End of COVID-19 Emergency Orders and State of Emergency by October 31

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Commonly Asked Questions - Licensed Practical Nurse

Overview

The broadly written laws and rules allow nurses to practice to their full scope of practice in any setting. It is impossible for the Nursing Care Quality Assurance Commission (NCQAC) to provide a comprehensive listing of the duties that licensed nurses are permitted to perform since nursing practice is reflective of the dynamic changes occurring in healthcare and society. The Revised Code of Washington (RCW) 18.79 and Washington Administrative Code (WAC) 246-840 provide the statutory and legal basis of nursing practice. The nursing commission provides advisory opinions and interpretive statements about specific areas of nursing practice.

These commonly asked questions and answers offer information and general guidance regarding the practice of professional nursing in the State of Washington and do not constitute legal advice. You should contact your legal advisor to obtain advice with respect to any particular issue or problem.

If you have a question related to nursing practice in the state of Washington, please contact nursingpractice@doh.wa.gov or arnppractice@doh.wa.gov for questions about advanced nursing practice.

Cardiology and Respiratory Procedures
Can a licensed practical nurse assist in performing a needle decompression for a tension pneumothorax?

It is within the scope of practice of the appropriately prepared and competent licensed practical nurse to assist an authorized health care practitioner, or a registered nurse, to perform needle decompression for a tension pneumothorax, following clinical practice standards. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice.

Can the licensed practical nurse change or reposition a tracheostomy tube?

It is within the scope of practice of an appropriately trained and competent licensed practical nurse to perform routine and non-complex tracheostomy care under the direction of an authorized health care practitioner, or under the direction and supervision of the registered nurse, following clinical practice standards including:

  • Suctioning of a non-established or established tracheostomy stoma. The licensed practical nurse may assist an authorized health care practitioner or the registered nurse in suctioning a fresh tracheostomy stoma;
  • Changing, repositioning, or reinserting a tracheostomy tube in an established tracheostomy tract, (Decannulation before a mature tract is an emergency situation as well as a complex procedure and is not within the scope of the licensed practical nurse. The licensed practical nurse may assist an authorized health care practitioner or the registered nurse in reinsertion of a tracheostomy tube if the decannulation occurs before the tract is established.);
  • Tracheostomy site care and dressing changes; and
  • Inflation and deflation of cuff in a healed and established stoma.

The licensed practical nurse should use the Scope of Practice Decision Tree to determine if the activity is within the nurse's legal and individual scope of practice. Standing orders may be used. See the Nursing Care Quality Assurance Commission's Neonatal Intubation and Related Procedures Advisory Opinion for additional information.

Can the licensed practical nurse perform cardiac stress testing?

It is within the scope of practice of an appropriately trained and competent licensed practical nurse to perform a routine and non-complex cardiac stress test under the direction of an authorized health care practitioner, or under the direction and supervision of a registered nurse, following clinical practice standards. A prescription or order from an authorized health care practitioner is required. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice. There may be other regulations, such as Centers for Medicare and Medicaid Services (CMS) who defines the requirements for supervision (general or direct), and other parameters, for reimbursement of the procedure.

Can the licensed practical nurse perform endotracheal intubation or other resuscitative procedures?

The Nursing Care Quality Assurance Commission determines it is beyond the scope of the licensed practical nurse due to the complexity of the activity to perform endotracheal intubation. The licensed practical nurse may be a member of the team and assist in performing individual activities during resuscitation based on the Scope of Practice Decision Tree under the direction of an authorized health care practitioner, or under the direction and supervision of the registered nurse, following clinical practice standards. See the Nursing Care Quality Assurance Commission's for additional information.

Can the licensed practical nurse perform pulmonary functioning testing?

It is within the scope of practice of an appropriately trained and competent licensed practical nurse to perform routine and non-complex pulmonary functioning testing under the direction of an authorized health care practitioner, or under the direction and supervision of a registered nurse, following clinical practice standards. A prescription or order from an authorized health care practitioner is required. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice. There may be other regulations, such as Centers for Medicare and Medicaid Services (CMS) who defines the requirements for supervision (general or direct), and other parameters for reimbursement of the procedure.

Can the licensed practical nurse perform respiratory therapy procedures?

It is within the scope of practice of an appropriately trained and competent licensed practical nurse to perform routine and non-complex respiratory therapy procedures under the direction of an authorized health care practitioner, or under the direction and supervision of the registered nurse, following clinical practice standards. It may be within the scope of practice for the licensed practical nurse to perform respiratory therapy procedures and activities such as administering or adjusting oxygen settings, adjusting ventilator settings, nebulizer treatments, suctioning, chest physical therapy, nebulizer treatments, intermittent positive pressure breathing therapy, or pulmonary function testing. Medical regimens require a prescription or order from an authorized health care practitioner. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice. The licensed practical nurse may not use the title of respiratory therapist unless the nurse is dually licensed.

Can the licensed practical nurse pull an intra-aortic balloon pump (IABP) and temporary pacer wires?

The Nursing Care Quality Assurance Commission determines it is beyond the scope of the licensed practical nurse to remove an IABP or temporary pacing wires due to the complexity of the procedure and concerns about the stability of the patient. The licensed practical nurse may assist an authorized health care practitioner or the registered nurse in performing this activity.

The licensed practical nurse should use the Scope of Practice Decision Tree to determine if any of the activities the licensed practical nurse is assisting with, is within the nurse's legal and individual scope of practice.

Is it with the scope of the licensed practical nurse to perform pulmonary artery pressure monitoring procedures?

The Nursing Care Quality Assurance Commission determines it is beyond the scope of the licensed practical nurse to perform pulmonary artery pressure monitoring procedures due to the complexity of the procedure. The licensed practical nurse may assist an authorized health care practitioner or the registered nurse in performing this activity. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice.

Is it within the scope of practice of a licensed practical nurse to administer the OSHA Respirator Medical Evaluation Questionnaire in accordance with the OSHA Respirator Protection Standard (29 CFR 1910.134) and perform a respiratory fit test?

It is within the scope of the appropriately prepared and competent licensed practical nurse to assist an authorized health care practitioner, or the registered nurse, in performing the OSHA Respirator Medical Evaluation Questionnaire and perform a respiratory fit test, following clinical practice standards. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if the activity is within the nurse's legal and individual scope of practice. Please see the regulations for OSHA Respirator Medical Evaluations. The licensed practical nurse may initiate the evaluation and/or respiratory fit testing following standing orders. The Nursing Care Quality Assurance Commission's Standing Orders and Verbal Orders Advisory Opinion and Verbal Orders provides additional guidance and recommendations.

Is it within the scope of the licensed practical nurse to assist in removing trans-thoracic (epicardial) pacing wire following open-heart surgery?

It is within the scope of practice of the appropriately prepared and competent licensed practical nurse to assist an authorized health care practitioner, or the registered nurse, in removing trans-thoracic (epicardial) pacing wire following open-heart surgery, following clinical practice standards. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice.

Is the licensed practical nurse required to have a current first aid certification and cardiopulmonary resuscitation certification (CPR), and if so, does it have to be the health care provider CPR?

The nursing laws and rules do not require the licensed practical nurse to maintain first aid certification, CPR or stipulate whether the licensed practical nurse needs to have Basic Cardiac Life Support (BLS) or have BLS for health care providers. The laws and rules require the licensed practical nurses to demonstrate competence and accountability in all areas of practice in which the nurse is engaged. The licensed practical nurse should consider the area of practice in which the nurse is working. Competent practice may require the administration of first aid and/or CPR. Employers or facilities may require the licensed practical nurse to maintain first aid and/or CPR certification. Some facility laws and rules require nurses to have a CPR certification. For example, WAC 246-320 Hospital Licensing Regulations require at least one nurse to have CPR and at least one nurse to have advanced cardiac life support (ACLS) in recovery areas and in critical care units. In neonatal and pediatric services in hospitals, at least one registered nurse or physician must be trained in infant/pediatric resuscitation; in obstetrics, at least one registered nurse must be trained in neonatal resuscitation when infants are present. WAC 246-330 Ambulatory Surgical Facilities require at least one registered nurse to have current ACLS certification. WAC 388-112-0260 Adult Family Homes and Assisted Living Facilities also have specific requirements for CPR and first aid training. The Centers for Medicaid and Medicare Services (CMS) and accreditation organizations (such as the Joint Commission) may have specific requirements. It is the employer's decision as to the first aid and CPR requirements including and what type (BCLS or BLS for Health Care Providers) in the absence of accreditation or facility regulations. The employer may also decide whether they want to require an in-person course or on-line course and other parameters.

What activities can the licensed practical nurse perform when caring for a patient with a chest tube?

It is within the scope of practice of the appropriately prepared and competent licensed practical nurse to perform the following tasks related to chest tube care under the direction of an authorized health care practitioner, or under the direction and supervision of the registered nurse, following clinical practice standards:

  • Chest tube insertion site are and dressing change;
  • Clamp the tube in an emergency;
  • Administer medications via a chest tube;
  • Monitor patency of the draining system;
  • Assist an authorized health care practitioner or the registered nurse in removing a chest tube; and
  • Assist an authorized health care practitioner or the registered nurse in changing bottles and/or disposable collection system.

It is not within the scope of the licensed practical nurse to perform the following tasks:

  • Independently change out chest tube bottles;
  • Independently remove a chest tube;
  • Independently change a disposable collection system; or
  • Manipulate, advance, irrigate, milk, or remove a chest tube.
Delegation in Community-Based and In-Home Care Settings During the COVID-19 Emergency
Can the registered nurse delegator use telehealth services to initiate and provide ongoing evaluation, and supervision of delegated tasks to UAP in community-based or in-home care settings during the COVID-19 emergency?

The nursing and nursing assistant laws and rules do not prohibit the registered nurse delegator from using telehealth services to initiate or provide ongoing evaluation, or supervision of delegated tasks to UAP. The nurse must use nursing judgment and consider what aspects of the initial and ongoing assessment, supervision, and evaluation need to be done face-to-face. Telehealth may not be appropriate in some circumstances. The most important consideration is whether it is safe for the patient to perform the initial and ongoing assessment, evaluation, or supervision using telehealth services following the nursing and delegation laws and rules (RCW 18.79WAC 246-840RCW 18.88AWAC 246-841).

The Washington State Department of Social and Health Services issued the following policies related to COVID-19, telehealth services, and delegation requirements:

Dermatology and Cosmetic Procedures
Can a licensed practical nurse administer Botox® or inject medications for sclerotherapy, asclerotherapy, or dermal fillers?

The nursing laws and rules allow a competent and appropriately trained licensed practical nurse to administer neuromodulators (such as Botox®, Dysport®, or Xeomin®) or administering medications for sclerotherapy, asclerotherapy, or dermal fillers under the direction of an authorized health care practitioner or under the direction and supervision of a registered nurse. These procedures require a prescription from an authorized health care practitioner. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice. The nursing laws and rules do not require an authorized health care practitioner or registered nurse to be on the premises when a licensed practical nurse provides nursing care or performs medical regimens. However, the Medical Quality Assurance Commission WAC 246-919-606 Nonsurgical Medical Cosmetic Procedures applies to nonsurgical medical cosmetic procedures that involve the injection of a medication or substance for cosmetic purposes, or use of a prescriptive device for cosmetic purposes (except for laser, light, radiofrequency and plasma devices). These rules allow delegation of these procedures to a properly trained licensed practical nurse. The delegating physician need not be on the premises during the procedure, but the physician must be reachable by telephone to be able to respond within thirty minutes to treat complications. The Nursing Care Quality Assurance Commission recommends following the WAC 246-919-606 for physicians.

Can a licensed practical nurse administer Botox® or dermal fillers under the direction of a dentist?

The nursing laws and rules allow a licensed practical nurse to take direction for a medical regimen from a dentist or other authorized health care practitioners practicing within their scope of practice. A dentist may prescribe neuromodulators (such as Botox®) or dermal fillers when it is used to treat functional esthetic dental conditions and their direct esthetic consequences. See the Dentist Scope of Practice - Use of Botulinum Toxin Injections/Dermal Fillers Interpretive Statement for more information.

Can a licensed practical nurse administer laser treatment for cosmetic purposes?

The nursing laws and rules allow a competent and appropriately trained licensed practical nurse from performing laser therapy for cosmetic purposes under the direction of an authorized health care practitioner or under the direction and supervision of a registered nurse. Laser treatment requires a prescription from an authorized health care practitioner. The nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice. The nursing laws and rules do not require an authorized health care practitioner or RN to be on the premises when a LPN provides nursing care or performs medical regimens. However, the Medical Quality Assurance Commission WAC 246-919-605 Use of Laser, Light, Radiofrequency, and Plasma (LLRP) Devices as Applied to the Skin includes language and requirements for physicians. The physician rules allow delegation to a properly trained and licensed professional and require a physician to be on the immediate premises during the patient's initial treatment. The authorized health care practitioner may provide treatment following an established treatment plan during temporary absences of the prescribing physician provided there is a local back-up physician who will be available by telephone and see the patient within sixty minutes. The Nursing Care Quality Assurance Commission recommends the nurse follow the WAC 246-919-605 for physicians when carrying out laser treatment procedures under the direction of an authorized health care practitioner.

Does a licensed practical nurse require an esthetician's license to perform laser treatment for cosmetic purposes?

