Arizona Board of Nursing Revised Date 03/10; 9/13, 5/20, 7/21
Reviewed by Sedation Certification – June 13, 2023
State Sedation Policy – Yes
Can LPN’s give sedation? – No
Can RN’s give sedation? – Yes
Can RNs give anesthetic medications? – Yes, but only under certain circumstances.
Can RN’s give Ketamine? – Yes, read Advisory Opinion link
Contact the Board of Nursing if you have any questions!
Doug Ducey – Governor
Joey Ridenour – Executive Director
Arizona State Board of Nursing
1740 W Adams Street, Suite 2000
Phoenix, AZ 85007
Phone (602) 771-7800
Home Page: www.azbn.gov
OPINION: SEDATION: DEEP, MODERATE AND PALLIATIVE
DATE APPROVED: 1/07
REVISED DATE: 03/10; 9/13, 5/20, 7/21 ORIGINATING COMMITTEE
SCOPE OF PRACTICE COMMITTEE
An advisory opinion adopted by AZBN is an interpretation of what the law requires. While an advisory opinion is not law, it is more than a recommendation. In other words, an advisory opinion is an official opinion of AZBN regarding the practice of nursing as it relates to the functions of nursing. Facility policies may restrict practice further in their setting and/or require additional expectations related to competency, validation, training, and supervision to assure the safety of their patient population and or decrease risk.
Within the Scope of Practice of __X__RN ____LPN
SEDATION: DEEP, MODERATE, AND PALLIATIVE
STATEMENT OF SCOPE
Administration of medications for moderate sedation, rapid sequence intubation (RSI), and deep or palliative sedation, including the administration of anesthetic agents, is NOT within the LPN scope of practice. The licensed practical nurse (LPN) scope of practice is limited to the administration and monitoring of medications (e.g., opioids) given for minimal sedation (anxiolysis).
It is NOT within the scope of practice of a registered nurse (RN) who is not a certified registered nurse anesthetist (CRNA) to provide deep sedation for non-ventilated patients or to administer or monitor medications given to a general anesthesia level.
It is within the scope of practice of an RN to administer medications to clinical response, when general requirements are met for the purpose(s) of:
a. Deep sedation of a patient in acute care settings in the following situations: 1) intubated, 2) mechanically ventilated (including continuous positive airway pressure [CPAP]), or 3) assisting with RSI.
b. Moderate sedation for diagnostic or therapeutic procedures when a qualified licensed independent practitioner (LIP) is present at the bedside.
c. Palliative (end of life) care.
Medications used for sedation may include opioids, barbiturates, and anesthetic agents. Anesthetic agents are intended to be administered at sub-anesthetic dosages; however, it should be noted that sedation exists along a continuum, and RNs who administer moderate sedation or deep sedation (with a ventilated patient) must be qualified to provide rescue support to patients who proceed to a deeper level of sedation.
The RN has the right and obligation to refuse to administer and/or continue to administer medication(s) in amounts/frequency that may produce sedation at a deeper level than desired.
Anesthetic agents administered locally to block sensations of pain in a specific area of the body and are not injected into the vascular system are not included in this advisory.
See also Definitions section (following Rationale section).
I. GENERAL REQUIREMENTS
A. Written policies and procedures are developed and maintained by the
employer/facility. These policies must include, but are not limited to:
1. Sedation medications must be prescribed within applicable legal and policy constraints by a credentialed and privileged licensed independent practitioner
2. Levels of sedation RNs may assist with at their facility.
3. An interdisciplinary team, that includes RN participation, identifies approved medications, including age-appropriate dosages, to be utilized for each level of sedation.
4. If titration is used, the RN must have a medication order that contains specific parameters for the titration based on a validated sedation scale and/or monitoring device data.
5. Emergency equipment, medications, and supplies must be available within
the immediate work area and appropriate to the age of the patient being sedated.
