REPLACES DR 96-1
MARYLAND BOARD OF NURSING
DECLARATORY RULING 2003-3
OCTOBER 28, 2003
RE: REGISTERED NURSE ADMINISTRATION OF PROCEDURAL SEDATION FOR
OPERATIVE, INVASIVE AND DIAGNOSTIC PROCEDURES AND FOR EPISODIC
TREATMENTS OR THERAPIES FOR THE ADULT AND PEDIATRIC PATIENT,
(E.G. INTRAVENOUS, INTRAMUSCULAR, INHALATION, ORAL, RECTAL, AND
The Board of Nursing received a petition from Johns Hopkins Hospital, Baltimore, Maryland and
additional telephone calls from the community requesting the Board=s recommendation to permit
the Certified Registered Nurse Practitioner (CRNP) and the Certified Registered Nurse
Midwife (CRNM) to prescribe procedural sedation when the CRNP or CRNM is performing
a client procedure or diagnostic test which is part of the CRNP or CRNM=s collaborative
agreement. The questions to be answered by this document included but were not limited to:
1. May a registered nurse administer conscious sedation at the direction of a physician assistant,
certified registered nurse practitioner (CRNP), or certified registered nurse midwife (CRNM)
licensed dentist, or licensed podiatrist?
2. May a registered nurse administer conscious sedation to a patient whose pre-anesthesia
assessment is classified as ASA III or ASA IV?
3. May a registered nurse administer procedural sedation for a operative, invasive and
diagnostic procedure exceeding two hours in length extending to possibly eight hours
4. Is the administration of chloral hydrate by oral route to the pediatric patient considered
5. Are there patient conditions or circumstances which require the patient to be assessed by a
licensed qualified anesthesia provider (e.g., licensed physician who has substantial
specialized knowledge, judgment and skill related to anesthesia or a certified registered
6. May a registered nurse monitor a patient receiving procedural sedation induced by a
medication the registered nurse is not permitted to administer and when the medication is
administered by the licensed physician or CRNP or CRNM performing the procedure?
7. May a registered nurse administer Ketamine, an anesthetic agent, intramuscularly to a
patient, for purposes of procedural sedation?
8. May a registered nurse administer Propofol or Ketamine, both anesthetic agents,
intravenously to patient requiring analgesia for pain treatments such as burn dressing
9. May the registered nurse obtain the patient=s informed consent for procedural sedation?
The Board is authorized to issue declaratory rulings pursuant to State Government Article
10-301 et seq. and the Maryland Board of Nursing Regulations Governing Issuance of Petitions
for a Declaratory Ruling COMAR 10.27.08.
For the purpose of clarity, the following terms have been defined to mean:
1. AProcedural sedation@ also known as conscious sedation or moderate sedation or sedation
analgesia is produced by the administration of a single pharmaceutical agent, or a combination of
pharmacological agents, by one of several common routes: intravenous, intramuscular,
inhalation, oral, rectal and intranasal. A patient under procedural sedation has a depressed level
of consciousness but retains the ability to: maintain protective reflexes, independently and
continuously maintain a patent airway, and respond appropriately to physical stimulation and/or
verbal command. Procedural sedation may be easily converted into a state of deep sedation
and/or loss of consciousness because of the unique characteristics of the medication or
combination of medications used, as well as other factors indicating the physical status and
medication sensitivities of the individual patient. The administration of procedural sedation
requires continuous monitoring of the patient and the ability to respond immediately to any
deviation from normal.
2. ADeep Sedation@ is a drug induced depression of consciousness during which the patient
cannot be easily aroused and may not respond purposefully following repeated or painful
stimulation. The ability to independently maintain ventilatory function may be impaired.
Patients may require assistance to maintain a patent airway and spontaneous ventilation may be
inadequate. Cardiovascular functioning is usually maintained.
3. ARescuing@ means the competency to manage a compromised airway, provide adequate
oxygenations and ventilation, and prescribe or administer reversal agents per the licensee=s scope
of practice until the patient recovers the ability to maintain a patent airway and ventilate to
adequate oxygenation or is transferred to a higher level of care.
4. AASA Pre-Anesthesia Assessment@ the American Society of Anesthesiologists define each of
the ASA classifications to be:
$ Class I A normal healthy patient other than surgical pathology-without systemic
$ Class II A patient with mild systemic disease - no functional limitations.