A licensed practical nurse does not require additional licensure as an esthetician to perform laser therapy for cosmetic purposes.

Does a licensed practical nurse require a special certificate to perform cosmetic procedures such as administering Botox® or performing laser treatments?

The laws and rules do not require a special certificate to perform cosmetic procedures. The nurse must be competent and getting a certificate may be one method to demonstrate training, knowledge, skills, and abilities. A facility or employer may require a specific certification or training program.

Can a licensed practical nurse apply eyelash extensions?

The nursing laws and rules allow a competent and appropriately trained licensed practical nurse to apply eyelash extensions under the direction of an authorized health care practitioner or under the direction and supervision of a registered nurse. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice. The Food and Drug Administration (FDA) approves cosmetics. No color additives are approved by the FDA for permanent dyeing or tinting of eyelashes or eyebrows. False eyelashes and extensions, as well as their adhesives, must meet the safety and labeling requirements for cosmetics. See the Food and Drug Administration's website, Using Eye Cosmetics Safely, for more information.

Can a licensed practical nurse apply Latisse® for eyelash growth?

The nursing laws and rules allow a competent and appropriately trained licensed practical nurse to apply medications, such as Latisse®, used for eyelash growth under the direction of an authorized health care practitioner or under the direction and supervision of a registered nurse. This procedure requires a prescription from an authorized health care practitioner. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice.

Can a licensed practical nurse apply chemical peels and microdermabrasion?

The nursing laws and rules allow a competent and appropriately trained licensed practical nurse to apply superficial chemical peels or microdermabrasion under the direction of an authorized health care practitioner or under the direction and supervision of a registered nurse. These procedures require a prescription from an authorized health care practitioner. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice.

Can a licensed practical nurse perform medical tattooing, body piercing, electrolysis, or application of permanent makeup?

The nursing laws and rules allow a competent and appropriately trained licensed practical nurse to perform medical tattooing, permanent makeup application, body piercing, and electrolysis under the direction of an authorized health care practitioner or under the direction and supervision of a registered nurse. These procedures require a prescription from an authorized health care practitioner. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice.

Can a licensed practical nurse perform body sculpting using cold methods (such as CoolSculpting®) or heat methods (such as Vanquish™) for fat removal?

The nursing laws and rules allow a competent and appropriately trained licensed practical nurse to apply cold therapy (cryotherapy) or heat therapy for fat removal under the direction of an authorized health care practitioner or under the direction and supervision of a registered nurse. These procedures require a prescription from an authorized health care practitioner. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice.

Can a licensed practical nurse perform wart removal using liquid nitrogen (cryotherapy) or topical medications?

The nursing laws and rules allow a competent and appropriately trained licensed practical nurse to perform wart removal using liquid nitrogen or topical medications under the direction of an authorized health care practitioner or under the direction and supervision of a registered nurse. These procedures require a prescription from an authorized health care practitioner. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice.

Can a licensed practical nurse administer phototherapy?

The nursing laws and rules allow a competent and appropriately trained licensed practical nurse to perform phototherapy such as Type B Ultraviolet (UVB), Grenz Ray, or Psoralen and Long-Wave Ultraviolet Radiation (PUVA) under the direction of an authorized health care practitioner or under the direction and supervision of a registered nurse. This procedure requires a prescription from an authorized health care practitioner. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice.

Can a licensed practical nurse perform a fine needle aspiration biopsy, shave biopsy or punch biopsy?

The nursing laws and rules allow a competent and appropriately trained licensed practical nurse to perform a final needle aspiration biopsy, shave biopsy or punch biopsy under the direction of an authorized health care practitioner or under the direction and supervision of a registered nurse. These procedures require a prescription from an authorized health care practitioner. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice.

Can a licensed practical nurse administer intralesional injections?

The nursing laws and rules allow a competent and appropriately trained licensed practical nurse to administer intralesional injections under the direction of an authorized health care practitioner or under the direction and supervision of a registered nurse. This procedure requires a prescription from an authorized health care practitioner. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice.

Can a licensed practical nurse remove skin growths using electrodesiccation and curettage?

The Nursing Care Quality Assurance Commission determines that it is not within the scope of a licensed practical nurse to perform electrodessication and curettage due to the complexity of the procedure. A licensed practical nurse may assist an authorized health care practitioner or registered nurse in performing the procedure, including administering the local anesthetic. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if any activities are within the nurse's legal and individual scope of practice.

Dispensing, Compounding, Legend Drugs, Controlled Substances
Are there any medications that the licensed practical nurse is not allowed to administer?

The nursing law and rule does not prohibit the competent and appropriately trained licensed practical nurse from administering any medication – legend or controlled substance (Schedule II-IV) or over-the-counter medications. The licensed practical nurse may administer medications by any route. The licensed practical nurse must be competent and follow the standards for medication administration.

Can the licensed practical nurse be delegated to enter medication prescriptions into an electronic health system or call in an order to a pharmacy?

Receiving telephone and verbal prescription orders, transcribing, and transmitting prescription orders are activities often performed by nurses and appropriately included by many organizations in the responsibilities of the licensed practical nurse. The licensed practical nurse has the skill and knowledge to receive a prescription order and transcribe it accurately for other nurses to implement or transmit the order to a pharmacist to dispense. There is no law or rule that prohibits the licensed practical nurse from calling in medication orders except for those restrictions in the Controlled Substances Act. The licensed practical nurse may enter medication prescriptions into an electronic health system under the direction of an authorized health care practitioner. These directions may come through standing orders or verbal orders. The standing orders are often used to renew medication prescriptions. See the NCQAC Standing and Verbal Orders Advisory Opinion for guidelines and recommendations. It is within the scope of practice of the appropriately prepared licensed practical nurse to write or enter the information into an electronic health record system the patient demographic information, as well as the drug, dosage, frequency and number of refills on a medical prescription as pursuant to a medical order. The nurse may not sign the nurse's name or the name of the individual authorizing the prescription on the prescription. WAC 246-870 Electronic Transmission of Prescription Information allows electronic prescriptions for legend drugs and controlled substances (except for Schedule II controlled substances). The laws states, “The system shall provide an audit trail of all prescriptions electronically transmitted that documents for retrieval all actions and persons who have acted on a prescription, including authorized delegation of transmission.” The order must be authenticated. See the Washington State Department of Health Pharmacies website for more information.

Can the licensed practical nurse renew a prescription?

It is not within the scope of practice for the licensed practical nurse to renew an existing medication without a new prescription from an authorized health care practitioner. The licensed practical nurse may follow standing orders or verbal orders to renew an existing medication. See the NCQAC Standing and Verbal Orders Advisory Opinion for guidelines and recommendations.

Can the licensed practical nurse give out drug samples?

Giving out drug samples is considered dispensing. Dispensing of medication is outside the scope of practice of the licensed practical nurse. It may be within the scope of practice of the licensed practical nurse to hand a patient a pre-packaged sample that is properly labeled by an authorized health care practitioner or pharmacist. The licensed practical nurse needs to be competent regarding the specific medication including the indications, contraindications, and side effects that is being delivered to the patient. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if handing out a pre-labeled, pre-packed sample is within the licensed practical nurse's regulatory and individual scope of practice.

Can the licensed practical nurse compound medications?

The competent and appropriately trained licensed practical nurse may compound medications under the direction of an authorized health care practitioner or under the direction and supervision of the registered nurse. A prescription or order from an authorized health care practitioner is required. The licensed practical nurse must follow the WAC 246-878 Compounding Practices and the United States Pharmacopeia (USP) compounding guidelines. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if performing compounding medications is within the licensed practical nurse's regulatory and individual scope of practice. See the Compounding Medications by Licensed Practical Nurses, Registered Nurses, and Advanced Registered Nurse Practitioners Advisory Opinion for more information.

Can the licensed practical nurse mix and administer allergy serums?

It may be within the scope of practice of the competent and appropriately trained licensed practical nurse to prepare allergenic extracts as compounded sterile preparations under the direction of an authorized health care practitioner or under the direction and supervision of the registered nurse. A prescription or order from an authorized health care practitioner is required. The licensed practical nurse must follow the WAC 246-878 Compounding Practices and the United States Pharmacopeia (USP) compounding guidelines. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if performing compounding medications and preparing and administering allergenic extracts is within the licensed practical nurse's regulatory and individual scope of practice. See the Compounding Medications by Licensed Practical Nurses, Registered Nurses, and Advanced Registered Nurse Practitioners Advisory Opinion for more information.

Can the licensed practical nurse administer medications following standing orders?

The nursing laws and rules do not prohibit the competent and appropriately trained licensed practical nurse from administering medications following standing orders. See the NCQAC Standing and Verbal Orders Advisory Opinion for guidelines and recommendations. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if administering medications following a specific standing order within the licensed practical nurse's regulatory and individual scope of practice.

Can the licensed practical nurse perform medication reconciliation?

The process for reconciliation of medication is the responsibility of the prescriber. It is important to remember that the licensed practical nurse is not authorized or approved to sign orders that must be reconciled with patient medication. Medication reconciliation is a formal process for creating the most complete and accurate list possible of a patient's current medications and comparing the list to those in the patient record or medication orders. The purpose of reconciliation is to avoid errors that include but are not limited to transcription, omissions, duplication, dosing errors, or drug interactions. Taking a medication history has always been part of the nursing assessment and this information should be conveyed to the prescriber. The NCQAC suggests the following:

  • Follow the policies and procedures relative to the documentation (paper or electronic) system used by the organization.
  • Collect and verify the patient's complete medication history.
  • Clarify that the medications and dosages taken by the patient are correct and enter the information into the patient's record.
  • Notify provider of updated list.
  • Licensed prescriber reviews the medications list and reconciles.
Can the licensed practical nurse administer and read a tuberculosis (TB) skin test?

It may be within the scope of practice of the competent and appropriately trained licensed practical nurse to administer and “read” the TB skin test under the direction of an authorized health care practitioner or under the direction and supervision of the registered nurse. A prescription or order from an authorized provider is required as TB skin test formulations are legend drugs. The Nursing Care Quality Assurance Commission recommends the licensed practical nurse use the Scope of Practice Decision Tree to determine if this activity is within the nurse's regulatory and individual scope of practice. The order may be made using a standing order. The prescriber or the registered nurse does not need to be on onsite when the licensed practical nurse administers medications. The licensed practical nurse should communicate with the medical provider or registered nurse as appropriate or follow standing orders for additional follow-up and referral. The Nursing Care Quality Assurance Commission recommends the licensed practical nurse follow the Washington State Tuberculosis Laws and Guidelines and the Centers for Disease Control Guidelines for TB Screening and Follow-Up. Refer to the Standing Order Advisory Opinion for more information on use of standing orders.

Can the licensed practical nurse fill medication organizers or repackage medications into an individual pill container with individual doses?

The Nursing Care Quality Assurance Commission supports the use of medication organizers following standards of practice for medication administration. It is acceptable for the licensed practical nurse to prepare a medication organizer or individual pill containers under the following conditions:

  • Medications being placed into an organizer or individual pill container must already be dispensed by a pharmacist or other authorized health care provider;
  • The medication organizer or individual pill container must be properly labeled with the patient's name, name of the medication, dosage of each medication, frequency which the mediation is given;
  • The licensed practical nurse must consult with the prescriber, pharmacist or other health care provider as appropriate; and
  • The medication must be stored properly and safely in a secured system.

See the Advisory Opinion on Medisets, the Medication Organizer Device Letter from Secretary of Health (PDF), and the Medication Organizer Device (PDF) for more information.

Can the licensed practical nurse give prescribed off-label medications?

The nursing law and rules do not prohibit the competent and appropriately trained licensed practical nurse from giving off-label medications under the direction of an authorized provider or under the direction and supervision of the registered nurse. A prescription or order from an authorized provider is required. The facility can be more restrictive. The Nursing Care Quality Assurance Commission recommends the licensed practical nurse use the Scope of Practice Decision Tree to determine if the administration of the off-label medication is within his or her regulatory and individual scope of practice. The Food and Drug Administration Understanding Unapproved Use of Approved Drugs "Off-Label" website provides information about using unapproved off-label drugs. Off-label use should be done with careful insight and understanding of the risks and benefits to the patient considering high-quality evidence supporting efficacy, effectiveness, and safety. The licensed practical nurse is always individually accountable and responsible for the nursing care the licensed practical nurse provides.

Can the licensed practical nurse give antineoplastic drugs, including administration by bladder installation?

The nursing law and rules do not prohibit the competent and appropriately trained licensed practical nurse from giving drugs, including antineoplastic drugs, under the direction of an authorized provider or under the direction and supervision of the registered nurse. A prescription or order from an authorized provider is required. The facility can be more restrictive. The Nursing Care Quality Assurance Commission recommends the licensed practical nurse use the Scope of Practice Decision Tree to determine if the administration of the off-label medication is within the nurse's regulatory and individual scope of practice. The licensed practical nurse is always individually accountable and responsible for the nursing care the licensed practical nurse provides.

Does the licensed practical nurse require a specific certification to give chemotherapy in the home setting?

The state and federal laws and regulations do not require the licensed practical nurse to have a special certification to give chemotherapy in the home setting. The facility or employer may require a specific certification or training program. The Nursing Care Quality Assurance Commission recommends the licensed practical nurse use the Scope of Practice Decision Tree to determine if the administration of the off-label medication is within the nurse's regulatory and individual scope of practice.

