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
Bryant D. Paris, Jr., Executive Secretary of the North Carolina Board of Medical Examiners, described a practice at Wake County Hospital System and Rex Hospital and asked whether it complied with the Nurse Practice Act. A physician places a caudal catheter, a teflon tube inserted into the epidural space between the dura and the spinal cord, and administers the first dose of an analgesic (Marcaine or Nescaine) through it. When the patient's pain returns, the nurse contacts the physician, the physician prescribes a refill dose, and the nurse injects that dose through the catheter that remains in place.
The 1979 AG concluded that this practice falls within the scope of registered nursing under G.S. 90-158(3)a. The opinion identifies the components of the practice and sorts each into either physician practice or nursing practice. Insertion of the catheter and prescription of dose amounts are physician work under G.S. 90-18 (the practice of medicine, defined as diagnosis, treatment, surgery, and prescription). Observation of the patient, notification of the physician when the analgesic begins to wear off, and administration of the physician-prescribed dose are nursing work under G.S. 90-158(3)a.
The opinion went out of its way to address an argument from skill or technical difficulty: surely catheter-injection requires more skill than oral administration of a pill. The AG said yes, but skill level is not the test for separating physician and nursing functions. The test is whether the act involves diagnosis, treatment, surgery, or prescription. The RN's role at the refill stage does none of those things. The physician has already done all of them by the time the nurse administers the refill dose. Skill level distinguishes RN practice from LPN practice, but not RN practice from medical practice.
Currency note
This opinion was issued in 1979. Subsequent statutory amendments, court decisions, or later AG opinions may have changed the analysis. Treat this page as historical context, not current legal advice. Verify current law before relying on any specific rule, deadline, or remedy mentioned here. The Nurse Practice Act has been amended several times since 1979, and modern scope-of-practice rules for advanced practice nurses (CRNAs in particular) differ from the framework the 1979 opinion analyzed. A current question about who can administer epidural or caudal anesthesia should be addressed to the North Carolina Board of Nursing and counsel familiar with current regulations.
Historical context: what the AG concluded
The opinion's analytical move is the sort-and-classify approach to scope of practice. Every act in the sequence (insertion, initial dose, observation, communication, refill dose) is examined separately. Each act gets assigned to either the medical practice category or the nursing practice category based on its statutory definition.
Insertion of the caudal catheter is treatment, which is medical practice. Initial dose prescription is prescription, which is medical practice. Each refill dose prescription is also prescription, which is medical practice. The physician must do those four things.
Observation of the patient is nursing practice. Notification of the physician of changes in patient condition is nursing practice. Administration of a physician-prescribed dose is nursing practice. The nurse does those three things.
The AG also pointed at the Board of Nursing's then-current "Interpretation of the Legal Definitions of Nursing Practice" (August 1977), which spells out the components of RN-administered medication: verifying the order, understanding the purpose, determining schedule and observations, and delegating implementation. None of those components require the RN to make a medical diagnosis or prescribe a treatment, even when the medication itself is unusual or technically demanding to administer.
The skill-versus-function distinction is the most generally applicable piece. A nurse can perform a technically difficult act and still be inside scope of practice if the act does not involve diagnosis, treatment, surgery, or prescription. Conversely, a nurse cannot perform a technically simple act if it does involve any of those four functions. The test is statutory category, not difficulty.
Background and statutory framework
The North Carolina Nurse Practice Act, codified in Article 9A of Chapter 90, defines the practice of nursing by a registered nurse in G.S. 90-158(3)a. The definition is broad: observation, care, counsel, supervision, teaching, and administration of medications and treatments prescribed by a licensed physician or dentist. The act explicitly excludes medical diagnosis and prescription unless under physician supervision.
G.S. 90-18 defines the practice of medicine in terms of four functions: diagnosis, treatment, surgery, and prescription. The two statutes operate as a paired scope-of-practice scheme. Anything that falls within G.S. 90-18 is medical practice and requires a medical license. The nurse can administer the result of physician practice (the prescribed medication) but cannot perform the physician practice itself.
Caudal anesthesia was an established obstetric pain management technique by 1979. The teflon catheter approach allowed continuous or intermittent dosing without repeated needle insertions. The technique required the physician to make the initial puncture and insertion (a surgical and treatment act) and to set the dose based on patient response. The nurse role was to maintain the open catheter, observe the patient, and administer prescribed refill doses on the physician's direct order.
The Board of Nursing's 1977 Interpretation operated as the bridge between the broad statutory definition and the specific question. It enumerated the RN's accountability framework for administration of medications: verifying the order is accurate and properly authorized, understanding the purpose, determining schedule and observations, and assigning actions to qualified personnel. That framework treats administration as the RN's work, regardless of the technical complexity of the administration route.
Common questions
Why did the Board of Medical Examiners ask the AG instead of asking the Board of Nursing?
The two boards regulate overlapping practices. The Board of Medical Examiners polices medical practice; the Board of Nursing polices nursing practice. When a procedure sits at the boundary between the two, both boards have an interest. Asking the AG produces a neutral interpretation that binds neither board to the other's view but gives both a common framework to work from.
Could a nurse insert the catheter as well, if the physician ordered it?
No, under the 1979 framework. Insertion of the catheter is a surgical act, which is physician practice under G.S. 90-18. The Nurse Practice Act does not authorize the RN to perform surgery, even on physician order. The opinion did not address advanced practice (CRNA) scope, which has expanded significantly since 1979 and may permit different conclusions today.
What about emergency situations where the physician is unavailable for each refill dose?
The opinion did not address standing orders or protocols for refill doses in emergencies. The factual setup describes the physician being contacted before each refill. A standing-orders question would require its own analysis, and the AG addressed standing orders separately in other 1979 to 1980 opinions on specific health services (gonorrhea treatment, for example) where the protocol could be written narrowly enough to avoid requiring nursing diagnosis.
Did the opinion approve any particular medication?
No. The opinion focused on the role assignment, not on Marcaine, Nescaine, or any specific drug. The framework would apply to any analgesic administered through a physician-placed catheter on physician-prescribed dose orders.
Does the answer change if the patient's condition deteriorates between doses?
The opinion does not address that scenario directly. The Board of Nursing's framework requires the RN to verify that administration is "appropriate" and that no "documented reasons" contraindicate it. A clinical change might mean the RN should withhold administration and consult the physician again rather than administering the previously ordered dose. That decision is an exercise of nursing judgment, not medical diagnosis.
Source
Citations
- G.S. 90-158(3) a.
- G.S. 90-18
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