$ Class III A patient with moderate to severe symptoms disturbance due to medical or
surgical disease - some functional limitation but not incapacitating.
$ Class IV A patient with severe systemic disturbance which poses a constant threat to
life and is incapacitating.
$ Class V A moribund patient not expected to survive 24 hours with or without
$ Class E If the case is an emergency, the physical status is followed by the AE@-
5. ANitrous oxide 50% or less@ means the administration of a fixed concentration of 50% nitrous
oxide and 50% oxygen.
6. ANitrous oxide 50% or less for procedural sedation@ means the administration of nitrous oxide
50% or less without any other sedative narcotics or other depressant drug before or concurrent with
the nitrous oxide 50% or less to an otherwise healthy ASA Class I or II patient.
7. APediatric Patient@ means a patient who is a full term infant of at least six weeks to twelve years
8. AEpisodic Treatments or Therapies@ means prescribed actions such as dressing changes or
debridement etc. that may occur once or on an ongoing basis that may cause the patient to become
agitated or increase the patient=s discomfort or alter the patient=s hemodynamic status.
9. AImmediately available@ means physically present, on site, in the unit of care and not otherwise
engaged in any other uninterruptable procedure or task.
The administration of procedural sedation by specially trained registered nurses other than
the Certified Registered Nurse Anesthetist (CRNA) requires thorough and comprehensive
assessment and evaluation of six critical elements which comprise the environment under which
.procedural sedation is administered. These six critical elements to be considered by the specially
trained registered nurse are:
1. The specialized education and training required for the registered nurse to administer,
monitor, and rescue the patient. The nurse=s considerations would include but not be limited to
patient assessment and potential interaction with or reaction to: the procedure to be performed; the
patient=s morbidity/co-morbidity factors; and the medication or combination of medications utilized
to induce and reverse procedural sedation.
2. The licensed physician or CRNP or CRNM prescribing the procedural sedation for the
procedure he or she is performing has been credentialed by the facility to prescribe procedural
sedation. Factors to be considered in the credentialling process include but may not be limited to:
the medication or combination of medications utilized to induce and maintain the patient in a state
of procedural sedation including dosage ranges, effects, side effects, contraindications, and
reversal agents; standardized nationally recognized patient anesthesia assessment guides; airway
classification and management; Dysrhythmia recognition; and knowledge and skills required to
rescue a patient.
3. Clinical status of the patient receiving procedural sedation including but not limited to:
procedure to be performed; current prescribed and over-the-counter medications, including
herbals; current clinical status including ability to cooperate; and morbidity/co-morbidity. A
significant factor for consideration concerns the administration of procedural sedation in an
emergency, when there has not been an opportunity to assess and prepare the patient for the
4. The requirements of the clinical setting in which the procedural sedation is to be
administered include but are not limited to: sufficient knowledge, skill, and availability of
personnel to respond to an emergency; and sufficient technology and emergency equipment
available (including the resources necessary to rescue a patient receiving procedural sedation). It
is noted that in the free standing ambulatory clinical setting, which may be comprised of one
primary physician who performs the procedure and also prescribes the procedural sedation and
one registered nurse administering and monitoring the patient during procedural sedation, these
identified elements are of a greater significance. When the clinical setting has limited resources
and those personnel resources have limited knowledge, skill and abilities, then there is a greater
risk for the patient. The registered nurse as a patient advocate has the obligation to evaluate these
factors prior to agreeing to assume responsibility for administering procedural sedation in this
7. Monitoring the patient receiving procedural sedation includes but is not limited to: the
activities which the registered nurse must perform to monitor the patient while simultaneously
administering the procedural sedation and the technical equipment required to perform the
monitoring and rescue activities.
8. The prescribing physician or CRNP or CRNM and the registered nurse administering the
procedural sedation have a dependent and inter-dependent relationship. Examples of this
dependent/inter-dependent relationship include but are not limited to:
1) the prescribing physician or CRNP or CRNM is depending upon the specially
trained registered nurse to possess the requisite knowledge, judgement and skill to
administer procedural sedation, safely monitor the patient, and practice in
compliance with the practice setting or facility=s written policies and procedures.
