LPN-C

1. LPN-C Unit One Legal Aspects of IV Therapy

2. Scope of Practice R/T IV Therapy • LPN-C = An LPN who has had additional education and has passed an examination to obtain certification in an advanced role permitting him/her to provide limited services in intravenous therapy. • LPN-C is the licensed title • An LPN can ONLY practice IV therapy under the LPN-C scope in the state of certification

3. Scope of Practice (cont’d) • Application requirements for a certificate to practice as an LPN-C are as follows: • Current license to practice as an LPN in the state of Nebraska • Successful completion of an approved certification course within one year of certification application • Submission of proof of certification course completion • Satisfactory passing of board approved exam for certification: 80% out of 100 multiple choice questions (results within 30 days)

4. Licensed Practical Nurse-CertifiedAct • Purpose: • To provide a means by which licensed practical nurses-certified (LPN-C) may perform certain activities related to intravenous therapy • To provide for the approval of certification courses to prepare licensed practical nurses-certified (LPN-C) • To ensure the health and safety of the general public

5. Scope and Authority of the Practice of LPN-C in the State of Nebraska Title 172, Chapter 102 • Perform limited IV therapy interventions under the direction of an RN or licensed practitioner. • Observe, initiate, monitor, discontinue, maintain, regulate, adjust, document, assess, plan, intervene, and evaluate with regard to IV treatment. • Provide IV interventions only when there is a licensed practitioner or RN assessing the patient at least once every 24 hours ( or more frequently with significant change in therapy or condition).

6. IV therapy is the responsibility of the RN as ordered by the licensed practitioner: • The RN must perform a physical assessment prior to initial IV insertion. • The RN need not be on premises in order for the LPN-C to perform directed activities EXCEPT: • Initial venipuncture for a peripheral line • Central line activities • The RN must be present at least once in 24 hours. • The RN must be present more than once in 24 hours in cases of a significant change in therapy or client condition.

7. LPN-C IV Activities(*Refer to LPN/LPN-C Comparison Chart) • Expanded scope of practice • LPN license AND certification as an LPN-C required • Approved certification course • Examination • General and direct supervision • Assessment by RN or licensed practitioner required every 24 hours (or more frequently when change in client’s condition or IV therapy occurs)

8. LPN-C ActivitiesAdult Patients(*Direct Supervision) • Initial venipuncture to upper extremity (with use of 3-inch device or less) • NOTE: RN MUST PERFORM FACE-TO-FACE ASSESSMENT OF PATIENT PRIOR TO IV INSERTION • Infuse IV fluids and administer medications through a continuous flow central line • NOTE: INFUSING FLUIDS AND ADMINISTERING MEDICATIONS THROUGH AN INTERMITTENT CENTRAL LINE IS NOT PERMITTED • Administer the initial dose of an approved medication • May add 500cc Dextrose 10% as a meal replacement

9. LPN-C ActivitiesAdult Patients(*Under Direction) • Venipuncture to upper extremity (with use of 3-inch device or less) • Infuse IV fluids and administer medications through an intermittent OR continuous flow peripheral line • Calculate and regulate rate of flow • Administer approved medications via push OR piggyback • Reinsert, convert and flush peripheral intermittent devices • Flush peripheral lock with heparin or saline solution • Add pain medication solutions to a PCA pump

10. LPN-C ActivitiesPatient-Controlled Analgesia (PCA) • Pain medication MUST be • Prepared by a pharmacist or physician • Prepared by the RN • Commercially prepared • All ordered settings and medications for PCA MUST be • Checked by the RN • Signed on the PCA infusion sheet

11. LPN-C ActivitiesPediatric Patients(*Under Direction) • Pediatric Patient = one who is both younger than 18 years of age AND under 35 KG • Administer pain medications by PCA • Only if medication is commercially prepared or prepared by physician, pharmacist, or RN • Always checked by RN after PCA pump has been set per order and before infusion is started • RN must sign the PCA infusion sheet • Flush intermittent peripheral device • May NOT calculate the rate of IV fluid infusions • May NOT perform venipuncture

12. Medications that are NOTapproved forLPN-C administration are as follows: • Blood • Blood products • Antineoplastic agents • Oxytocics • Pitocin • Ergotrate • Methergine • Syntocinon • Anti-arrhythmics • Hyperalimentation