Can the licensed practical nurse give experimental drugs?

The nursing law and rules do not prohibit the competent and appropriately trained licensed practical nurse from giving experimental drugs by any route under the direction of an authorized provider or under the direction and supervision of the registered nurse. A prescription or order from an authorized provider is required. The licensed practical nurse must be competent. The facility can be more restrictive. The Nursing Care Quality Assurance Commission recommends the licensed practical nurse use the Scope of Practice Decision Tree to determine if the administration of experimental drugs is within his or her regulatory and individual scope of practice. The licensed practical nurse is always individually accountable and responsible for the nursing care the licensed practical nurse provides.

Does the licensed practical nurse need a written order to administer medications from a properly labeled prescription bottle?

The label will suffice if the label completed following state law, is legible, properly identified, has the name of the patient on it, and the medication prescription has not expired. The facility or employer may require a prescription or other authentication/documentation for verification. The licensed practical nurse is always individually accountable and responsible for the nursing care the licensed practical nurse provides.

Can the licensed practical nurse administer medications or perform treatments or procedures without a registered nurse or physician onsite?

The licensed practical nurse works under the direction of an authorized health care practitioner within the practitioner's. A licensed practical nurse may administer medications and perform treatments or procedures without the registered nurse or other authorized health care practitioner on the premises. A prescription or order from an authorized provider is required for legend drugs, controlled substances, over-the-counter drugs, or for medical treatments.
RCW 18.79.270 LPN - Activities Allowed

Can the licensed practical nurse administer immunizations under the direction of a pharmacist?

A pharmacist is not identified as an authorized health care practitioner that the licensed practical nurse may take orders or direction from. This does not mean the licensed practical nurse may not work in a pharmacy setting administering immunizations. It is acceptable for orders for immunizations to be made by an authorized health care practitioner using standing orders. See the NCQAC Standing and Verbal Orders Advisory Opinion for guidelines and recommendations.

Can the licensed practical nurse crush or split medications without an order?

The nursing law and rule does not prohibit the licensed practical nurse in making a decision to crush or split medications without an order. The licensed practical nurse can use nursing judgment. The employer may have policies or guidelines about crushing or splitting medications. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if crushing a medication is within the nurse's regulatory and individual scope of practice. The licensed practical nurse should make the decision whether or not to crush or split the medication based on patient needs, prescribing information by the provider, and safety of the medication being administered in this form. The licensed practical nurse administering the medication is responsible for ensuring the medication is safe to crush or split before giving it. Follow-up with the prescribing provider is warranted if a medication order states to crush or split the medication is necessary, but it is not recommended. Other alternatives may be necessary such as a liquid medication. The Institute for Safe Medication Practices (ISMP) is a good resource for determining whether a medication is safe to crush. Splitting medications may result in dosage errors. Not all medications may be split. The licensed practical nurse needs to determine whether the medication can be safety split to ensure proper dosage. The licensed practical nurse should consider consulting with a pharmacist and follow current guidance or standards and/or contact the prescriber or pharmacist to see if there is another alternative, such as liquid form or getting the medication in the appropriate dose.

Can the licensed practical nurse hide medication in food for a patient who refuses to take the medication?

The nursing laws and rules do not address this question. Some facility laws do address medication refusal. The WAC 388-76 Adult Family Home Minimum Licensing Requirements addresses medication refusal: WAC 388-76-10435 Medication Refusal. Hiding medications and not notifying the patient may be a violation of patient rights. See the Washington State Department of Health Patient Rights Guidelines for more information.

Can the licensed practical nurse administer epinephrine for anaphylaxis without an order?

The licensed practical nurse may carry and administer epinephrine under the direction of an authorized health care practitioner or under the direction and supervision of the registered nurse. The licensed practical nurse may not administer epinephrine without an order from an authorized health care practitioner. The order or prescription may be for a specific patient or through the use of standing orders. Another option is for the facility or employer to become an authorized entity. SSB 6421 was passed in 2016 allowing authorized entities to obtain epinephrine autoinjectors. This allows an authorized health care practitioner to issue a prescription made out in the name of the authorized entity. Authorized entities that choose to acquire epinephrine autoinjectors must have people connected with the entity, such as employees, who have completed an anaphylaxis and epinephrine autoinjector training. These people will be responsible for the storage, maintenance, and general oversight of the epinephrine autoinjectors. They may administer or provide an epinephrine autoinjector to people who are experiencing anaphylaxis. An authorized entity is required to report to the Washington State Department of Health each incident of use of an obtained epinephrine autoinjector that was provided or administered to a person. Other laws may apply depending on the setting. RCW 28A.210.380 and 28A.210.383 regulations stipulate the requirements for epinephrine autoinjector use in public and private schools including the option of having a school stock supply of epinephrine autoinjectors for nurses to give following standing orders approved by an authorized health care practitioner. See the Washington State Department of Health's Epinephrine Autoinjectors and Anaphylaxis Training and Reporting for Authorized Entities Frequently Asked Questions and the SSB 6421 Status Update Document for more information.

Can the licensed practical nurse administer naloxone for a suspected opioid overdose without an order?

The licensed practical nurse may administer naloxone or other opioid antagonist to anyone at risk for having or witnessing an opioid overdose. See the NCQAC's Prevention and Treatment of Opioid-Related Overdoses Advisory Opinion and Frequently Asked Questions for Nursing Professionals of the Prevention and Treatment of Opioid-Related Overdoses for more information.

Can the licensed practical nurse implement range orders?

The laws and rules do not prohibit the competent and appropriately trained licensed nurse from implementing a drug order that has a dosage range. The medical provider makes the "medical judgment" as to the specific medication and dosage. The licensed practical nurse is given the latitude to use "nursing judgment" in determining the amount to be administered based on the patient's clinical status. The licensed practical nurse must apply adequate knowledge and skills in determining the dosage to be administered at any given time. Appropriate documentation of a focused patient assessment and evaluation must substantiate intervention. It is recommended that medication orders be patient/condition specific even if prescribed pro re nata (PRN), when needed. This would take away some of the notion of the nurse "prescribing" the medication. There should be some consultation with the physician to initiate a standing order particularly if the signs/symptoms are deviations from the patient's norm. Standing orders are certainly not to be used in lieu of medical consultation or intervention. Range orders should ideally consist of:

  • The full name of the medication being ordered;
  • The total amount of medication to be given in a specified time period;
  • The order should state if the dose can be given in divided doses;
  • The order should state if the dose can be repeated;
  • If repeated, the order should indicate how frequently, and in what time frame; and
  • The order should include what action should be taken if pain is unrelieved
Can the licensed practical nurse assist in providing case management and preparing prescriptions for patients in a medication assisted treatment (MAT)?

The state laws and rules do not prohibit the competent and appropriately trained licensed practical nurse from assisting in providing case management and support for patients in MAT within the licensed practical nurse's scope of practice. The Drug Enforcement Administration (DEA) does state that, “an individual (secretary or nurse) may be designated by the practitioner to prepare prescription for the practitioner's signature.”

Can the licensed practical nurse administer intra-articular injections?

The nursing law and rules do not prohibit the competent and appropriately trained licensed practical nurse from administering intra-articular injections under the direction of an authorized provider, or under the direction and supervision of the registered nurse. A prescription or order from an authorized provider is required. The facility can be more restrictive. The Nursing Care Quality Assurance Commission recommends the licensed practical nurse use the Scope of Practice Decision Tree to determine if the administration of intra-articular injections with within his or her regulatory and individual scope of practice. The licensed practical nurse is always individually accountable and responsible for the nursing care the licensed practical nurse provides.

Can the licensed practical nurse destroy, witness, and/or cosign the destruction or wasting of controlled substances in a skilled nursing facility (SNF)?

The licensed practical nurse may destroy, witness, and/or cosign the destruction of wasting of controlled substances in a SNF home. See the WAC 246-865-060 Pharmaceutical Services-Extended Care Facility for more information.
See the WAC 246-874-050 Accountability Requirements for an Automated Drug Dispensing Device (ADDD) if using an ADDD.

Can the licensed practical nurse administer or recommend over-the-counter (OTC) drugs without an order from a physician?

It is not within the scope of practice of a licensed practical nurse to administer or recommend OTC drugs. The licensed practice nurse must work under the direction of an authorized health care practitioner or under the direction and supervision of a registered nurse. Orders for OTC drugs or devices may be done using standing orders from an authorized health care practitioner or a registered nurse as identified in the nursing care plan. See the NCQAC Standing and Verbal Orders Advisory Opinion for guidelines and recommendations.

Gastroenterology Procedures
Can the licensed practical nurse insert a feeding tube in a neonate or infant?

It is within the scope of practice of an appropriately trained and competent licensed practical nurse to insert a feeding tube in a neonate, infant, child, or adult under the direction of an authorized health care practitioner, or under the direction and supervision of the registered nurse, following clinical practice standards. An order from an authorized health care practitioner is required. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the licensed practical's legal and individual scope of practice.

Can the licensed practical nurse assist with inserting a percutaneous endoscopic gastrostomy (PEG) tube?

It is within the scope of practice of an appropriately trained and competent licensed practical nurse assist with an authorized health care practitioner or registered nurse to insert a PEG tube, . The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the licensed practical nurse's legal and individual scope of practice.

Can the licensed practical nurse manipulate the endoscope when assisting during an endoscopic procedure?

It is within the scope of practice of an appropriately trained and competent licensed practical nurse to manipulate the endoscope when assisting in performing an endoscopic procedure. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the licensed practical nurse's legal and individual scope of practice.

Can the licensed practical nurse assist in performing an endoscopy, colonoscopy or sigmoidoscopy?

It is within the scope of practice of an appropriately trained and competent licensed practical nurse to assist in performing an endoscopy, sigmoidoscopy, or colonoscopy. The licensed practical nurse may assist an authorized provider or the registered nurse in performing these procedures following clinical practice standards. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if specific activities are within the licensed practical nurse's legal and individual scope of practice.

Can the licensed practical nurse perform colostomy care?

It is within the scope of practice of an appropriately trained and competent licensed practical nurse to perform ostomy care under the direction of an authorized provider or under the direction and supervision of a registered nurse, following clinical practice standards. A prescription or order from an authorized provider may be necessary if complications occur or if medical treatment is required. Generally, a prescription from an authorized health care practitioner is required for reimbursement of medical supplies. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the licensed practical nurse's legal and individual scope of practice.

Can the licensed practical nurse re-insert a dislodged gastrostomy tube?

It is within the scope of practice of an appropriately trained and competent licensed practical nurse to re-insert a gastrostomy tube in a mature stoma site under the direction of an authorized health care practitioner, or under the direction and supervision of the registered nurse, following clinical practice standards. If there are signs of infection or other concerns, the licensed practical nurse should seek advice from an authorized provider or the registered nurse before attempting to re-insert. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the registered nurse's legal and individual scope of practice.

General Scope of Practice
How can the licensed practical nurse determine if a specific procedure or skill is the nurse's scope of practice?

The RCW 18.79 Nursing Care and theWAC 246-840 Practical and Registered Nursing allow nurses to employ their full scope of practice in multiple settings. The Nursing Care Quality Assurance Commission also approves advisory opinions and interpretive statements that address specific nursing practice questions. The Nursing Care Quality Assurance Commission recommends the licensed practical nurse use the Scope of Practice Decision Tree to determine if an activity is within the nurse's scope of practice.

Can a licensed practical nurse practice independently?

It is not within the scope of practice for a licensed practical nurse to practice independently. The licensed practical nurse must work under the direction of an authorized health care practitioner or under the direction and supervision of a registered nurse.

What settings can a licensed practical nurse practice in?

A licensed practical nurse may work in any setting where nursing care is provided. Scope of practice remains the same regardless of setting. Examples of settings include (but not limited to): Hospitals, nursing homes, assisted living facilities, adult family homes, schools, camps, clinics, public health clinics, homes, hospice, community health centers, homeless shelters, insurance companies and other businesses, law offices, travel clinics, occupational health centers, private clinics, outpatient clinics, ambulatory surgery centers, dialysis centers, mental health centers, infusion centers, medical spas, nursing informatics programs, correctional centers/jails, county health departments, government offices, cruise ships, churches, casinos, and retail clinics.

Can a licensed practical nurse practice in a complex care setting such as intensive care unit (ICU), post-anesthesia care unit (PCU), or recovery room?

The nursing laws and rules allow a licensed practical nurse to provide care in an ICU, PCU, or recovery room. A licensed practical nurse may provide direct patient care and perform functions within the nurse's legal and individual scope of practice under the direction of an authorized health care practitioner or under the direction and supervision of a registered nurse.

Can a medical assistant or non-nurse supervise a licensed practical nurse or can a licensed practical nurse supervise a registered nurse?

