Iowa Admin. Code r. 655-6.3

Current through Register Vol. 47, No. 5, September 4, 2024

Rule 655-6.3 - Standards of nursing practice for licensed practical nurses

(1) The licensed practical nurse shall recognize and understand the legal boundaries for practicing nursing within the scope of nursing practice. The scope of practice of the licensed practical nurse is determined by the nurse's education, experience, and competency and the rules governing nursing.

(2) The licensed practical nurse shall demonstrate professionalism and accountability by:

a. Demonstrating honesty and integrity in nursing practice.

b. Basing nursing decisions on nursing knowledge and skills, the needs of patients, and licensed practical nursing standards.

c. Maintaining competence through ongoing learning and application of knowledge in practical nursing practice.

d. Reporting instances of unsafe nursing practices by self or others to the appropriate supervisor.

e. Being accountable for judgments, individual nursing actions, competence, decisions, and behavior in the course of practical nursing practice.

f. Assuming responsibility for the nurse's own decisions and actions.

g. Wearing identification which clearly identifies the nurse as a licensed practical nurse when providing direct patient care unless wearing identification creates a safety or health risk for either the nurse or the patient.

(3) The licensed practical nurse, practicing under the supervision of a registered nurse, advanced registered nurse practitioner (ARNP), or licensed physician, consistent with the accepted and prevailing practices and practice setting, may participate in the nursing process by:

a. Participating in nursing care, health maintenance, patient teaching, evaluation and collaborative planning and rehabilitation to the extent of the licensed practical nurse's education, experience, and competency.

b. Conducting a thorough, ongoing nursing assessment based on the patient's needs after the initial assessment is completed by the registered nurse.

c. Assisting the supervising registered nurse, ARNP, or physician in planning for patient care by identifying patient needs and goals.

d. Demonstrating attentiveness and providing patient surveillance and monitoring.

e. Seeking clarification of orders when needed.

f. Obtaining education and ensuring competence when encountering new equipment, technology, medication, procedures or any other unfamiliar care situations.

g. Implementing treatment and therapy as identified by the patient's overall health care plan.

h. Documenting nursing care accurately, thoroughly, and in a timely manner.

i. Evaluating continuously the patient's response to nursing care and other therapies, including:

(1) Patient's response to interventions.

(2) Need for alternative interventions.

(3) Need to communicate and consult with other health team members.

(4) Need to revise the plan of care.

j. Collaborating and communicating relevant and timely patient information with patients and other health team members to ensure quality and continuity of care, including:

(1) Patient concerns and special needs.

(2) Patient status and progress.

(3) Patient response or lack of response to interventions.

(4) Significant changes in patient condition.

(5) Interventions which are not implemented, based on the licensed practical nurse's professional judgment, and providing:

1. A timely notification to the physician, ARNP, registered nurse, or other health care provider who prescribed the intervention that the order was not executed and reason(s) for not executing the order;

2. Documentation in the medical record that the physician, ARNP, registered nurse, or other health care provider was notified and reason(s) for not implementing the order; and

3. If appropriate, a timely notification to other persons who, based on the patient's circumstances, should be notified of any orders which were not implemented.

k. Providing a safe environment for the patient.

l. Participating in the health care education of the patient and others, according to nursing standards and evidence-based practices.

(4) A licensed practical nurse shall not perform any activity requiring the knowledge and education of a registered nurse, including but not limited to:

a. Initiating a procedure or therapy that requires the knowledge and education level of a registered nurse.

b. Performing an assessment of a procedure or therapy that requires the knowledge and education level of a registered nurse.

c. Initiating or administering blood components.

d. Initiating or administering medications requiring the knowledge and education level of a registered nurse.

(5) A licensed practical nurse, under the supervision of a registered nurse, may engage in the limited scope of practice of intravenous therapy. The licensed practical nurse shall be educated and have documentation of competency in the limited scope of practice of intravenous therapy. Limited scope of practice of intravenous therapy may include:

a. Addition of intravenous solutions without adding medications to established peripheral intravenous sites.

b. Monitoring and regulating the rate of nonmedicated intravenous solutions to established peripheral intravenous sites.

c. Administration of maintenance doses of analgesics via the patient-controlled analgesia pump set at a lock-out interval to established peripheral intravenous sites.

d. Discontinuation of peripheral intravenous therapy.

e. Administration of a prefilled heparin or saline syringe flush, prepackaged by the manufacturer or premixed and labeled by a registered pharmacist or registered nurse, to an established peripheral lock, in a licensed hospital, a nursing facility or a certified end-stage renal dialysis unit.

