Title: Administration of Medications for Sedation/Analgesia
(formerly Procedural Sedation and/or Mild to Moderate Sedation/Analgesia)
Advisory Ruling Number: 9101
Authority: The Massachusetts Board of Registration in Nursing (Board) issues this Advisory Ruling on nursing practice pursuant to Massachusetts General Laws, chapter 30A, section 8 and chapter 112, section 80B.
Date Issued: 9/21/91
Date Revised: 9/26/96, 11/10/99, 6/10/09, 9/11/13
Scope of Practice: Registered Nurse
Purpose: To guide the practice of the Registered Nurse (RN) whose clinical responsibilities include the administration and management of medications intended to produce a depressed level of consciousness.
Minimal sedation is defined by the American Society of Anesthesiologists (ASA)* as a drug-induced state during which patients respond normally to verbal commands. Although cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are unaffected.
Moderate sedation/analgesia is defined by ASA* as a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulations, patients do not require intervention to maintain a patent airway, maintain adequate spontaneous ventilation, and usually do not require intervention to maintain cardiovascular function.
Deep Sedation is defined by ASA* as a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired and may cause spontaneous ventilation to be inadequate; the patient may require assistance in maintaining a patent airway. Cardiovascular function is usually maintained.
Such practice must be in compliance with: G.L. c. 112, s. 80B; 244 CMR 3.02: Responsibility and Functions - Registered Nurse; 244 CMR 9.03 (5): Adherence to Standards of Nursing Practice; 244 CMR 9.03 (9): Responsibility and Accountability; 244 CMR 9.03 (10): Acts within Scope of Practice; 244 CMR 9.03 (11): Performance of Techniques and Procedures; 244 CMR 9.03 (12): Competency; 244 CMR 9.03(14): Asepsis and Infection Control; 244 CMR 9.03(35) Security of Controlled Substances; 244 CMR 9.03 (38): Administration of Drugs; 244 CMR 9.03(39) Documentation of Controlled Substances; and 244 CMR 9.03(44): Documentation.
Advisory: The RN licensed by the Board will engage in the practice of nursing in accordance with accepted professional standards.** The nurse must only assume those duties and responsibilities within the scope of practice for which necessary knowledge, skills, and abilities have been acquired and maintained.
Administration of Medications Intended for Mild to Moderate Sedation
The RN who is duly educated and qualified may receive, accept, and transcribe orders from duly authorized prescribers for medications capable of producing minimal to moderate sedation/analgesia.
The RN may administer medications intended for minimal to moderate sedation/analgesia when ordered by a duly authorized prescriber.
Professional standards recognize the nurse as responsible and accountable for possessing the knowledge, skills and abilities to perform the activity safely, effectively and competently including, but not limited to:
- patient selection and screening;
- pharmacological selection, properties and mechanism of physiological response;
- competent and safe administration of the medication by the specified route;
- ability to anticipate and recognize potential complication of the medications being administrated; and
- ability to recognize and appropriately react to emergency situations.
Organizational policies must include, but are not limited to:
- listing the specific medications to be used for sedation/analgesia including the purpose, goals, techniques, desired outcomes of administration, and the recommended dose per kilogram of body weight that may be safely administered by a RN, taking into account the patient’s age and co-morbidities;
- nursing care responsibilities, including, but not limited to patient assessment, monitoring, medication administration, potential complications, and documentation criteria;
- emergency protocols including, but not limited to, immediate, on site availability of resuscitative equipment, medications and personnel;
- protocols for assessing and documenting the education and validation for RN initial competency and continued competency; and
- protocols for provision of clear, complete and culturally appropriate informed consent.
Administration of Medications Intended for Deep Sedation
A RN who is duly educated and qualified may receive, accept, and transcribe orders from duly authorized prescribers for medications capable of producing deep sedation.
The RN may administer medications intended for deep sedation when ordered by a duly authorized prescriber to a patient who is intubated.
The RN may administer medications intended for deep sedation when ordered by a duly authorized prescriber to a non-intubated patient when, in addition to those listed above, organizational policies must require:
- the registered nurse whose sole responsibility is to manage the patient's airway does so in the presence of a provider trained in anesthesia or expert in airway management; and
- uninterrupted monitoring of patient consciousness and the early detection of adverse signs of deep sedation is provided by an individual with no other significant responsibilities that would compromise or compete with his/her ability to continually monitor the patient.
* American Society of Anesthesiologists (ASA) continuum of Depth of Sedation: Definition of General Anesthesia and Levels of Sedation/Analgesia (2009)
** Professional standards include, but are not limited to the following:
American Association of Nurse Anesthetists
Emergency Nurses Association
American Nurses Association
Society of Gastroenterology Nurses
American Association of Moderate Sedation Nurses
American College of Emergency Physicians
American Society of Anesthesiologists