Most health care facilities or employers include an organizational structure that defines a person's manager or supervisor. A non-nurse may be a “supervisor” of a licensed practical nurse. A licensed practical nurse may be a “supervisor” of a registered nurse in an organizational structure related to human resource and administrative functions. This is different than the definition of “supervision” of a nursing activity. The nursing rules define “supervision” as, “The provision of guidance and evaluation for the accomplishment of a nursing task or activity with the initial direction of the task or activity; periodic inspection of the actual act of accomplishing the task or activity; and the authority to require corrective action.” A registered nurse practices independently and does not require supervision or evaluation of nursing care. Only a registered nurse or advanced registered nurse practitioner may supervise and evaluate the practice of nursing provided by a licensed practical nurse. It is beyond the scope of a licensed practical nurse to independently perform training, performance appraisals, or competency validation related to nursing practice of the registered nurse or advanced registered nurse practitioner. A licensed practical nurse may assist in providing training, performing appraisals, or competency validation related to nursing practice within the scope of the licensed practical nurse and under the direction of the registered nurse or advanced registered nurse practitioner.

Is there any activity that require a licensed practical nurse to have a health care practitioner or registered nurse on the premises?

The nursing laws and rules requires general supervision of a licensed practical nurse. The nursing law and rule does not require the registered nurse or an authorized health care practitioner to be on the premises when a licensed practical nurse provides care in any setting. A facility or supervisor may require direct or immediate supervision for specific activities or if there are concerns about the licensed practical nurse's competency. An exception exists in the physician rules that require a physician to be on the immediate premises during the patient's initial treatment when a nurse is performing laser therapy: WAC 246-919-605 Use of Laser, Light, Radiofrequency, and Plasma (LLRP) Devices as Applied to the Skin.

Can the employer or registered nurse expand the scope of practice of a licensed practical nurse if a physician or advanced registered nurse practitioner signs off on the procedure?

 

The employer may not expand licensed practical nurse scope of practice. The licensed practical nurse must provide nursing care within the nurse's statutes and regulations that govern nursing practice.

Can the licensed practical nurse train unlicensed assistive personal (UAP)?

It may be within a licensed practical nurse's scope of practice to provide routine or basic training to UAP if the licensed practical nurse is competent under the direction of an authorized health care practitioner or under the direction and supervision of a registered nurse based on the nursing care plan. In some settings (community-based and in-home care) only a registered nurse may delegate and is required to validate competency prior to nursing delegation.

Can the licensed practical nurse provide or delegate nursing care in an assisted living facility (ALF)?

The ALF may choose to provide, but is not required to provide, intermittent nursing services. Some nursing services may be done through registered nurse delegation to a nursing assistant or home care aide. A licensed practical nurse may provide nursing care in an ALF within the licensed practical nurse's scope of practice under the direction of an authorized health care practitioner or under the direction and supervision of a registered nurse. Only a registered nurse may delegate nursing activities to a nursing assistant-certified (NA-C), nursing assistant-registered (NA-R), or home care aid-certified (HCA-C) in an ALF. See the RCW 18.20 Assisted Living Facilities and WAC 388-78A Assisted Living Facility Licensing Rules for more information.

Can the licensed practical nurse give test results to a patient?

It is not in the scope of practice for a licensed practical nurse to make a medical diagnosis based on interpretation of diagnostic test results. Medical test results must be interpreted by an authorized health care practitioner. The nursing laws and rules allow the licensed practical to relay test results or a medical diagnosis if already made by an authorized health care practitioner. It is important to consider what types of questions or discussion the patient might have when receiving test results or when a diagnosis is relayed to the patient by the nurse. Abnormal test results should be communicated by someone who can provide supporting information about the test, implications, and follow-up care. The complexity and seriousness of the test results may also determine who gives the results and by what method test results should be given. The person giving the test results or diagnosis must be competent to answer the patient's questions.

Can the licensed practical nurse provide nursing care to a minor patient without parental consent?

The general age of majority for health care is eighteen years old in Washington State as defined in . Other laws do allow exceptions for specific types of treatment: See the Providing Health Care to Minors under Washington Law Summary for more information.

Can the licensed practical nurse admit a patient to a skilled nursing facility (SNF) with an order from an authorized health care practitioner without a registered nurse on the premises?

WAC 388-97-1080 addresses the nursing services requirements in a SNF. A SNF may limit the admission of a patient if a registered nurse is not available to perform the admission assessment. The SNF may allow the licensed practical nurse to initiate the admission assessment within licensed practical nurse's scope of practice including collecting information and data without a registered nurse on the premises with the intent that the registered nurse will complete the comprehensive assessment and care planning.

Infusion Therapy, Phlebotomy, and Laboratory Tests
Does a licensed practical nurse require a special certification to perform infusion therapy, phlebotomy, or laboratory tests?

The nursing laws and rules do not require a licensed practical nurse to get a special certification to perform infusion therapy, phlebotomy, or laboratory tests. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are the nurse's legal and individual scope of practice.

What activities can a licensed practical nurse perform related to a vascular access device (VAD) or other infusion devices?

The nursing laws and rules allow the competent and appropriately trained licensed practical nurse to perform infusion therapy. Invasive procedures require an order from an authorized health care practitioner. It may be within the scope of practice of the competent and appropriately trained licensed practical nurse to perform the following tasks related to a VAD or other infusion devices under the direction of an authorized health care practitioner or under the direction and supervision of a registered nurse:

  • Short peripheral catheter line intraosseous access device, and subcutaneous infusion device insertion and removal;
  • Preparing, initiating, managing, and monitoring infusion pumps;
  • Peripheral (including short peripheral or midline), CVAD, arterial, umbilical arterial catheter (UAC) or umbilical venous catheter (UVC), intraspinal, intraosseous access device, and subcutaneous infusion device site monitoring, care, and dressing changes;
  • Administration of infusion fluids and medications via peripheral, CVAD, and arterial catheters including through an implanted vascular access port, hemodialysis VAD, and UAC) or UVC;
  • Medication administration via a VAD using piggyback, push, or bolus methods;
  • Transfusion of blood products;
  • Infusion of biologic therapies;
  • Blood sampling via a peripheral, VAD, and arterial device;
  • Administration of total parenteral nutrition;
  • Monitor patency of the peripheral, CVAD, and arterial catheters;
  • Change infusion sets; and
  • Assist an authorized health care practitioner or registered nurse in removing or reinserting a CVAD or arterial catheter.

It is not within the scope of a licensed practical nurse to perform the following tasks:

  • Independently insert or remove a CVAD, arterial catheter, or intraspinal catheter;
  • Insert a peripherally inserted midline catheter.

The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice. The nurse must follow clinical standards of care. Examples include the Infusion Nurses Society (INS) and the National Infusion Center Association (NICA) practice, training, and competency standards for the licensed practical nurse.

  • Complete an infusion therapy educational program, including supervised clinical practice on infusion therapy to document competency assessment and validation;
  • Practice analysis for the licensed practical nurse including venipuncture for blood sampling and insertion and removal of peripheral catheters, maintenance of central vascular access devices (CVADs), and administration of IV medications by piggyback method; and

Perform infusion-related tasks under the supervision of a registered nurse or other authorized health care practitioner with appropriate infusion therapy knowledge and skills.

Can a licensed practical nurse start an intravenous line without an order from an authorized health care practitioner in certain situations, such as for an unstable/high acuity patient or if a practitioner ordered a blood transfusion but did not order in

It is not within the scope of practice for a licensed practical nurse to start an intravenous line without an order from an authorized health care practitioner. The RCW 18.71.011 Definition of the Practice of Medicine stipulates the practice of medicine to include severing penetrating the tissues of human beings. Standing orders may be an option to allow the nurse to start an intravenous line based on specific criteria (such as a high acuity patient), admission to a specific unit (such as intensive care), or for a specific condition. Standing orders may also be used to allow a nurse to start more than one intravenous line based on specific criteria. The nurse should use the Scope of Practice Decision Tree to determine if specific activities are within the nurse's legal and individual scope of practice. The Nursing Care Quality Assurance Commission's Standing Orders and Verbal Orders Advisory Opinion provides additional guidance and recommendations.

Does a licensed practical nurse need an additional order to restart an intravenous line that is no longer patent?

The licensed practical nurse does not need an additional order from an authorized health care practitioner to restart an intravenous line that is no longer patent. The nurse may want to consult with an authorized health care practitioner or a registered nurse in situations when the nurse is unsure if the patient still requires an intravenous line or if the patient's intravenous line is insufficient to support the therapy needed.

Can the licensed practical nurse administer stem cell transplants?

The nursing laws and rules allow a competent and appropriately trained licensed practical nurse from administering stem cell-based products via a peripheral intravenous line, intra-arterial catheter, intradermal technique, or intramuscular technique. An order is required from an authorized health care practitioner. The Nursing Care Quality Assurance Commission determines that it is not within the scope of the licensed practical nurse to administer stem cell transplants by intravitreal infusion, retrobulbar infusion, spinal infusion, or other complex administration techniques. The nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice.

Can a licensed practical nurse perform venipuncture to obtain blood samples for laboratory tests in the home setting?

The nursing laws and rules allow the competent and appropriately trained licensed practical nurse performing venipuncture to obtain blood samples for laboratory testing in any setting. The licensed practical nurse must work under the direction of an authorized health care practitioner or under the direction and supervision of a registered nurse. These procedures require a prescription from an authorized health care practitioner. The nurse must follow Federal and State blood-borne pathogen and Clinical Laboratory Improvement Amendments (CLIA) regulations. The nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's regulatory and individual scope of practice.

Does a licensed practical nurse require an order to perform Clinical Laboratory Improvement Amendments (CLIA) Food and Drug Administration tests such as a human chorionic gonadotropin (hCG), urine dipstick, occult blood screening, or blood glucose capill

The licensed practical nurse does not practice nursing independently. A licensed practical nurse must have direction from an authorized health care practitioner or a registered nurse to perform tests such as a human chorionic gonadotropin (hCG), urine dipstick, occult blood screening, blood glucose capillary tests or other CLIA approved waiver under the CLIA criteria. Any CLIA waived test involving puncturing the skin requires an order from an authorized health care practitioner. The nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice.

Can a licensed practical nurse obtain blood specimens and submit to a laboratory to do lead screening, hepatitis B screening, or other employee health laboratory tests?

The nursing laws and rules allow a competent and appropriately trained licensed practical nurse to obtain a blood specimen via a capillary or venous blood sample to perform lead screening, hepatitis B screening, or other employee health laboratory tests under the direction of an authorized health care provider or under the direction and supervision of a registered nurse. An order is required from an authorized health care practitioner for laboratory tests involving puncturing of the skin. Standing orders may also be followed to direct occupational health activities. The Nursing Care Quality Assurance Commission's Standing Orders and Verbal Orders Advisory Opinion provides additional guidance and recommendations. The nurse should use the Scope of Practice Decision Tree to determine if specific activities are within the nurse's legal and individual scope of practice.

Can a licensed practical nurse perform an arterial blood draw for an arterial blood gas (ABG)?

The nursing laws and rules allow the competent and appropriately trained licensed practical nurse to obtain an arterial blood gas directly from an artery or through an arterial line under the direction of an authorized health care practitioner or under the direction and supervision of a RN. This procedure requires a prescription from an authorized health care practitioner. The nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice.

Can a licensed practical nurse perform iliac crest bone marrow aspirations and biopsies?

The Nursing Care Quality Assurance Commission determines that it is not within the scope of a licensed practical nurse to perform iliac crest bone marrow aspirations and biopsies due to the complexity of the procedure. A licensed practical nurse may assist an authorized health care practitioner or registered nurse in performing the procedure.

Can a licensed practical nurse perform therapeutic phlebotomy?

The nursing laws and rules allow the competent and appropriately trained licensed practical nurse to perform therapeutic phlebotomy for conditions, such as polycythemia vera, under the direction of an authorized health care practitioner or under the direction and supervision of a RN. These procedures require a prescription from an authorized health care practitioner. The nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice.

Neurological and Musculoskeletal Procedures
Can the licensed practical nurse operate a transcutaneous electrical nerve stimulation unit (TENS) for pain relief?

It is within the scope of practice of the appropriately prepared and competent licensed practical nurse to apply and operate a TENS for chronic and acute pain, following clinical practice standards. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if performing these activities is within the licensed practical nurse's regulatory and individual scope of practice.

Can the licensed practical nurse perform a lumbar puncture?

The Nursing Care Quality Assurance Commission determines it is beyond the scope of the licensed practical nurse to lead this activity due to the complexity of the procedure. The licensed practical nurse may assist an authorized health care practitioner or the registered nurse in performing a lumbar puncture, following clinical practice standards. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the licensed practical nurse's legal and individual scope of practice.

Can the licensed practical nurse perform electroencephalography (EEG) or electromyography (EMG)?

It is within the scope of practice of the appropriately prepared and competent licensed practical nurse to perform an EEG or EMG under the direction of an authorized health care practitioner or under the direction and supervision of a registered nurse, following clinical practice standards. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the licensed practical nurse's legal and individual scope of practice.

Can the licensed practical nurse perform iliac crest bone marrow aspirations and biopsies?

The Nursing Care Quality Assurance Commission determines it is beyond the scope of the licensed practical nurse to lead this activity due to the complexity of the procedure. The licensed practical nurse may assist an authorized health care practitioner or the registered nurse in performing a lumbar puncture, following clinical practice standards. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the licensed practical nurse's legal and individual scope of practice.

Nursing Assessment
What is the difference between a pre-admission/resident assessment and a comprehensive nursing care assessment?

pre-admission/resident assessment is a needs assessment screening tool used to obtain information about the personal care needs and requests of a potential resident. The pre-admission/resident assessment findings may identify needs for a comprehensive nursing care assessment.

nursing care assessment gathers information about the person's health status through the collection of data and/or physical examination. This assessment includes the use of the nursing process (WAC 246-840-700). Although a nursing care assessment may include elements of a non-skilled personal care assessment, it is a comprehensive nursing care evaluation and must be performed by the registered nurse. The licensed practical nurse may assist in gathering information for the nursing care assessment under the direction and supervision of the registered nurse.