(6) In a certified end-stage renal dialysis unit, nursing tasks which may be delegated by a registered nurse to a licensed practical nurse, for the sole purpose of hemodialysis treatment, include:

a. Initiation and discontinuation of the hemodialysis treatment utilizing any of the following established vascular accesses: central line catheter, arteriovenous fistula, and graft.

b. Administration, during hemodialysis treatment, of local anesthetic prior to cannulation of the vascular access site.

c. Administration of prescribed dosages of heparin solution or saline solution utilized in the initiation and discontinuation of hemodialysis.

d. Administration, during hemodialysis treatment via the extracorporeal circuit, of the routine intravenous medications erythropoietin, Vitamin D Analog, intravenous antibiotic solutions prepackaged by the manufacturer or premixed and labeled by a registered pharmacist or registered nurse, and iron, excluding any iron preparation that requires a test dose. The registered nurse shall administer the first dose of erythropoietin, Vitamin D Analog, antibiotics, and iron.

(7) The licensed practical nurse shall act as an advocate for the patient by:

a. Always practicing under the supervision of a registered nurse, ARNP, or physician.

b. Respecting the patient's rights, confidentiality, concerns, decisions, and dignity.

c. Identifying patient needs.

d. Attending to patient concerns or requests.

e. Promoting a safe environment for the patient, others, and self.

f. Maintaining appropriate professional boundaries.

(8) The licensed practical nurse shall apply the delegation process when delegating to another licensed practical nurse by:

a. Delegating only those nursing tasks that fall within the scope of practice of a licensed practical nurse.

b. Delegating only those nursing tasks that fall within the delegatee's scope of practice, education, experience, and competence.

c. Matching the patient's needs and circumstances with the delegatee's qualifications, resources, and appropriate supervision.

d. Communicating directions and expectations for completion of the delegated activity and receiving confirmation of the communication from the delegatee.

e. Supervising the delegatee by monitoring performance, progress and outcomes and ensuring appropriate documentation is complete.

f. Evaluating patient outcomes as a result of the delegation process.

g. Intervening when problems are identified, revising plan of care when needed, and reassessing the appropriateness of the delegation.

h. Retaining accountability for properly implementing the delegation process.

i. Promoting a safe and therapeutic environment by:

(1) Providing appropriate monitoring and surveillance of the care environment;

(2) Identifying unsafe care situations; and

(3) Correcting problems or referring problems to appropriate management level when needed.

(9) The licensed practical nurse shall apply the delegation process when delegating to an unlicensed assistive personnel (UAP) by:

a. Delegating only those nursing tasks that fall within the scope of practice of a licensed practical nurse.

b. Ensuring the UAP has the appropriate education and training and has demonstrated competency to perform the delegated task.

c. Ensuring the task does not require assessment, interpretation, and independent nursing judgment or nursing decision during the performance or completion of the task.

d. Ensuring the task is consistent with the UAP's scope of employment and can be safely performed according to clear and specific directions.

e. Verifying that, in the professional judgment of the delegating nurse, the task poses minimal risk to the patient.

f. Communicating directions and expectations for completion of the delegated activity and receiving confirmation of the communication from the UAP.

g. Supervising the UAP and evaluating the patient outcomes of the delegated task.

(10) The licensed practical nurse may provide nursing care in an acute care setting so long as a registered nurse, ARNP, or physician is present in the proximate area. Acute care settings requiring a registered nurse, ARNP, or physician to be in the proximate area include but are not limited to:

a. Units where care of the unstable, critically ill, or critically injured individual is provided.

b. General medical-surgical units.

c. Emergency departments.

d. Operating rooms. (A licensed practical nurse may assist with circulating duties when supervised by a registered nurse circulating in the same room.)

e. Postanesthesia recovery units.

f. Hemodialysis units.

g. Labor and delivery/birthing units.

h. Mental health units.

i. Diagnostic testing centers.

j. Surgery centers.

k. Outpatient procedure centers.