13. IV administration by the LPN-C of approved medications by approved methods shall be those for which nursing interventions are routine and predictable in nature related to individual responses and adverse reactions. The RN must consider: • Adverse consequences • How adverse consequences are manifested • How adverse consequences are measured • What intervention is required • How intervention is applied

14. LPN-C Renewal • Certification as an LPN-C must be renewed along with LPN license • Must complete 5 hours of IV-related continuing education; these hours can be included in the 20 hours required for LPN renewal • Renewal of LPN license and certification is due on or before October 31st during odd-numbered years

15. Clinical Competencies for HLTH1210 The LPN must demonstrate the ability to: • Select administration site • Hands • Forearms • Antecubitus • Upper arm • Assemble equipment and set up flow control administration devices • Gravity • Pump(s)

16. Clinical Competencies (cont’d) • Perform at least 3 venipunctures in the lab and/or clinical area under the direct supervision of faculty • Selection of appropriate site • Preparation of site • Selection of appropriate type/size of catheter • Completing the venipuncture • Securing the device • Problem-solve non-functioning peripheral IV lines • Convert and flush a peripheral intermittent infusion device • Drawing up correct irrigant

17. Clinical Competencies (cont’d) • Add a fluid to a functioning central venous line • Change central line tubing and sterile dressings at insertion site • Document the insertion of a peripheral IV • Document the administration of select fluids • Document the administration of acceptable medications • Add a fluid and/or medication to an infusion pump • Change tubing • Reset administration parameters

18. Pathway to achieving and demonstrating competence in IV therapy Study the professional and legal implications of expanded practice and accountability ↓ Undertake study relating to IV therapy, obtaining knowledge, skills, and evidence for practice ↓ Undergo a period of supervision from faculty who is experienced in IV therapy ↓ Demonstrate competence

19. It is essential for the LPN to develop a knowledge base in the following areas: 1. Accountability 2. Circulatory anatomy and physiology 3. Fluid and electrolyte balance 4. Techniques and equipment used for IV therapy administration 5. Pharmacology 6. Administration of fluids 7. Risk management relating to IV therapy 8. Possible effects of treatment on the patient physically, socially, and psychologically

20. Elements of Competence • Describes the rationale for administration of medications via IV • Describes the risks associated with IV medication administration • Demonstrates knowledge of medications routinely administered by IV in the clinical area • Describes the signs and symptoms exhibited if a medication reaction occurs • Describes and takes appropriate action in the event of a medication reaction • Correctly calculates doses, volumes, and rates of medications to be given by IV

21. Elements of Competence (cont’d) • Demonstrates appropriate techniques and actions in preparation of medications for IV administration • Demonstrates SAFE practice in the administration of prescribed IV medications • Demonstrates appropriate techniques in the administration of IV medications by bolus or infusions-over-time • Demonstrates health promoting practices in caring for IV access and medication administration • Describes how to act appropriately in the event of a drug error or adverse incident associated with administration of IV medications

22. Elements of Competence (cont’d) • Demonstrates awareness of professional accountability • Demonstrates knowledge of available resources related to medication information, local policy, and current evidence for practice

23. The Five Rights of Medication Administration • Right patient • Right medication • Right dose • Right route • Right time

24. The Three Checks of Medication Administration 1. Read the label of the medication as it is removed from the shelf, unit dose cart, refrigerator, or dispensing system 2. Read the label of the medication when comparing it with the MAR 3. Read the medication label again before administering the medication to the patient

25. Medication Verification (cont’d) • LOOK at the label for verification of the medication name, dosage, route, and expiration date • CHECK the medication itself, NOT just the pharmacy label • Be overly cautious with regards to dose, proper dilution, and administration rate • Watch decimal points • Be aware of the unit • Is the medication dispensed in mcg or mg? • What is ordered in comparison?