Who can perform the pre-admission/resident assessment in adult family homes and assisted living facilities?

The laws and rules found in Aging and Adult Service Section of WAC 388-78A (assisted living facilities) and 388-76 (adult family homes) define the qualifications required for an individual to perform the required pre-admission/resident assessment. An individual with a nursing license (licensed practical nurse or registered nurse) meets the qualifications to perform the pre-admission/resident assessment. Other professionals may also perform the pre-admission/resident assessment (WAC 388-76-10150 and WAC 388-78A-2080).

This pre-admission/resident assessment (screening tool) does not necessarily require the services of a professional licensed nurse or the use of the nursing process (WAC 246-840-700). The goal of the pre-admission/resident assessment is to determine the personal care services needs of a potential resident and at times, the nursing care needs of said resident. If a comprehensive nursing assessment is contemplated as part of the care plan, the registered nurse must undertake that portion of the pre-admission assessment.

Who can provide training of staff in adult family homes and assisted living facilities related to personal care services?

Staff must meet the credentialing, training and competency requirements established in the state and federal laws and rules specific to the setting. Training and competency assessment for personal care services (non-nursing care) does not require the services of a Washington state licensed professional nurse. Training and education of staff employed in these facilities that address personnel, performance and other administrative activities do not require the utilization of a registered nurse.

Nursing Process
What is the licensed practical nurse's role in the nursing process?

The licensed practical nurse's scope of practice in the nursing process is limited and focused. The licensed practical nurse practices in an interdependent role when carrying out nursing care and a dependent role when carrying out medical regimens. The licensed practical nurse may perform nursing care under the direction of an authorized health care practitioner or at the direction and under the supervision of the registered nurse. The licensed practical nurse implements health care plans developed by the registered nurse or other authorized health care practitioner.

Can the licensed practical nurse use clinical judgment?

Clinical judgment (critical thinking) is used throughout all components of the nursing process. It is within the scope of the licensed practical nurse to use critical thinking skills. It is also an expectation. Critical thinking is purposeful and reflective judgment in response to events, observations, experiences, and verbal or written expressions. It involves determining the meaning and significance of what is observed or expressed to determine need for action. The licensed practical nurse is required to use critical thinking in clinical problem-solving and decision-making processes relative to scope of practice, knowledge, competency, and experience.

Can the licensed practical nurse perform a hospital, residential treatment facility, or skilled nursing facility (SNF) admission assessment?

Different types of assessments, such as “initial”, “admission”, or “event-focused” assessment, are not defined in the nursing law and rules. These terms are often used by health care agencies to describe different types of assessment. Other examples include post-fall and pre-transfer assessments. The nursing laws and rules do not prohibit the competent and appropriately trained licensed practical nurse from initiating the admission of a patient to a hospital or SNF. Agency policy based on statutes and regulations, standards of care, accreditation standards, and reimbursement requirements may stipulate who can perform a specific assessment in different practice settings. The licensed practical nurse may contribute to the patient assessment in a hospital, SNF, or other health care facility under the direction of an authorized health care practitioner or under the direction and supervision of the registered nurse. Joint Commission Nursing Assessment standards require the registered nurse to perform the nursing assessment within twenty-four hours after admission to a hospital. The licensed practical nurse may collect the data and then have the registered nurse review the data and complete the assessment to determine the patient' needs and developing the nursing care plan. It is not within the scope of practice of the licensed practical nurse to perform an assessment by proxy.

Can the licensed practical nurse perform a pre-anesthesia assessment?

The nursing laws and rules do not prohibit the competent and appropriately trained licensed practical nurse from collecting the information for a pre-anesthesia assessment. The Centers for Medicare and Medicaid Services (CMS) does not allow the licensed practical nurse to perform a pre-anesthesia assessment. It is expected that the registered nurse would complete an appropriate age-specific nursing assessment and nursing care plan. The licensed practical nurse may assist in carrying out the assessment process and carrying out these plans. Frequency of assessment may be determined by institutional policy, patient condition, CMS requirements, and accreditation standards. See the NCQAC's Administration of Sedating, Analgesic, and Anesthetic Agents Advisory Opinion for more information.

Can the licensed practical nurse perform an Emergency Medical Treatment and Active Labor Act (EMTALA) Medical Screening Exam (MSE)?

The EMTALA is a federal law established in 1986 that requires hospitals or other acute care facilities who offer emergency services to provide MSE to each person presenting to the emergency department to determine if a medical emergency exists. MSE is beyond initial triage. EMTALA requires the assessment of a patient for the existence of an emergency medical condition before the patient can be transferred or released from the emergency department. The EMTALA Interpretive Guidelines identify the licensed registered nurse to be considered qualified medical personnel who can perform the EMTALA MSE and circumstances where the registered nurse consult with a physician. The licensed practical nurse may assist the registered nurse in performing the MSE collecting the information and data and performing a focused assessment. The MSE requires a comprehensive assessment. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the licensed practical nurse's legal and individual scope of practice.

Can the licensed practical nurse perform a pulmonary function assessment?

It may be within the scope of practice of a competent and appropriately trained licensed practical nurse to perform a focused assessment and monitor the patient collecting the information and data related to pulmonary function. It would be within the scope of practice for the licensed practical nurse to assess lung sounds before and after treatments. The licensed practical nurse must be competent to do these activities. WAC 246-840-700 allows the licensed practical nurse to make basic observations, gather data and assist in identification of needs and problems relevant to the patient, collect specific data as directed, and, communicate outcomes of the data collection process in a timely manner to the registered nurse or other authorized health care provider. The method of communication must be appropriate for the situation. The Nursing Care Quality Assurance Commission recommends the licensed practical nurse use the Scope of Practice Decision Tree to determine if these activities are within the licensed practical nurse's legal and individual scope of practice.

Can the licensed practical nurse make a nursing diagnosis using North American Nursing Diagnosis Association, International (NANDA-I) taxonomies in the medical record?

A nursing diagnosis is used to determine the appropriate nursing care plan for the patient. The nursing diagnosis drives interventions and patient outcomes, enabling the registered nurse to develop the nursing care plan. WAC 246-840-700 Standards of Nursing Conduct or Practice clarifies that only the registered nurse is permitted to make a nursing diagnosis. The licensed practical nurse may provide data to assist in the development of a nursing diagnosis. The licensed practical nurse may document symptoms or other findings and may document using a nursing diagnosis already made by the registered nurse. The licensed practical nurse uses and applies nursing diagnosis (formulated by the registered nurse) as a foundation for implementing interventions.

What is the licensed practical nurse's role in implementing the nursing care plan?

The licensed practical nurse's role in implementing the care plan includes the following activities:

  • Procuring resources needed;
  • Implementing nursing interventions and medical orders consistent with nursing rules and within an environment conducive to patient safety;
  • Prioritizing performance of nursing interventions within the assignment;
  • Recognizing responses to nursing interventions;
  • Modifying immediate nursing interventions based on changes in the patient's status; and
  • Delegating specific nursing tasks as outlined in the plan of care and consistent with nursing delegation laws and rules.
What is the licensed practical nurse's role in evaluating the nursing care plan?

The licensed practical nurse's role, in collaboration with the registered nurse, assists in making adjustments in the care plan and reporting outcomes of care to the registered nurse or other authorized health care practitioner.

What is the licensed practical nurse's role in performing nursing assessment and care plan development?

Nursing assessment may include a comprehensive nursing assessment and/or a focused nursing assessment. A comprehensive nursing assessment means collection, analysis, and synthesis of data performed by the registered nurse used to establish a health status baseline, plan care and address changes in a patient's condition as defined in the National Council State Boards of Nursing (NCSBN) Model Act (2012). The licensed practical nurse may perform a focused nursing assessment. A focused nursing assessment means recognizing patient characteristics that may affect the patient's health status, gathering and recording nursing assessment data and demonstrating attentiveness by observing, monitoring and reporting signs, symptoms, and changes in patient conditions in an ongoing manner to the registered nurse or other authorized medical provider. The focused assessment may include obtaining health care history information and physical assessment. The competent and appropriately trained licensed practical nurse may also perform specific assessments or screening activities, such as mental health status screening, suicidal risk screening, substance use screening, behavioral health screening, oral health screening, growth and developmental screening, neonatal abstinence syndrome scoring system, or nutritional health screening. The licensed practical nurse not analyze, synthesize, or evaluate the data or develop the nursing care plan. The licensed practical nurse is a valuable member of the health care team and should contribute to the development of the nursing care plan.

Can the licensed practical nurse assist in performing a sports physical examination?

The nursing laws and rules do prohibit the competent and appropriately trained licensed practical nurse from assisting in performing a sports physical examination under the direction of an authorized provider or under the direction and supervision of the registered nurse. Organizational policies may dictate who can perform a sports physical examination. RCW 28A.600.200 Interscholastic Athletic and Other Extracurricular Activities for Students provides authority to the school district board of directors to control, supervise, and regulate the conduct of interschool athletic activities including delegating control, supervision and regulation to the Washington Interscholastic Activities Association (WIAA) or other voluntary nonprofit entity. The WAII Handbook identifies a Medical Doctor (MD), Doctor of Osteopathy (DO), Advanced Registered Nurse Practitioner (ARNP), Physician' Assistant (PA), and Naturopathic Physician as a medical authority to perform a sports physical examination.

Obstetrical. Gynecological, and Reproductive Care
Can the licensed practical nurse apply or remove an external or internal electronic fetal monitor?

It is within the scope of an appropriately prepared and competent licensed practical nurse to apply or remove an external electronic fetal monitor under the direction of an authorized health care practitioner, or under the direction and supervision of the registered nurse, following clinical practice standards. It is beyond the scope of the licensed practical nurse to apply or remove an internal electronic fetal monitor. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice.

Can the licensed practical nurse insert a fetal spiral electrode (FSE) or an intrauterine pressure catheter (IUPC)?

The Nursing Care Quality Assurance Commission determines it is beyond the scope of the licensed practical nurse to insert a FSE or IUPC. The licensed practical nurse may assist an authorized health care practitioner or the registered nurse, in inserting a FSE or IUPC, following clinical practice standards. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice.

Can the licensed practical nurse insert prostaglandin analogs (e.g. misoprostol or dinoprostone) into the vagina for cervical ripening or induction of labor with a viable fetus?

It is within the scope of an appropriately prepared and competent licensed practical nurse to insert prostaglandin into the vagina for a cervical ripening or induction of labor with a viable fetus under the direction of an authorized health care practitioner, or under the direction and supervision, of the registered nurse, following clinical practice standards. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice.

Can the licensed practical nurse insert prostaglandin into the vagina to induce abortion?

It is within the scope of an appropriately prepared and competent licensed practical nurse to insert prostaglandin into the vagina for a chemical abortion under the direction of an authorized health care practitioner, or under the direction and supervision of the registered nurse, following clinical practice standards. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice.

Can the licensed practical nurse perform a fetal non-stress test (NST) and an amniotic fluid index level using ultrasound?

It is within the scope of an appropriately prepared and competent licensed practical nurse to perform a fetal NST and amniotic fluid index level using ultrasound under the direction of an authorized health care practitioner, or under the direction and supervision of the registered nurse, following clinical practice standards. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice.

Can the licensed practical nurse perform a sterile speculum examination and obtain specimens for cytologic, such as a Papanicolaou (PAP) smear, in a pregnant patient?

The Nursing Care Quality Assurance Commission determines it is beyond the scope of a licensed practical nurse to perform a sterile speculum examination. The licensed practical nurse may assist an authorized health care practitioner, or the registered nurse, in performing a sterile speculum examination, including obtaining cytology specimens, following clinical practice standards. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice.

Can the licensed practical nurse perform a vaginal examination?

The Nursing Care Quality Assurance Commission determines it is beyond the scope of a licensed practical nurse to perform a vaginal examination. The licensed practical nurse may assist an authorized health care practitioner, or the registered nurse, in performing a vaginal examination, following clinical practice standards. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice.

Can the licensed practical nurse perform Assisted Reproductive Technology (ART) to treat infertility including Intrauterine Insemination (IUI)?

The Nursing Care Quality Assurance Commission determines it is beyond the scope of the licensed practical to perform IUI. It is in the scope of an appropriately prepared and competent licensed practical nurse to assist an authorized health care practitioner or the registered nurse, in providing IUI or other ART procedures, following clinical practice standards. The licensed practical nurse may perform some activities related to ART within the nurse's scope of practice, such as medication administration, routine laboratory testing, and basic education, under the direction of an authorized health care practitioner, or under the direction and supervision, of the registered nurse. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice.

Can the licensed practical nurse perform electronic fetal monitoring?

It is within the scope of an appropriately prepared and competent licensed practical nurse to perform internal or external electronic fetal monitoring under the direction of an authorized health care practitioner, or under the direction and supervision of the registered nurse, following clinical practice standards. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice.

Can the licensed practical nurse perform sexual assault examinations, including using colposcopy to collect forensic evidence collection?