(11) The licensed practical nurse may provide nursing care in a non-acute care setting. However, a registered nurse, ARNP, or physician must be present in the proximate area if the licensed practical nurse provides nursing care in the following non-acute care settings:

a. Community health settings, except:

(1) The licensed practical nurse shall be permitted to provide supportive and restorative care in the home setting under the supervision of a registered nurse or a physician. However, the initial assessment shall be provided by the registered nurse, and the licensed practical nurse is responsible for requesting nurse consultation as needed.

(2) The licensed practical nurse shall be permitted to provide supportive and restorative care in a camp setting under the supervision of a registered nurse or a physician. However, the initial assessment shall be performed by the registered nurse, and the licensed practical nurse is responsible for requesting registered nurse consultation as needed.

b. Schools, except:

(1) The licensed practical nurse shall be permitted to provide supportive and restorative care to a specific student in the school setting in accordance with the student's health plan when under the supervision of, and as delegated by, the registered nurse employed by the school district.

(2) The licensed practical nurse shall be permitted to provide supportive and restorative care in a Head Start program under the supervision of a registered nurse or a physician if the licensed practical nurse was in this position prior to July 1, 1985.

c. Occupational health settings.

d. Correctional facilities, except:

(1) The licensed practical nurse shall be permitted to provide supportive and restorative care in a county jail facility or municipal holding facility operating pursuant to Iowa Code chapter 356. The supportive and restorative care provided by the licensed practical nurse in such facilities shall be performed under the supervision of a registered nurse. However, the initial assessment shall be performed by the registered nurse, and the licensed practical nurse is responsible for requesting registered nurse consultation as needed. The registered nurse shall be available 24 hours per day by teleconferencing equipment.

(2) Reserved.

e. Community mental health settings.

f. Health care clinics, except:

(1) The licensed practical nurse shall be permitted to conduct height, weight and hemoglobin screening and record responses to health questions asked in a standardized questionnaire under the supervision of a registered nurse in a Women, Infants and Children (WIC) clinic. A registered nurse employed by or under a contract with the WIC agency will assess the competency of the licensed practical nurse to perform these functions and must be available for consultation. The licensed practical nurse is responsible for requesting registered nurse consultation as needed.

(2) The licensed practical nurse shall be permitted to provide care, including but not limited to dispensing medications such as methadone, buprenorphine, and naltrexone, in opioid treatment program facilities and opioid treatment medication units. A registered nurse employed by or under a contract with the opioid treatment program or opioid treatment medication unit will assess the competency of the licensed practical nurse to dispense medications and must be available for consultation at all times. The licensed practical nurse is responsible for requesting registered nurse consultation as needed.

(12) A licensed practical nurse may be permitted to supervise other licensed practical nurses or unlicensed assistive personnel, pursuant to Iowa Code section 152.1(5)"b," in the following practice settings, in accordance with the following:

a. A licensed practical nurse working under the supervision of a registered nurse may be permitted to supervise in an intermediate care facility for persons with an intellectual disability or in a residential health care setting.

b. A licensed practical nurse working under the supervision of a registered nurse who is in the proximate area may direct the activities of other licensed practical nurses and unlicensed assistive personnel in an acute care setting in giving care to individuals assigned to the licensed practical nurse.

c. A licensed practical nurse working under the supervision of a registered nurse may supervise in a nursing facility if the licensed practical nurse completes the National Healthcare Institute's Supervisory Course for Iowa's Licensed Practical Nurses within 90 days of employment in a supervisory role. Documentation of the completion of the course shall be maintained by the licensed practical nurse. A licensed practical nurse shall be entitled to supervise without completing the course if the licensed practical nurse was performing in a supervisory role on or before October 6, 1982. A licensed practical nurse who is currently enrolled as a full-time student in a registered nurse program and is scheduled to graduate within one year is not required to complete the course. If the licensed practical nurse does not obtain a registered nurse license within one year, the licensed practical nurse must take the course to continue supervisory duties.