26. Infusion Nurses Society (INS)(781) 440-9408www.ins1.org • Recognized globally as an authority in infusion therapy • Places the highest priority on the care and safety of patients receiving infusion therapy • Dedicated to exceeding the public’s expectations of excellence by setting the standard for infusion care • Developed standards of practice backed by evidence-based research • Supports professional certification

27. The INS’s Infusion Nursing Standards of Practice • The Standards of Practice have undergone an extensive review process by INS nurses, pharmacists, physician, legal advisors, healthcare clinicians, and manufacturers of infusion therapy products • Defines the accountability of nursing in the participation and delivery of specialized nursing care • Provides measurable components in establishing nursing competencies, performance improvement criteria, and identification and evaluation of patient outcomes

28. INS Standards of Practice (cont’d) • Used as a framework for the development of organizational infusion-based policies and procedures applicable for all practice settings and all patient populations • The Infusion Nurses Society’s Infusion Nursing Standards of Practice include nursing practice, patient care, documentation, infection control and safety compliance, infusion equipment, site selection and device placement, access devices, site care and maintenance, infusion-related complications, nursing interventions, nonvascular access devices, and infusion therapies

29. Legal Aspects of IV Therapy Administration • Legal aspects of IV therapy administration are important as your role as LPN is expanding • With the increase in responsibility comes an increase in liability • You have a duty to care for the patient without exceeding the scope of your LPN Certification • Knowledge of the standards of practice within the bounds of the LPN Certification is critical to malpractice prevention • Over 85% of hospitalized patients will receive IV therapy

30. Legal Aspects (cont’d) • Of the 180 million IV’s inserted, 150 million are peripheral IV’s • Therefore, there are 150 million opportunities for the nurses who insert peripheral lines to become involved in litigation • Most lawsuits involve cases of infiltration and phlebitis that juries feel could have been prevented

31. Liability Issues • Infiltration = the leakage of IV solution or medication into surrounding tissue • The nurse is responsible for selecting the appropriate device, needle gauge, venipuncture technique, and venipuncture site • If an infiltration occurs, the priority concerns include: • What was the solution that infiltrated? • Could the vesicant cause tissue necrosis? • How much of the solution infiltrated? • How soon was the infiltration discovered? • Was the patient injured by the infiltrate? • What injury occurred (i.e. nerve compression, tissue loss, disfigurement, loss of function)?

32. Causes of Legal Action inNursing Practice • The two most common causes of legal action in nursing practice are • Unprofessional practice = failure to conform to minimal standards • Professional malpractice (civil action) = professional misconduct or unreasonable lack of skill that results in harm • Professional nursing practice is measured based on what a reasonable and prudent nurse would do • Measuring tools include the Nurse Practice Act, institutional policy and procedures, the Nurse’s Code of Ethics, and HIPAA

33. Nurse Practice Act • Determines the scope of professional nursing practice in a particular state • Establishes guidelines whereby the nurse can perform skills or services • Describes rules and regulations that provide guidance • Establishes educational, examination, and behavioral standards for nurses that protect the public • Enforces these requirements

34. Institutional Policy and Procedures • KNOW the specific policy and procedures related to LPN-C functions in your facility Code of Ethics • Statement of values developed by the American Nurses Association (ANA) to provide guidance to the nurse and protection for the client and family

35. Code of Ethics (cont’d) • Correlates with the Patient’s Bill of Rights • Consists of ethical principles that dictate nursing action: • Autonomy = the right to independence • Beneficence = doing good for patients • Nonmaleficence = doing no harm to patients • Veracity = truthfulness • Fidelity = an obligation to be faithful • Justice = an obligation to be fair to all people • In decision-making, the nurse’s choices and actions should ideally reflect three criteria: • They should be best-practice clinically • They should be within the legal scope of policies, procedures, and practice acts • They should be the right things to do morally

36. Dilemmas of Autonomy • Involves freedom to take action for self and make decisions that will impact own welfare • Ability to determine personal goals • Complete understanding of choice • Freedom to implement plan or choice • Dilemmas of autonomy are often related to beneficence issues • Occurs when individuals other than the patient must determine, or attempt to determine, what’s best for the patient

37. Dilemmas of Beneficence • Involves acting in the best interest of others, such as through patient advocacy • To contribute to the well-being of others • To promote good • To prevent harm • To remove harm • Dilemmas of beneficence occur when health care providers, the patient, and/or family members disagree about what course of action is in the patient’s best interest

38. Dilemmas of Nonmaleficence • Involves the avoidance of intentional or unintentional harm • Related to the principle of beneficence • Often involves the nurse’s responsibility to “blow the whistle” if another is seen as compromising the patient’s safety • The nurse is charged with protecting those that cannot protect themselves, such as the mentally challenged, the unconscious, the weak, and the debilitated • Discourages experimental health research that may have a negative outcome • Prohibits the performance of unnecessary procedures used as learning experiences