The Nursing Care Quality Assurance Commission determines it is beyond the scope of the licensed practical nurse to perform sexual assault examinations and perform colposcopy to collect forensic evidence. The licensed practical nurse may assist an authorized health care practitioner, or the registered nurse in performing colposcopy and collecting forensic evidence, following clinical practice guidelines. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice.

Can the licensed practical nurse provide epidural care during labor and delivery?

The Nursing Care Quality Assurance Commission determines it is beyond the scope of the licensed practical to provide epidural care during labor and delivery. It is within the scope of an appropriately prepared and competent licensed practical nurse to assist an authorized health care practitioner or the registered nurse, in providing epidural care, following clinical practice standards. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice. See the Nursing Care Quality Assurance Commission's Administration of Sedating, Analgesic, and Anesthetic Agents Advisory Opinion for additional guidance and recommendations.

Can the licensed practical nurse remove a Strut Assisted Volume Implant (SAVI) applicator device?

The Nursing Care Quality Assurance Commission determines it is beyond the scope of the licensed practical nurse to remove a SAVI® applicator device. The licensed practical nurse may assist an authorized health care practitioner or the registered nurse to remove the device, following clinical practice standards. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice

Can the licensed practical nurse to perform an amniotomy?

The Nursing Care Quality Assurance Commission determines it is beyond the scope of the licensed practical nurse to perform an amniotomy. The licensed practical nurse may assist an authorized health care practitioner or the registered nurse, in performing an amniotomy, following clinical practice standards. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice.

Can the licensed practical nurse use standing orders to provide birth control or to screen for and treat sexually transmitted diseases?

It is within the scope of an appropriately prepared and competent licensed practical nurse to follow standing orders to provide routine birth control or to screen for and treat sexually transmitted diseases. The Nursing Care Quality Assurance Commission's Standing Orders and Verbal Orders Advisory Opinion provides additional guidance and recommendations in using standing orders. The Public Health Nurses: Dispensing Medications/Devices for Prophylactic and Therapeutic Treatment of Communicable Diseases and Reproductive Health Advisory Opinion provides guidelines and recommendations. While this is specific to public health nurses, the general concepts apply to any setting. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice.

Physician's Order for Life Sustaining Treatment
What is a Physician's Order for Life Sustaining Treatment (POLST) form?

POLST is a set of medical orders, executed by an adult patient (or legal surrogate) and the patient's medical provider, to guide medical treatment based on the patient's current medical condition and goals. The POLST form is usually for persons with serious illness or frailty. The “rule of thumb” is to recommend POLST for patients if their provider would not be surprised if they die within a year.

The POLST concept was originally created to guide emergency medical services (EMS) personnel in emergency situations. EMS staff was not able to honor advance directives or family member instructions for no cardiopulmonary resuscitation (CPR), because EMS must follow medical orders. POLST was developed to allow EMS to honor patients' no-CPR decisions by turning them into medical orders.

POLST is intended to prevent unwanted or futile treatment, reduce patient and family suffering, and help ensure that individual's wishes regarding end-of-life care are honored. A POLST is valid in all care settings and is portable from one care setting to another. It does not replace advance directives or a durable power of attorney. It is valid with or without advance directives or durable power of attorney. In Washington, it is a bright green form (photocopies and faxes of signed POLST forms are also legal and valid) and should be located in a prominent, easily noticeable location in the home or bedside and in the medical record.

What medical orders are included in a POLST?

The POLST order allows patients to specify whether they desire CPR or whether they prefer to allow a natural death to occur if they are in cardiopulmonary arrest. It contains additional instructions as well, indicating if they have a pulse and/or are breathing, whether they want comfort measures only, specific limited additional interventions, or full treatment.

The POLST form is separated into four sections:

  • Section A identifies what action to take if the person is not breathing and does not have a pulse (CPR/Attempt Resuscitation or DNAR (Do Not Attempt Resuscitation) (Allow Natural Death).
  • Section B identifies what action to take if the person has a pulse and/or is breathing, such use of oxygen, suction, intravenous fluids, airway support, and advanced interventions such as intubation, mechanical ventilation, and other intensive care-related procedures.
  • Section C includes validation and signatures.
  • Section D identifies non-emergency medical treatment preferences including whether the patient should receive antibiotics, medically assisted nutrition and hydration, and dialysis.
How should the decisions in a POLST be made?

The patient (or surrogate decision-maker) and the health care provider should discuss information to assure the POLST reflects the patient's wishes, as expressed in an advance directive or through communications with family or others. The patient's most recent communications, made in the context of their current medical condition, are the most likely to reflect their current wishes. If the patient's wishes are not known, the POLST should direct care in the patient's best interest. RCW 7.70.065(1)(c).

Is POLST mandated by law?

No. Preparing and signing a POLST is always voluntary for patients. Care providers should follow a POLST as they would follow any other medical order. Chapter 43.70.480 RCW Emergency Medical Personnel - Futile Treatment and Natural Death Directives - Guidelines requires the Washington State Department of Health to adopt guidelines and protocols for how emergency medical personnel respond for the treatment of a person with a POLST.

Does the law provide legal immunity for health care workers who follow POLST orders?

Currently, only emergency medical responders are protected from legal liability when following the POLST orders. However, if a POLST order reflects a patient's wishes stated in an advance directive, the caregiver honoring those wishes would have legal protection under the Natural Death Act RCW 70.122. POLST is a medical order, and caregivers should follow it according to the standard of care. According to the Washington State POLST Task Force, no healthcare provider has reported being sued for following a POLST order since POLST was established in Washington State in 2000.

May facilities require POLST as a part of the admission process?

No. Preparing and signing a POLST is always voluntary. The Federal Patient Self-Determination Act (PSDA) and the Joint Commission require that health care facilities take steps to educate all adult patients on their right to accept or refuse medical care. Facilities must ask on admission whether a patient has made an advance directive, maintain policies and procedures on advance directives, and provide information to patients. The PDSA prohibits providers from conditioning care on whether or not an individual has an advance directive. The PDSA definition of advance directive has been interpreted to include a variety of advance planning documents, including POLST.

Should facilities write a new POLST for each patient or resident when they are admitted?

Not necessarily. The patient or resident's POLST is portable, and facilities should incorporate the patient's existing POLST into their records. Facilities may adopt policies requiring a provider with privileges to counter-sign the POLST.

A POLST should be reviewed upon admission. If a POLST has a recent date (within a year generally) and no major changes to the patient's condition have happen since the signing, it is acceptable to consider a confirmation of the POLST as meeting the requirement for inquiry of advance directives on admission.

There is a section on the POLST providers may initial to indicate that a review has been conducted and no changes are required.

What should facility policies do if a patient or resident has no POLST at the time of admission?

If a patient or resident has no POLST at the time of admission, suggest a care planning conference to evaluate whether POLST would be appropriate. These planning conferences should include the patient's medical provider, the patient and surrogate decision-maker, and key family members. These discussions should include a review of the patient's medical history and recommendations from treating providers. A POLST should generally not be written as part of routine admission paperwork without medical professional involvement and extensive discussion.

May facilities refuse to honor a POLST?

Yes. The Natural Death Act RCW 70.122 allows health care facilities or personnel to refuse to participate in withholding or withdrawing life-sustaining treatment due to moral or ethical objections. Residents or patients must be informed of this policy or practice when the provider or facility becomes aware of the existence of a directive or POLST order they do not intend to honor. If an individual provider objects, the facility should try to make a willing staff member available to provide care according to the patient's POLST order. If the facility objects, it should cooperate with the patient or resident and family in finding and transferring the patient to another facility willing to honor the POLST order.

When should a POLST be changed?

The POLST should be reviewed if the patient is transferred from one care setting or care level to another; if there is substantial change in the patient's health status; or if the patient's or decision-maker's treatment preferences change. There is a section on the POLST providers may initial to indicate that a review has been conducted and no changes are required. RNs and LPNs may explain or review the POLST form or existing POLST with the patient or surrogate.

Discussions about the appropriateness of the POLST or making significant changes to a POLST should include the patient's medical provider, the patient and surrogate decision-maker, and key family members. These discussions should include a review of the patient's medical history and recommendations from treating providers.

Discussions should consider whether the patient has advanced dementia, osteoporosis, bleeding disorder or other conditions and situations in which chest compressions or other CPR interventions may cause more harm than benefit to the patient. If the patient or surrogate and provider conclude this patient should not receive CPR even in case of choking or other accident, note “DNAR-No Exceptions” in Section A of the POLST. This note should be initialed by the provider authorized to sign the POLST.

What if a family member tells the caregiver to do CPR when the POLST says DNAR?

A competent adult patient or the legal surrogate may always change their medical decisions and request alternative treatment. However, in an emergency situation, it may be difficult to determine whether or not the family member is the legal surrogate. Facilities should establish policies to manage legal risk in these situations.

What is the purpose of the NCQAC POLST advisory opinion?

The purpose of this advisory opinion is to provide guidance about POLST for advanced registered nurse practitioners (ARNPs), registered nurses (RNs), licensed practical nurses, LPNs), and nursing assistants (NAs). Advisory opinions do not have the force of law.

Is it within the scope of practice for an ARNP to sign POLST orders?

Yes. A licensed ARNP, physician or physician assistant may sign a POLST. The health care practitioner signing the form assumes full responsibility for obtaining informed consent from the patient or surrogate decision-maker. The form must also be signed by the patient or surrogate to be valid. Verbal orders are acceptable with a follow-up signature following facility policy.

The ARNP should periodically review the POLST instructions with the individual or family for any treatment preference changes and consistency with any advance directive, especially if there are substantial changes in the person's health status. The Washington State Medical Association provides many resources and references in helping individuals receive the end-of-life care they specify.

May an ARNP, LPN or registered nurse (RN) follow POLST orders?

Yes. ARNPs, LPNs and RNs may follow valid POLST orders as they would follow any other medical orders, in any setting, based on their regulatory and individual scope of practice.

May a RN or LPN delegate POLST orders to nursing assistants or other unlicensed assistive personnel (UAP)?

Delegation is not required for a nursing assistant to follow the CPR/DNAR POLST orders in Section A. Sections B and D of the POLST may require delegation of some tasks using the delegation process.

May a RN, LPN or NA pronounce death?

An ARNP, RN or LPN may pronounce death. ARNPs may file a death certification. It is not within the nursing assistant's scope of practice to pronounce death.

May a nursing assistant follow a POLST order stating DNAR?

Yes. Nursing Assistants may follow the CPR/DNAR order in Section A of the POLST. Nursing assistants and other non-credentialed UAP may use nursing judgment in emergency situations. A patient without a heartbeat, even if death is expected, is in an emergency situation. A nursing assistant with appropriate training may assess the patient's vital signs and decide if a heartbeat is present. If there is no heartbeat, a nursing assistant may follow a patient's POLST order Section A to start CPR or to provide comfort measures and allow a natural death, depending on the patient's POLST.

May a nursing assistant follow orders in Sections B and D of POLST?

Section B of a POLST include orders on medical interventions, including use of oxygen, suction, IV fluids, airway support and advanced interventions such as intubation, mechanical ventilation, and other intensive care-related procedures. Section D includes non-emergency treatment decisions including whether the patient should receive antibiotics, medically assisted nutrition and hydration, and dialysis. Some of these POLST orders may indicate medical interventions outside the scope of a nursing assistant. Specific activities may require delegation of certain medical interventions identified in the POLST sections B and D, depending on the task, equipment available, and competency of the nursing assistant.

What training about POLST is available for nursing assistants and unlicensed assistive personnel?

The Washington State Department of Social and Health Services (DSHS) and POLST stakeholders have developed a short training video for home care aides and other bedside caregivers. The video includes instruction on how these staff should respond when they find a resident who is nonresponsive. This video will be part of a continuing education program which DSHS plans to approve in 2015.

May nursing assistants perform nursing activities that require nursing judgment?

Yes. Nursing assistants and other UAP may perform activities that require nursing judgment only in emergency situations. When a patient has no heartbeat, it is an emergency situation in which a nursing assistant may use nursing judgment to follow a POLST order to either perform CPR or to provide comfort care while allowing natural death to occur.

In many community-based settings personal care may be given by nursing assistants without nurse direction or supervision. Can nursing assistant follow POLST instructions if a nurse is not directing and supervising the care?

An individual is working under their nursing assistant credential only when being directed and supervised by a nurse. In situations where the nurse is not directing and supervising the care, the individual is not working under the nursing assistant credential. The employer or facility should have policies and procedures in place to address this situation.

What should nursing assistants do if they find a patient who is non-responsive or has no heartbeat?
  • They should call the nursing supervisor, 911, or hospice for emergency help, and stay with the patient. This plan should be made in advance as part of the patient plan of care.
  • If the POLST says DNAR, nursing assistants should not initiate CPR. They should provide comfort care and wait for assistance to arrive.
  • If the POLST says CPR/Attempt Resuscitation, nursing assistants should begin CPR and continue until help arrives.
What if a person stops breathing because of an accident, such as choking? Do I follow a POLST order to not give CPR?

In most circumstances, if a person's heartbeat stops during a witnessed choking incident or other accident, perform basic first aid measures per standard training. If the person has no pulse or becomes nonresponsive, begin CPR even if the POLST says “No CPR/allow natural death.” Continue CPR until licensed staff or emergency medical responders arrive.

