Administration of Additional Dosage of Caudal Analgesia

Subject:

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