6. Guidelines and equipment for patient monitoring, drug administration, and addressing potential complications.
7. Documentation and monitoring requirements for level of sedation and physiologic measurements (e.g., blood pressure, respiratory rate, oxygen saturation, capnography, heart rate, and cardiac rhythm).
8. Venous access will be maintained for all patients having moderate sedation, RSI, or deep sedation.
9. Documentation of basic life support (BLS) is required for palliative sedation.
10. Documentation of advanced life support is required for moderate to deep sedation.
11. Only RNs who have completed an instructional program and have had supervised clinical practice can administer and manage deep, moderate, and palliative sedation.
B. Specific requirements related to individual sedation levels:
1. Deep sedation:
a. Identification of which medications and/or anesthetic agents can be given by the RN as a continuous administration (non-bolus), IV bolus or push
(intermittent dose), or titration to clinical response for patients who are intubated and mechanically ventilated.
b. The RN provides and documents ongoing monitoring, including oxygenation, respiratory or ventilator rate, cardiac rhythm, and blood pressure measurements.
c. Equipment for suctioning and maintaining the airway/resuscitation is available.
2. Rapid sequence intubation (RSI) or drug assisted intubation (DAI):
a. Identification of which medications and/or anesthetic agents can be given by IV bolus or push by the RN assisting the LIP during an intubation.
b. Equipment for suctioning and maintaining the airway/resuscitation is available.
c. Note: This does not apply to prehospital or transport personnel providing emergency care while in direct communication with their medical director or while following approved medical protocols.
3. Moderate sedation (procedural or conscious sedation):
a. Identification of which medications and/or anesthetic agents can be given by the RN as a continuous administration (non-bolus), IV push
(intermittent dose), or titration to clinical response.
b. The LIP ordering the medication and performing procedures for moderate sedation must be credentialed for such medications and must be at the bedside from the time the medication is initiated through the completion of the procedure.
c. A LIP capable of managing complications must be immediately available in the facility during the post-procedure period and must remain in the facility until the patient is medically discharged from the post-procedure area.
d. The RN administering medications and monitoring the patient receiving moderate sedation will have no other duties that would interfere with primary responsibility of monitoring the patient during the procedure.
e. A pre-sedation assessment and collaborative sedation plan must be performed for each patient by the LIP and administering RN to determine that the patient is a candidate for moderate sedation.
f. Supplemental oxygen must be available during and throughout the recovery period.
g. Documentation and monitoring of physiologic measurements including, but not limited to blood pressure, respiratory rate, oxygen saturation, heart rate and cardiac rhythm, and level of consciousness via approved scale is recorded per facility guidelines during the procedure and throughout the recovery period. Documentation of adequate ventilation using continuous capnography is strongly recommended.
4. Palliative care sedation:
a. Identification of which medications and/or anesthetic agents can be administered as a continuous infusion, IV bolus, or IV push (intermittent dose) for the purpose of palliative sedation without the presence of an LIP.
b. Pre- and post-sedation symptom assessments and ongoing assessments are performed by the RN to maintain sedation at the ordered level. Monitoring may or may not include electronic physiological monitoring modalities.
II. COURSE OF INSTRUCTION
A. Only RNs who have the knowledge and have demonstrated competency may administer deep, moderate, or palliative sedation. The instructional program includes, but not limited to:
1. Anatomy and physiology of the respiratory system including principles of oxygen delivery, gas exchange, transport, and uptake.
2. Physiology of levels of sedation including minimal sedation,
moderate sedation, deep sedation and anesthesia.
3. Indications and contraindications for the sedation level to be provided
and potential adverse consequences including over or under sedation.
4. Legal implications, responsibility, and documentation associated with sedation.
5. Pharmacology of drugs used singly or in combination for sedation and anesthesia including drug implementation and discontinuation, action, onset, peak, duration, side effects, contraindications, and adverse reactions.
6. Knowledge regarding administration of available reversal agents for sedation and anesthesia agents, as applicable.
7. Required nursing interventions in the event of complications
or adverse outcomes.