However, some patients may want to refuse CPR under all circumstances including choking or accidents. This may be the medically appropriate decision for patients with advanced dementia at risk for aspiration, patients with osteoporosis, or other conditions and situations in which chest compressions or other CPR interventions may cause more harm than benefit to the patient.

Each patient's care plan should include details specifying if the POLST DNAR order applies in all circumstances. The POLST should include a note in Section A stating “DNAR-No Exceptions” initialed by an authorized provider. Bedside caregivers and supervisors should be familiar with this detail in the patient care plan and POLST.

What if someone starts CPR on a patient with a POLST indicating "Do Not Attempt Resuscitation"?

If a patient's POLST order indicates no CPR, CPR should not be initiated. In the event that CPR is initiated for a person in violation of a POLST with a DNAR order, CPR should be discontinued if no pulse is detectable. This is an example of a situation where all health care providers caring for the patient must be aware of the medical orders for the patient. Facilities should establish policies to manage legal risk in such a situation.

Prevention and Treatment of Opioid-Related Overdoses
What opioid antagonists are commonly prescribed to reverse the effects of opioid overdose?

Opioid antagonists reverse the effects of an opioid overdose. Naloxone (Narcan®) is the current standard of treatment for opioid overdose. The Food and Drug Administration (FDA) approves administration by intravenous, intramuscular, or subcutaneous routes; a hand-held auto-injector (Evzio®) for intramuscular or subcutaneous injection; and, in 2018, approved the first generic Naloxone Hydrochloride nasal spray. These are legend drugs, and not categorized as a controlled substance. Naloxone has not been shown to produce tolerance or cause physical or psychological pain. It will produce withdrawal symptoms. Severity and duration of the withdrawal relate to the dose of naloxone and the degree and type of opioid dependency. See the Washington State Department of Health Overdose Education and Naloxone Distribution Webpage for more information.

Is the Licensed Practical Nurse required to carry naloxone?

RCW 69.41.095 does not require the Licensed Practical Nurse to carry an opioid antagonist, such as naloxone. For more information, go to the Washington State Department of Health Overdose Education and Naloxone Distribution Website.

Can the Licensed Practical Nurse administer naloxone follow a standing order for a suspected opioid overdose?

The Licensed Practical Nurse may administer an opioid antagonist following a standing order from an authorized health care practitioner. This includes following the Washington State Department of Health Statewide Standing Order to Dispense Naloxone. The Licensed Practical Nurse should use the Scope of Practice Decision Tree to determine if the activity is within the nurse's legal and individual scope of practice. The Nursing Care Quality Assurance Commission's Standing Orders and Verbal Orders Advisory Opinion provides guidance and recommendations. For more information, go to the Washington State Department of Overdose Education and Naloxone Distribution Website.

Can the Licensed Practical Nurse carry naloxone for emergent administration for a suspected drug overdose to an unknown person?

RCW 69.41.095 allows the Licensed Practical Nurse to carry and administer an opioid antagonist (such as naloxone) to a person suspected of experiencing an opioid overdose in any setting. The nurse must have a valid prescription, either in the nurse's name, in the name of an entity, in the name of a person or patient, or through a standing order. The nurse may get a prescription from a pharmacist with a Collaborative Drug Therapy Agreement (CDTA) or use the Washington State Department of Health Statewide Standing Order to Dispense Naloxone to get a prescription from a pharmacy. The nurse may also get a prescription in their own name from their health care practitioner. The Licensed Practical Nurse should use the Scope of Practice Decision Tree to determine if specific activities are within the registered nurse's legal and individual scope of practice. For more information, go to the Washington State Department of Health Overdose Education and Naloxone Distribution Website.

Can the Licensed Practical Nurse dispense or distribute naloxone?

RCW 69.41.095 allows the Licensed Practical Nurse to dispense or distribute an opioid antagonist (such as naloxone) for a high-risk person, their family members, or friends following standing orders or a prescription from an authorized health care practitioner. Any person or entity may lawfully possess, store, deliver, distribute, or administer an opioid overdose reversal medication with a prescription or standing order. The Licensed Practical Nurse should use the Scope of Practice Decision Tree to determine if specific activities are within the registered nurse's legal and individual scope of practice. For more information, go to the Washington State Department of Health Overdose Education and Naloxone Distribution Website.

Is the Licensed Practical Nurse required to have a special certification or specific training to prescribe, dispense, and administer naloxone for a suspected drug overdose?

The Licensed Practical Nurse, just as in all care the nurse provides, must be appropriately prepared and competent to perform the activity safely. The Washington state laws and rules do not require a specific training course or certification. Stop Overdose.com offers education, resources, and technical assistance for individuals, professionals, and communities in Washington State who want to learn to prevent and respond to overdose and improve the health of people who use drugs. An employer or institution may have specific requirements for training or certification. The Licensed Practical Nurse should use the Scope of Practice Decision Tree to determine if specific activities are within the registered nurse's legal and individual scope of practice. For more information and training resources, go to the Washington State Department of Health Overdose Education and Naloxone Distribution Website.

Can the Licensed Practical Nurse get a prescription to carry and administer naloxone in a non-work setting?

RCW 69.41.095 allows the Licensed Practical Nurse to have a prescription for an opioid antagonist in the nurse's name to carry and administer in the non-work setting. Nurses may carry and administer an opioid antagonist (such as naloxone) in a suspected opioid overdose whether the person is a family member, friend, stranger, or a patient. The Licensed Practical Nurse should use the Scope of Practice Decision Tree to determine if specific activities are within the registered nurse's legal and individual scope of practice. For more information, go to the Washington State Department of Health Overdose Education and Naloxone Distribution Website.

Can the Licensed Practical Nurse delegate to the nursing assistant to administer naloxone for a suspected opioid overdose?

It is not within the Licensed Practical Nurse's scope of practice to delegate administration of an opioid antagonist by any route in any setting. RCW 69.41.095 provides an exception to the nursing delegation laws and rules and does not require delegation for a nursing assistant to administer an opioid overdose medication by intranasal spray or by injection. The Licensed Practical Nurse should use the Scope of Practice Decision Tree to determine if specific activities are within the registered nurse's legal and individual scope of practice. For more information, go to the Washington State Department of Health Overdose Education and Naloxone Distribution Website.

Radiology Procedures
Can the licensed practical nurse perform radiology procedures?

It is within the scope of an appropriately prepared and competent licensed practical nurse to perform routine and non-complex diagnostic imaging procedures under the direction of an authorized health care practitioner, or under the direction and supervision of the registered nurse, following clinical practice standards. A prescription or order from an authorized provider is required. The prescription or order may be done following standing orders. Examples of diagnostic imaging procedures include:

  • Routine radiology tests (such as chest, extremity);
  • Computerized axial tomography (CAT) scans;
  • Fluoroscopy, including upper gastrointestinal and barium enema procedures;
  • Magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA);
  • Mammography;
  • Nuclear medicine such as bone scans, thyroid scans, and thallium cardiac stress tests;
  • Positron emission tomography (PET); and
  • Ultrasound.

While the licensed practical nurse may perform routine, diagnostic imaging procedures, because of the complexity, it is not within the scope of the licensed practical nurse to perform interventional radiology procedures. Interventional radiology is performed using minimally invasive therapies under imaging guidance. Common interventional radiology procedures include thrombolysis, needle biopsies, paracentesis, and thoracentesis. The licensed practical nurse may assist an authorized health care practitioner, or the registered nurse, in performing interventional radiology procedures. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice. See the Nursing Care Quality Assurance Commission's Standing Orders and Verbal Orders Advisory Opinion for additional information.

School Nursing
Can the licensed practical nurse in a school setting delegate to assistive personnel for asthma management?

It is not within the scope of practice for the licensed practical nurse to delegate to assistive personnel nursing tasks in the public and private, kindergarten through twelve grade school setting (RCW 28A.210 Common School Provisions: Health-Screening and Requirements). Only the registered nurse may delegate to assistive personnel to perform asthma management tasks in this setting.

Can the licensed practical nurse in the school setting delegate administration of nursing tasks for diabetes to non-credentialed assistive personnel?

It is not within the scope of practice for the licensed practical nurse to delegate nursing tasks to non-credentialed assistive personnel in the public and private, kindergarten through twelve grade school setting (RCW 28A.210 Common School Provisions: Health-Screening and Requirements). Only the registered nurse may delegate to assistive personnel to perform diabetes management tasks in this setting.

Can Symjepi® be substituted for an epinephrine autoinjector (EAI) currently allowed to be delegated to unlicensed assistive personnel (UAP) in schools?

The Nursing Care Quality Assurance Commission does not have authority to interpret the laws governing the provision of health care in K-12, public and private schools. Chapter 28A.210.383 RCW provides that the Office of the Superintendent of Public Instruction (OSPI) and school districts have the authority to develop anaphylactic policies for schools.

The law specifies that epinephrine autoinjectors may be prescribed to be maintained by schools for use when necessary. RCW 28A.210.383(2)(a). However, it may be feasible for OSPI and school districts to develop written policies to allow a substitution for the EAI for an individual student when the substitution is permitted by the prescriber according to the student's anaphylaxis care plan. RCW 28A.210.383(2)(b). RCW 28A.210.383(4)(b) provides: “In the event a school nurse or other school employee administers epinephrine in substantial compliance with a student's prescription that has been prescribed by an authorized health care practitioner with prescriptive authority and written policies of the school district or private school, then the school employee, the school district or school of employment, and the members of the governing board and chief administrator are not liable in any criminal action or for civil damages as a result of administering epinephrine.” (RCW 28A.210.383).

RCW 28A.210.380 and RCW 28A.210.383 specifically require the use of an “autoinjector” to administer epinephrine. Symjepi® (https://www.symjepi.com/) is not classified as an EAI. This may apply to prescriptions for individual students as well as for the school supply.

RCW 28A.210.370 allows self-administration of medications, including epinephrine, if the student meets the requirements under the treatment plan for anaphylaxis, and has a prescription from their health care practitioner. This may include self-administering epinephrine using an EAI or a prefilled medication device if authorized in the prescription.

School Nursing During the COVID-19 Emergency
Can school nurses provide telehealth services to students during the coronavirus (COVID-19) emergency?

School registered nurses or licensed practical nurse (LPN) may provide telehealth services to students during the COVID-19 emergency within their legal scope of practice. The same standards apply regardless of whether the services are provided face-to-face or through telecommunication technology.

Can the school registered nurse delegate to unlicensed assistive personnel (UAP) using telehealth services?

The nursing and nursing assistant laws and rules do not prohibit the registered nurse delegator from using telehealth services to initiate or provide ongoing evaluation, or supervision of delegated tasks to UAP. The nurse must use nursing judgment and consider what aspects of the initial and ongoing assessment, supervision, and evaluation need to be done face-to-face. Telehealth may not be appropriate in some circumstances. The most important consideration is whether it is safe for the patient to perform the initial and ongoing assessment, evaluation, or supervision using telehealth services following the nursing and delegation laws and rules (RCW 18.79WAC 246-840RCW 18.88AWAC 246-841).

Standing Orders, Verbal Orders, Electronic Orders, Telehealth, Triage, Case Management
Can the licensed practical nurse follow standing orders or verbal orders?

The nursing laws and rules do not prohibit the competent and appropriately trained licensed practical nurse from following a standing order or obtaining and carrying out a verbal order that is non-complex and routine. Standing orders and verbal orders may include medical orders or nursing orders. The licensed practical nurse may assist an authorized provider or registered nurse in carrying out a complex standing order or verbal order. The licensed practical nurse must be competent to carry specific steps identified in the standing order or verbal order. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if specific activities are within the licensed practical nurse's legal and individual scope of practice. The Nursing Care Quality Assurance Commission's Standing Orders and Verbal Orders Advisory Opinion provides additional guidance and recommendations.

Can the licensed practical nurse accept a verbal or written order from a physician relayed through an unlicensed person or an order that has been electronically transmitted?

The laws and rules do not prohibit the licensed practical nurse from accepting an order from an authorized medical provider through another unlicensed or licensed person. The licensed practical nurse should use nursing judgment and determine whether additional verification or clarification is required. The laws and rules place accountability on the nurse who is implementing the order to implement or clarify that the order is accurate, valid, properly authorized, and is not harmful or potentially harmful to the patient, or is not contraindicated by documented information. The licensed practical nurse implementing the order is required to see clarification of the order when the licensed practical nurse has any reason to believe any contraindications exists, and to take any other action necessary to assure the safety of the patient. The licensed practical nurse must be competent to carry specific steps identified in the standing order or verbal order. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if specific activities are within the licensed practical nurse's legal and individual scope of practice. The Nursing Care Quality Assurance Commission's Standing Orders and Verbal Orders Advisory Opinion provides additional guidance and recommendations.

Can the licensed practical nurse call in medication ordered by an authorized provider to a pharmacy?

The laws and rules do not prohibit the licensed practical nurse from calling in a medication ordered by an authorized health care provider order, or under the direction and supervision of the registered nurse, to a pharmacist. The licensed practical nurse should use nursing judgment and determine whether additional verification or clarification is required. The licensed practical nurse implementing the order is required to see clarification of the order when the licensed practical nurse believes or has any reason to believe one of these contraindications exists, and to take any other action necessary to assure the safety of the patient.

Can the licensed practical nurse work as a case manager or care coordinator?

