. 6-15-2011; 38
Ky.R. 1764; 1945; eff. 6-20-2012.)
