Delaware Administrative Code
Title 24 - Regulated Professions and Occupations
Department of State
Division of Professional Regulation
1900 - Board of Nursing
Section 1900-7.0 - Standards of Nursing Practice
Universal Citation: 24 DE Admin Code 1900-7.0
Current through Register Vol. 28, No. 3, September 1, 2024
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 Board that interpret the legal definitions of nursing, as well as provide criteria against which violations of the law can be determined. Such standards shall not be assumed the only evidence in civil malpractice litigation, nor shall they be given a different weight than any other evidence.
"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 Registered and Licensed Practical Nurse, and to serve as a guide for the Board to evaluate safe and effective nursing practice.
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 act.
"Supervision" - The guidance by a registered nurse (RN) for the accomplishment of a function or activity. The guidance consists of the activities included in monitoring as well as establishing the initial direction, delegating, setting expectations, directing activities and courses of action, critical watching, overseeing, evaluating, and changing a course of action.
"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 Del.C. § 1921(a)(4) of the Nurse Practice Act).
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.
Disclaimer: These regulations may not be the most recent version. Delaware may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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