Can a registered nurse give a refill dose of caudal anesthesia through a catheter the physician already set in place, when the physician orders the specific refill amount each time?

Plain-English summary

The North Carolina Board of Medical Examiners asked whether a registered nurse could give an additional dose of caudal analgesia through a catheter already placed by a physician. In the described hospital practice, the physician inserted the catheter and gave the first dose. When its effect waned, the nurse contacted the physician, who prescribed each refill dose; the nurse then injected that dose through the catheter.

The 1979 Attorney General answered yes for that sequence. G.S. 90-158(3) a. included administration of medications and treatments prescribed by a licensed physician or dentist within registered nursing. The opinion described catheter insertion and prescribing dose amounts as traditional physician functions, and observing the patient, contacting the physician, and administering a directly ordered dose as traditional RN functions.

The AG said injection through the caudal catheter required more skill and judgment than oral medication, but that degree of skill was not the test for distinguishing an RN's role from a physician's. The opinion did not decide whether a nurse could insert the catheter, with or without a physician's order, and did not classify insertion as surgery.

Currency note

This opinion was issued in 1979 under the Nurse Practice Act and hospital procedure described in the request. Verify current North Carolina nursing and medical practice law before applying it today.

What this means for you

Registered nurses. The opinion approved the described refill administration after the attending physician prescribed a new dose. It did not approve standing refills without renewed physician contact.

Physicians and hospital staff. The answer depends on the specific allocation of tasks stated in the request: physician catheter placement and dose prescription, nurse observation and administration under direct orders. The opinion leaves catheter insertion by an RN unanswered.

Common questions

Could an RN give the next dose through the catheter?

Yes, under the described arrangement. The physician prescribed each refill dose after being contacted, and the RN administered that dose by syringe through the catheter already in place.

Did the AG decide whether an RN could insert the catheter?

No. A physician inserted it in the facts presented. The opinion calls insertion a traditional physician function, but does not analyze whether a nurse could perform it on a physician's order or call it a surgical act.

Was a standing order for all later doses enough?

The opinion does not address that. Its facts say the RN contacted the physician for a new order before each additional dose.

Did technical difficulty alone put injection outside RN practice?

No. The AG acknowledged the extra skill involved but said skill level was not the physician-versus-RN test for this task.

Background and statutory framework

G.S. 90-158(3) a. included administration of physician-prescribed medications and treatments in the definition of registered nursing. The opinion also cites the Board of Nursing's August 1977 interpretation, which lists responsibilities for verifying and implementing medication orders. G.S. 90-18 supplied the physician-function comparison. Applying those sources to the stated hospital procedure, the AG concluded the RN could administer additional prescribed analgesic doses through the physician-placed catheter.

Citations

• G.S. 90-158(3) a.
• G.S. 90-18

Source

• Landing page: https://ncdoj.gov/opinions/administration-of-additional-dosage-of-caudal-analgesia/

Original opinion text

Requested By: Mr. Bryant D. Paris, Jr., Executive Secretary North Carolina Board of Medical Examiners

Question: Following the setting in place of the needle for the injection of caudal analgesia and the administration of such analgesia to the patient, is it permissible for a registered nurse to administer additional dosage of the same medication pursuant to direct orders from the attending physician?

Conclusion: Yes.

The question concerns the general practice and procedure at Wake County Hospital System, Inc. and Rex Hospital with respect to the administration of caudals. A caudal catheter is put in place by a physician. The catheter is a teflon tube which is inserted in the caudal space between the dura, which encloses the spinal cord and fluid, and the epidural space. An initial or charge-up dosage of the analgesic agent (either Marcaine or Nescaine) is administered by the physician by injection with a syringe into the catheter. The physician gauges from the patient's response to the initial dosage the proper amount for a refill dose. The physician instructs the registered nurse to call him or her when the analgesic begins to wear off. The physician then prescribes the refill dosage which the registered nurse administers by injection with a syringe through the caudal catheter which remains continuously in place. All subsequent refill doses are administered by the registered nurse only after the physician has been contacted and issues a new order.

G.S. 90-158(3) a. of the Nurse Practice Act defines "Nursing by a Registered Nurse" as follows:

"The practice of nursing by registered nurse means the performance for compensation of any act in the observation, care, and counsel of persons who are ill, injured, or experiencing alterations in normal health processess; and/or in the supervision and teaching of others who are or will be involved in nursing care; and/or the administration of medications and treatments as prescribed by a licensed physician or dentist. Nursing by registered nurses requires specialized knowledge, judgment, and skill, but does not rquire nor permit except under supervision of a physician licenses to practice medicine in North Carolina medical diagnosis or medical prescription of therapeutic or corrective measures. The use of skill and judgment is based upon an understanding of principles from the biological, social, and physical sciences. Nursing by registered nurse requires use of skills in modifying methods of nursing care and supervision as the patient's needs change."

The phrase "the administration of medications and treatments as prescribed by a licensed physician or dentist" is the focus of our inquiry. The North Carolina Board of Nursing's "Interpretation of the Legal Definitions of Nursing Practice" (Adopted August, 1977) sets forth the functions of a registered nurse as including:

"4. administration of medications and treatments – the RN is accountable for:

a. verifying that the medical order is accurate, appropriate, properly authorized and there are no documented reasons to contraindicate administration; b. understanding the purpose of the medications and treatments; c. determining: schedule, observations to be made, actions to be taken; d. assigning of actions to self or other personnel for implementation; and, e. establishing that the nursing staff member to whom action is assigned has the necessary competence and credentials to administer the medications and treatments."

The traditional functions of a physician, as codified in G.S. 90-18, are to diagnose, treat, operate on and prescribe. The insertion of the catheter and the prescription of dosages of an analgesic agent are traditional and accepted functions of a physician. The observation of the patient, the notification of the physician of a change in a patient's condition and the administration of dosages of an analgesic agent pursuant to the direct orders of the attending physician are the traditional and accepted functions of a registered nurse. See G.S. 90-158(3) a. and the "Interpretations" of the Board of Nursing. The administration of dosages by a registered nurse through a caudal catheter by injection with a syringe clearly involves more skill and judgment than the oral administration of medications. However, the degree of skill and judgment involved is not the test for discerning a physician's function from a legitmate function of a registered nurse. (The degree of skill and judgment does distinguish nursing by a registered nurse from nursing by a licensed practical nurse.) Rather, the test is whether the function involves diagnosis, treatment, surgery or prescription for any human ailment. (See G.S. 90-18.) As noted above, the registered nurse does not perform any of these physician functions.

Therefore, it is the opinion of this Office that the administration of additional dosage of the same medication through a caudal catheter by injection with a syringe pursuant to direct order from the attending physician may be performed by a registered nurse.

Rufus L. Edmisten
Attorney General

Robert R. Reilly
Assistant Attorney General