(13) A licensed practical nurse shall be permitted to practice as a diagnostic radiographer while under the supervision of a licensed practitioner provided that appropriate training standards for use of radiation-emitting equipment are met as outlined in 641-Chapter 42.

(14) A licensed practical nurse shall be permitted to perform, in addition to the functions set forth in subrule 6.3(5), procedures related to the expanded scope of practice of intravenous therapy upon completion of the board-approved expanded intravenous therapy certification course and in accordance with the following:

a. To be eligible to enroll in the course, the licensed practical nurse shall:

(1) Hold a current unrestricted Iowa license or an unrestricted license in another state recognized for licensure in this state pursuant to the nurse licensure compact contained in Iowa Code chapter 152E.

(2) Have documentation of 1,040 hours of practice as a licensed practical nurse.

(3) Be practicing in a licensed hospital, a nursing facility or a certified end-stage renal dialysis unit whose policies allow the licensed practical nurse to perform procedures related to the expanded scope of practice of intravenous therapy.

b. The course must be offered by an approved Iowa board of nursing provider of nursing continuing education. Documentation of course completion shall be maintained by the licensed practical nurse and employer.

c. The board-approved course shall incorporate the responsibilities of the licensed practical nurse when providing intravenous therapy via a peripheral intravenous catheter, a midline catheter and a peripherally inserted central catheter (PICC) to children, adults and elderly adults.

d. Upon completion of the course, when providing intravenous therapy, the licensed practical nurse shall be under the supervision of a registered nurse. Procedures which may be performed if delegated by the registered nurse are as follows:

(1) Initiation of a peripheral intravenous catheter for continuous or intermittent therapy using a catheter not to exceed three inches in length.

(2) Administration, via a peripheral intravenous catheter, midline catheter, and a PICC line, of premixed electrolyte solutions or premixed vitamin solutions. The first dose shall be administered by the registered nurse. The solutions must be prepackaged by the manufacturer or premixed and labeled by a registered pharmacist or registered nurse.

(3) Administration, via a peripheral intravenous catheter, midline catheter, and a PICC line, of solutions containing potassium chloride that do not exceed 40 meq per liter and that do not exceed a dose of 10 meq per hour. The first dose shall be administered by the registered nurse. The solutions must be prepackaged by the manufacturer or premixed and labeled by a registered pharmacist or registered nurse.

(4) Administration, via a peripheral intravenous catheter, midline catheter, and a PICC line, of intravenous antibiotic solutions prepackaged by the manufacturer or premixed and labeled by a registered pharmacist or registered nurse. The first dose shall be administered by the registered nurse.

(5) Maintenance of the patency of a peripheral intravenous catheter, midline catheter, and a PICC line with a prefilled heparin or saline syringe flush, prepackaged by the manufacturer or premixed by a registered pharmacist or registered nurse.

(6) Changing the dressing of a midline catheter and a PICC line per sterile technique.

e. Intravenous therapy procedures which shall not be delegated by the registered nurse to the licensed practical nurse are as follows:

(1) Initiation and discontinuation of a midline catheter or a PICC.

(2) Administration of medication by bolus or IV push except maintenance doses of analgesics via a patient-controlled analgesia pump set at a lock-out interval.

(3) Administration of blood and blood products, vasodilators, vasopressors, oxytoxics, chemotherapy, colloid therapy, total parenteral nutrition, anticoagulants, antiarrhythmics, thrombolytics, and solutions with a total osmolarity of 600 or greater.

(4) Provision of intravenous therapy to a patient under the age of 12 or any patient weighing less than 80 pounds, with the exception of those activities authorized in the limited scope of practice found in subrule 6.3(5).

(5) Provision of intravenous therapy in any other setting except a licensed hospital, a nursing facility and a certified end-stage renal dialysis unit, with the exception of those activities authorized in the limited scope of practice found in subrule 6.3(5).

Iowa Admin. Code r. 655-6.3

ARC 9329B, IAB 1/12/11, effective 2/16/11

Amended by IAB February 24, 2021/Volume XLIII, Number 18, effective 3/31/2021

Amended by IAB November 17, 2021/Volume XLIV, Number 10, effective 12/22/2021