39. Dilemmas of Veracity • Veracity = truthfulness • Patients may not be given information about health care treatment or outcomes if the information would cause further harm to the patient • Not telling the patient the truth may show lack of respect for others and untrustworthiness of the person telling the lies or omitting the truth

40. Dilemmas of Fidelity • Embodies the nurse’s duty to be loyal, faithful, and keep promises • Dilemma occurs when the nurse is forced to be loyal and accountable to two opposing interests • One situation may be a conflict between duties and loyalties to the patient and the economic needs of the employer -- • Example: The nurse is forced to discharge a patient from outpatient care because the patient can no longer pay for services

41. Dilemmas of Justice • Encompasses the nurse’s duty to be fair and equitable, and provide access and appropriate care to all patients • Begs the question, “Who is entitled to these goods and services?”, when dividing limited health care services • One example may be an organ procurement system

42. Moral Dilemmas • Moral dilemmas occur when one must make choices that are complicated by uncertainty, psychological pressures, and personal emotions • In health care, choices must often be made quickly, further complicating the dilemma • Ethics, the law, and best practice do not always agree -- • Example: A patient verbalizes to the nurse that she does not want to have surgery, but has given consent because her husband insisted. Since this is not a valid consent via informed consent protocol, the nurse contacts the physician even though the surgery is in the patient’s best interests.

43. The Health Insurance Portability and Accountability Act (HIPPA) • Protects the patient’s privacy, confidentiality, and security of medical information • ONLY those who need to know patient information for the care of the patient, and those authorized by the patient to have access to his or her medical information, can lawfully enter a patient’s medical record • Take care when faxing patient information • Health care facilities must demonstrate that their computer systems are trustworthy enough to be used in court (i.e. software automatically records entries with time, date, and author; when an error is corrected, the software preserves both original and corrected versions)

44. The Patient’s Bill of Rights • Guarantees certain rights and privileges to every patient • The nurse shall be an advocate for the patient’s rights • The Bill of Rights should be given to each patient upon admission to a health care facility

45. Areas Most at Risk for Malpractice • A study of 747 malpractice claims in which nursing negligence (i.e. failure to adhere to a standard of care) led to a settlement was conducted in 1997 • Of the 747 cases, 219 resulted in death • 76 of these deaths were related to inadequate communication to the physician • 46 were caused by inadequate assessment • Medication errors led to 42 deaths • 17 resulted from inadequate nursing intervention • 21 deaths were caused by inadequate care • 7 deaths were due to an unsafe environment • 7 were related to inadequate infection control • 3 deaths were caused by the improper use of equipment and products

46. Most Common Causes of Lawsuits*All involved failure to maintain a standard of practice • Medication and treatment errors • Lack of observation and timely reporting on the patient • Defective technology or equipment • Infections caused or worsened by poor nursing care • Poor communication of important information • Failure to intervene to protect the patient from poor medical care

47. Factors Impacting Practice Standards • Certain knowledge and skills are essential to nursing practice • In court, it is difficult to argue the 5 rights of safe drug administration • The public is better informed than they used to be • When accidents or injuries occur, the public expects accountability • Patients are more acutely ill on admission to the hospital and more invasive treatments are required, which can lead to more accidents • Nursing shortage and cost containment increases nurse-to-patient ratios

49. Legal Terms • Tort = a wrong committed by an act or an omission • There are two types of torts – • Intentional: Assault, battery, restraints as a form of false imprisonment, slander, and breach of confidentiality • Unintentional: Negligence • Assault = the unjustifiable attempt or threat to touch a person without consent that results in fear of immediately harmful or threatening contact (actual contact need not occur) • Battery = the unlawful, harmful, or unwarranted touching of another, or the carrying out of threatened physical harm, REGARDLESS of the intent or outcome

50. Legal Terms (cont’d) • Invasion of privacy is an intentional tort that may involve • Releasing private information about a patient to a third party • Allowing unauthorized persons to read a patient’s medical records • Allowing unauthorized persons to observe a procedure • Taking pictures of a patient without his or her consent • Slander = making false statements about a patient that cause damage to the patient’s reputation