8. Assessment of patients receiving deep, moderate, or palliative sedation.
9. Use of specialized monitoring devices or sedation scales.
10. Education specific for different types of sedation or specific agents:
a. If providing deep sedation: instruction in mechanical ventilation including mode of ventilation.
b. For palliative-specific sedation, knowledge of the process of dying and death, and end of life symptom assessment and management of care.
Because medicine is ever evolving, this advisory opinion is not intended to limit what medications can or cannot be given but rather to focus the nurse on providing safe care at the desired level of sedation.
The administration of anesthetics for the purpose of general anesthesia is outside of the scope of practice for RNs or advanced practice nurses who are not a CRNA. However, it is within the scope of practice of the RN to safely provide sedation, including the use of an anesthetic agent, provided the conditions set in this advisory opinion are met. The ultimate responsibility of the RN is to assure patient safety and this independent obligation under his or her licensure supersedes any LIP order or facility policy.
Anesthetic agents are medications which cause partial or complete loss of sensation with or without loss of consciousness.
Immediately available is defined as being present in the facility and not otherwise engaged in any other uninterruptable procedure or task.
IV bolus is a small volume of medication or large volume solution that is given rapidly intravenously (IV) to hasten or magnify the response.
IV push is the direct injection of medication via an IV. The rate of injection is determined by the type of the medication being given and the patient’s response.
Licensed independent practitioner (LIP) is a physician, dentist, nurse practitioner, nurse midwife, certified nurse anesthetists, or any individual permitted by law and the organization to provide care and services without direction or supervision within the scope of the individual’s license.
Minimal sedation (anxiolysis) is a drug-induced state during which patients respond normally to verbal commands, may have impaired cognitive function or coordination but respiratory and cardiovascular functions remain stable.
Moderate sedation (procedural or conscious sedation) is defined as “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. Centers for Medicare and Medicaid Services (CMS) consistent with American Society of Anesthesiologist (ASA) guidelines, does not define moderate or conscious sedation as anesthesia” (CMS, 2011).
Deep sedation is a drug-induced depression of consciousness during, which patient cannot be easily aroused but responds purposefully, following repeated or painful stimulation. While, cardiovascular function is usually maintained, the ability to independently maintain respiratory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate, therefore the patient must be intubated and mechanically ventilated. *Reflex withdrawal from a painful stimulus is NOT considered a purposeful response.
General anesthesia is a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. General anesthesia affects the patient’s ability to maintain an adequate airway and respiratory function and may impair cardiovascular function.
Palliative sedation is the monitored use of medications at end of life intended to provide relief of intolerable and refractory symptoms but not to intentionally hasten death. This distinction separates it from euthanasia and/or assisted suicide where the intent is solely to end life. A refractory symptom is one that cannot be controlled in a tolerable time frame despite use of therapies and seems unlikely to be controlled by further therapies without excessive or intolerable acute or chronic side effects/complications.
Rapid sequence intubation (RSI) or drug assisted intubation (DAI) is an airway management technique in which a powerful sedative or anesthetic induction agent is administered virtually simultaneously with a paralytic agent.
ADVISORY OPINION KETAMINE ADMINISTRATION
STATEMENT OF SCOPE
It is NOT within the Scope of Practice of a Registered Nurse (non-CRNA) to administer IV
Ketamine for the purposes of anesthesia. For sub-anesthetic ketamine given for sedation, refer to the Sedation: Deep, Moderate, and Palliative advisory opinion.
It is NOT within the Scope of Practice of a Registered Nurse (non-CRNA) to administer IV or
intranasal Ketamine via bolus dose for analgesia, except in areas capable of monitoring and
managing complications of unintended sedation as per the Sedation: Deep, Moderate, and
Palliative advisory opinion.
It is within the Scope of Practice of a Registered Nurse (RN) to administer low-dose (subanesthetic) IV or intranasal Ketamine for the purposes of pain control (analgesia), depression, and sedation