September 12, 1980 Subject: Nurse Practice Act; Administration of Certain Medications Pursuant to Standing Orders to Patients in Venereal Disease Clinic of Local Health Department.
Requested By: Mr. Dwight H. Wheless Dare County Attorney
Question: May a registered nurse administer certain medication pursuant to standing orders to a patient in a venereal disease clinic of a local health department after it is determined that he has a gonorrheal type discharge or is a contact of a case of gonorrhea?
Conclusion: Yes. Standing orders in a venereal disease clinic of a local health department provide as follows:
"TREATMENT OF GONORRHEA IN ABSENCE OF PHYSICIAN:
When a person presents himself to the Dare County Health Department and either states that he has a gonorrheal type discharge or is a contact of a case of gonorrhea and no physician is in attendance the clinic nurse may administer orally as follows:
- Appropriate cultures and serology on all new patients.
- Inquire carefully about sensitivity to medications, especially Penicillin.
- Ask about LMP; use of contraceptives and possibility of pregnancy
- If culture is positive or if patient is a contact
- Oral Penicillinn routine
- If allergic to Penicillin use Tetracycline routine.
- If pregnant use Spectinomycin and follow up with serology in three months for syphilis.
- Try to find out contacts and get them in for treatment."
The practice of medicine entails the diagnosis, treatment, operation on and prescription for any human ailment. See G.S. 90-18. The practice of nursing by a registered nurse includes "the administration of medications and treatment as prescribed by a licensed physician." See G.S.
90-158(3)a. Standing orders describe certain conditions and the medication to be given to the patients for whom the conditions are found to exist. The 1973 Legislative Research Commission Report to the General Assembly on the Nurse Practice Act stated that "Under current law, a physician may not delegate the authority to make a medical diagnosis or to determine the treatment modality. Thus, if the standing orders provide the nurse with guidelines for translating symptoms into a treatable condition, the orders are invalid." The validity of the standing orders under consideration therefore depend on whether recognition of the condition or conditions for implementation of the orders require diagnosis of a human ailment and on whether the physician who wrote the orders or the nurse implementing the orders is the one who determines the treatment modality.
In the present case, the determination of a positive culture (a serology is performed on a female patient; a gram stain, on a male patient) or that the patient is a contact triggers the administration of certain medications. n1 The recognition of either condition does not involve the translation of symptoms into a treatable condition. Secondly, upon determination of either condition, specific medications are fixed in the standing orders are administered by the registered nurse. The physician who wrote the standing orders is the one who prescribed the appropriate medication for the gonorrhea. The physician is the one who determined the treatment modality. The registered nurse who implements the standing orders under consideration is administering medication within the boundaries of the Nurse Practice Act.
n1 The language of the standing orders should be revised to more clearly describe the procedure which is actually followed. For example, a serology is not "(administered) orally."
Therefore, it is the opinion of this Office that a registered nurse may administer the described medications pursuant to standing orders to a patient in a venereal disease clinic of a local health department after it is determined that he has a gonorrheal type discharge or is a contact of a case of gonorrhea.
Rufus L. Edmisten Attorney General
Robert R. Reilly Assistant Attorney General