The nursing laws and rules do not prohibit the competent and appropriately trained licensed practical nurse from working as a case manager or care coordinator. The licensed practical nurse must practice within his or her legal scope of practice. It is not within the scope of a licensed practical nurse to practice independently. The licensed practical nurse practices interdependently when providing nursing care and dependently when carrying out medical regimens. The licensed practical nurse may contribute and assist in collecting information and performing case management or care coordination activities identified in the nursing care plan within the licensed practical nurse's scope of practice. The nursing care plan may only be developed, implemented, and evaluated by a registered nurse.

Can the licensed practical nurse perform triage or a Medical Screening Exam (MSE)?

The competent and appropriately trained licensed practical nurse can perform triage under the direction of an authorized health care practitioner or under the direction and supervision of the registered nurse. The licensed practical nurse does not work “under” authorized health care practitioner's license the registered nurse's license. For example, it would not be within the licensed practical nurse's scope of practice to modify the standing or verbal order without consulting with the registered nurse or other authorized health care practitioner. The licensed practical nurse must consult with an authorized health care practitioner or the registered nurse if the patient's situation is going outside the standing order. Any changes to the standing order must be documented and communicated to an authorized health care practitioner or the registered nurse. The licensed practical nurse cannot provide nursing care independently. The licensed practical nurse must have the training, knowledge, skills and abilities to perform triage competently (RCW) 18.79(WAC) 245-840 and Advisory Opinion on Telenursing. The licensed practical nurse must be competent to carry specific steps identified in the standing order or verbal order. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if specific activities are within the licensed practical nurse's legal and individual scope of practice. The Nursing Care Quality Assurance Commission's Standing Orders and Verbal Orders Advisory Opinion provides additional guidance and recommendations.

What is the licensed practical nurse's scope of practice when triaging calls dealing with an unstable situation or complex issue such as a caller disclosing he/she wants to harm themselves?

Triaging occurs in various setting such as managed care organization, primary and specialty care, emergency departments, and crisis lines. The laws and rules do not prohibit the competent and appropriately trained licensed practical nurse from triaging calls under the direction (direction can be following a standing order) of an authorized health care practitioner or under the direction and supervision of the registered nurse if the licensed practical nurse has the training, knowledge, skills and ability to carry out the activity safely and competently and is willing to accept any consequences of his/her actions.

Some settings may use the licensed practical nurse to manage calls after specialized training and under the supervision of the registered nurse or other authorized health care provider. The licensed practical nurse may collect demographic data from the caller and screen the patient who presents with suicide thoughts. If a patient is deemed potentially dangerous to others, the licensed practical nurse may need to consult with the registered nurse cases are considered more complex and are often deferred to the registered nurse or other professional team member who is trained to handle the needs and complexities of the patient.

It would be prudent to identify steps in the standing order as to what level a triage call becomes complex requiring the licensed practical nurse to refer to or consult with the registered nurse or other authorized health care practitioner. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if specific activities are within the licensed practical nurse's legal and individual scope of practice. The Nursing Care Quality Assurance Commission's Standing Orders and Verbal Orders Advisory Opinion provides additional guidance and recommendations.

All nurses in Washington State are required to complete a suicide prevention training course from an approved list. For more information, see the Washington State Department of Health's Suicide Prevention Training for Health Professionals Approved Courses.

Can the licensed practical nurse take verbal or telephone orders?

The nursing laws and rules do not prohibit the licensed practical nurse from taking a verbal or telephone order. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if specific activities are within the licensed practical nurse's legal and individual scope of practice. The Nursing Care Quality Assurance Commission's Standing Orders and Verbal Orders Advisory Opinion provides additional guidance and recommendations.

Telehealth During the COVID-19 Emergency
Can the licensed practical nurse (LPN) or the registered nurse (RN) provide care using telehealth services during the Coronavirus (COVID-19) emergency?

The LPN and RN may provide telehealth nursing services within their scope of practice to patients in Washington state. The nurse must be licensed in Washington, or be approved through the Emergency Volunteer Health Practitioners Program during the COVID-19 emergency.

Can the licensed practical nurse (LPN) or the registered nurse (RN) follow standing orders when providing telehealth services during the Coronavirus (COVID-19) emergency?

The LPN or RN may provide telehealth nursing services within their scope of practice to patients in Washington state following standing orders approved by an authorized practitioner. The commission's advisory opinion on provides Standing Orders and Verbal Orders (PDF) additional information and guidance.

Is there any guidance for nurses working for home care, home health, or hospice agencies about using telehealth services instead of going to the home during the COVID-19 Pandemic?

The Washington State Department of Health COVID-19 Guidance for Home Care, Home Health, and Hospice Agencies provides guidance and resources for health care professionals providing services in these settings.

What should the licensed practical nurse (LPN) or the registered nurse (RN) consider when determining if telehealth nursing services is an option in caring for a patient during the COVID-19 emergency?

The licensed practical nurse (LPN) or registered nurse (RN) should consider what they are trying to accomplish based on the patient needs and safety and within their scope of practice. It is up to the nurse, using nursing judgment, to determine which patients and services are appropriate for telehealth.

During the coronavirus pandemic can the Washington state licensed practical nurse (LPN) or registered nurse (RN) provide nursing care to patients in other states using telehealth services?

Washington state is not a member of the Nurse Licensure Compact (NLC) through the National Council of State Boards of Nursing (NCSBN) that allows the nurse to practice in member states with one state licensure in another state in the NLC. The nurse would need to contact the other state(s) to see if they can practice in their state with a Washington state license during the pandemic.

Does the LPN or RN need to be in the physical building of the employer using established systems compliant with HIPAA when they are providing telehealth services or can they perform telehealth services from their home during the COVID-19 emergency?

The U.S. Office of Health and Human Services-Office of Civil Rights Frequently Asked Questions on Telehealth and HIPAA provides information on waivers and exceptions and guidance during the COVID-19 emergency about HIPAA and telehealth services.

Can nursing staff participate in assisting a medical team in a facility performing telemedicine with an electronic stethoscope or through a computer/telehealth system?

There are models of care in place that involve a medical team including nursing staff. Please refer to the Scope of Practice Decision Tree that will help you walk through your scope area.

Telemedicine Training Requirements
Is a registered nurse (RN), licensed practical nurse (LPN), or Advanced Registered Nurse Practitioner (ARNP) required to take telemedicine training?

Yes, licensed nurses (RN, LPN, or ARNP) in Washington state are required to take telemedicine training if the nurse provides telemedicine services. RCW 43.70.495 requires the nurse who provides clinical services through telemedicine independently or under the direction of an authorized health care practitioner to complete telemedicine training. “Telemedicine” as defined in RCW 70.41.020(13) means, “the delivery of health care services through the use of interactive audio and video technology, permitting real-time communication between the patient at the originating site and the provider, for the purpose of diagnosis, consultation, or treatment [but] does not include the use of audio-only telephone, facsimile, or email.”

The Washington State Telehealth Collaborative uses the following slightly different Medicaid definition of telemedicine in the training:

“Telemedicine is when a health care practitioner uses HIPAA-compliant, interactive, real-time audio and video telecommunications (including web-based applications) or store and forward technology to deliver covered services that are within his or her scope of practice to a client at a site other than the site where the provider is located.” WAC 182-531-1730(1). It does not include “the use of audio-only telephone, facsimile, or email.”

Does the training requirement apply to a nurse who provides telephone triage?

No, the telemedicine training requirement doesn't apply to audio-only telephone (telephone triage), facsimile, or email. However, the Nursing Care Quality Assurance Commission (NCQAC) recommends licensed nurses complete the telemedicine training if they provide services such as; telephone triage, remote patient monitoring (“RPM”, which enables recording and monitoring health data remotely), asynchronous telehealth (such as Store and Forward technology that allows patient data to be collected, stored, and later retrieved by another professional), Mobile Health (“mHealth,” using smart devices such as smartphones and smart wearables that allow continuous data collection about a person's behavior or condition) or other types of telehealth. The telemedicine training provides a valuable overview of the roles, responsibilities, liability, and legal requirements when providing telehealth services.

Does the nurse need to send in the certification to the Nursing Care Quality Assurance Commission (NCQAC)?

The law, RCW 43.70.495, requires the nurse to sign and retain an attestation of completion. The nurse does not need to send the attestation or documentation to the NCQAC unless requested.

When is completion of telemedicine training required?

The Nursing Care Quality Assurance Commission (NCQAC) recommends telemedicine training be completed as soon as possible as a demonstration of competency. The licensed nurse (RN, LPN, or ARNP) providing telemedicine clinical services licensed prior to January 1, 2021, will need to complete telemedicine training by December 31, 2021. The newly licensed RN, LPN, or ARNP or the RN, LPN, or ARNP licensed through the endorsement process who provides clinical services will need to meet the requirement one year after the initial license is issued. The Nursing Care Quality Assurance Commission (NCQAC) recommends all Washington nurses complete the telemedicine training as a demonstration of competence as soon as practical to provide an overview of the roles, responsibilities, liability, and legal requirements for providing telehealth services.

Does telemedicine training taken prior to January 1, 2021 meet the telemedicine training requirement?

Telemedicine training taken prior to January 1, 2021 meets the requirement if it includes the content defined in RCW 43.70.495(2). The RN must be appropriately trained and competent to provide nursing telehealth services. To learn more about the different training options available and access additional resources, see the Washington State Telehealth Collaborative Training webpage. To complete the free and publicly available telemedicine training, see the Washington State Medical Professional Telemedicine Training website.

What are the options to meet telemedicine training requirements?

To learn more about the different training options available and access additional resources, please visit the Washington State Telehealth Collaborative Training webpage. To complete the free and publicly available telemedicine training, see the Washington State Medical Professional Telemedicine Training webpage.

Urological and Hemodialysis
Can the licensed practical nurse perform bladder instillation therapy?

It is within the scope of practice of an appropriately prepared and competent licensed practical nurse to perform bladder instillation therapy under the direction of an authorized health care practitioner, or under the direction and supervision of the registered nurse, following clinical practice standards. Examples include instillation of dimethyl sulfoxide (DMSO), chemotherapy (e.g. Mitomycin C), and Bacillus Calmette-Guérin (immunotherapy) drugs. There must be an order from an authorized provider. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice.

Can the licensed practical nurse perform hemodialysis in the home setting?

It is within the scope of practice of an appropriately prepared and competent licensed practical nurse to perform peritoneal dialysis under the direction of an authorized health care practitioner, or under the direction and supervision of the registered nurse, following clinical practice standards. The procedure may be performed in a home setting or an in-center setting. A prescription or order from an authorized provider is required. This includes preparing and monitoring the dialysis machine, accessing an arteriovenous (AV) fistula or graft or a central venous catheter, initiating or discontinuing hemodialysis, collecting specimens, catheter site care, and performing tubing or adaptor changes. The patient must be in a stable condition. If the patient is not in a stable condition, the licensed practical nurse may assist an authorized provider, or the registered nurse, in performing these procedures. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice.

Can the licensed practical nurse perform peritoneal in the home setting?

It is within the scope of practice of an appropriately prepared and competent licensed practical nurse to perform peritoneal dialysis under the direction of an authorized health care practitioner, or under the direction and supervision of the registered nurse, following clinical practice standards. The procedure may be performed in a home setting or an in-center setting. A prescription or order from an authorized provider is required. This includes initiating or discontinuing therapy using pre-mixed medicated peritoneal dialysis bags, collecting specimens, catheter site care, and performing tubing or adaptor changes. The patient must be in a stable condition. If the patient is not in a stable condition, the licensed practical nurse may assist an authorized provider, or the registered nurse, in performing these procedures. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice.

Can the licensed practical nurse remove a suprapubic catheter?

It is within the scope of practice of an appropriately prepared and competent licensed practical nurse to remove a suprapubic under the direction of an authorized health care practitioner, or under the direction and supervision of the registered nurse, following clinical practice standards. There must be an order from an authorized provider. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice.

Can the licensed practical nurse replace a suprapubic catheter?

It is within the scope of practice of an appropriately prepared and competent licensed practical nurse to replace a suprapubic in an established tract under the direction of an authorized health care practitioner, or under the direction and supervision of the registered nurse, following clinical practice standards. There must be an order from an authorized provider. It is not within the scope of the licensed practical nurse to replace a suprapubic catheter in a non-established tract. The licensed practical nurse may assist an authorized provider in replacing a suprapubic catheter in a non-established tract. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse's legal and individual scope of practice.

Is it acceptable practice for the licensed practical nurse to withhold medications prior to dialysis without an order from an authorized provider?

Withholding medications, primarily anti-hypertensives, prior to dialysis is not uncommon. Due to the frequent tendency for patients to become hypotensive during treatment, and also the “pulling off” of medications during the dialysis procedure, nurses often withhold medications. It has often been considered a ‘community practice' and has been taken for granted that medications could be withheld whether written orders by an authorized provider are obtained or not. Then the withheld medications are given post dialysis, usually with communication to the provider on the patient's tolerance and outcomes for a successful dialysis and the provider's determination of the next dialysis. It is not acceptable for the licensed practical nurse to routinely withhold medications without any medication prior to dialysis without an order from an authorized provider. This order may be written for an individual patient or through a standing order. The Nursing Care Quality Assurance Commission's Standing Orders and Verbal Orders Advisory Opinion and Verbal Orders provides additional guidance and recommendations.