2) The registered nurse is depending on the prescribing physician or CRNP or
CRNM to be knowledgeable about how to appropriately assess the patient=s status
in anticipation of procedural sedation, the medication(s) the physician is
prescribing to induce procedural sedation and the practice setting or facility=s
written policies and procedures.
3) The inter-dependence of the relationship is reflected throughout the process of
performing the procedure, administering sedation, monitoring and Arescuing@ a
patient. An example of the inter-dependence may be Arescuing@ which may
include but is not limited to each individual=s knowledge, skill and judgment to
manage the patient=s airway, select or administer reversal agents and other
emergency medications etc.
Given the above definitions and description of the critical elements , the Board has
determined that it is within the scope of practice of a specially trained registered nurse to
administer and monitor procedural sedation for a defined patient population (e.g. pediatric or
adult) undergoing an operative, invasive and/or diagnostic procedure and for episodic treatments
or therapies given specific conditions/circumstances. For a specially trained registered nurse to
administer procedural sedation, all of the following specific conditions must be met:
1. Medication(s) must be ordered only by the licensed physician or CRNP or CRNM who is
performing the procedure or caring for the patient during the diagnostic test, and who is:
A. credentialed by the facility to prescribe procedural sedation; and
B. immediately available.
Immediately available as used in this document means physically present on site, in the unit of
care and not otherwise engaged in any other uninterruptible procedure or task.
2. The registered nurse has the right and the responsibility to REFUSE to administer any
medication(s) that may induce procedural sedation when in the professional
judgement of the registered nurse, the medication or combination of medications,
the dosages prescribed, or frequency of administration may produce a state of deep
sedation or place the patient at risk for complication.
3. The practice setting or facility must have in place an educational and
credentialing mechanism which includes a process for evaluating and documenting
the registered nurse's demonstration of the knowledge, skills, and abilities related
to the management of patients receiving procedural sedation. Evaluation and
documentation of ongoing competency should occur on an annual basis.
4. In order for the RN to be able to administer procedural sedation the practice
setting or facility must have policies and procedures detailing:
A) dosing parameters for each drug or combinations of drugs which the registered
nurse may administer for procedural sedation;
B) reversal agents and dosages of each for the agents utilized to reverse the effects
of procedural sedation and evaluation criteria to determine the continuation or
discontinuation of the procedural sedation.
C) a pre-anesthesia patient classification system.
D) an airway classification system.
E) fasting protocol
F) a patient discharge criteria.
G) provisions for backup personnel who possess proficiency in airway
management including endotracheal intubation and pharmacological interventions
including Advanced Cardiac Life Support (ACLS) Pediatric Advanced Life
Support (PALS) or substantially equivalent training.
H) the critical elements that must be documented when these dosing parameters
have been exceeded.
I) The registered nurse=s right to refuse to administer and monitor procedural
sedation (congruent with this declaratory ruling) and the action the registered nurse
is to take when the right to refuse is exercised.
5. To be qualified to administer procedural sedation and to monitor the patient receiving
procedural sedation, the registered nurse must possess knowledge, skill and educational
preparation which would include but is not limited to:
A. Basic anatomy and physiology specific to the defined patient population.
B. Pharmacology of the medications given during procedural sedation including:
1. Dosage parameters appropriate to the age and weight of the patient and over
what period of time these drugs should be administered;
2. Mechanism of action of commonly prescribed procedural sedation
3. Contraindications(s) to the administration of each procedural sedation
medication and the appropriate interventions;
4. The effects of procedural sedation medication(s) on the patient=s pre-existing
5. Side effects and complications associated with each procedural sedation
medication and the appropriate reversal agents(s).
6. Mechanism of action and use of appropriate reversal agents.
C. Considerations relative to common therapeutic, diagnostic or surgical procedures and
the administration of procedural sedation, (an example is the prone positioning for
Endoscopic Retrograde Cholangio Pancreatography (ERCP).
D. Familiarity/or orientation to the practice setting in which the registered nurse would be
administering the procedural sedation.
E. Principles of oxygen delivery.
F. Knowledge regarding resuscitation, airway management, and life threatening
G. Completion of Basic Life Support (BLS) for the Health Care Provider or substantially
H. Completion of a supervised clinical practicum to obtain competency prior to
performing procedural sedation.
I. Knowledge of medical and legal implications, responsibilities and ramifications of
administration of procedural sedation.
6. The registered nurse administering the procedural sedation must have the primary
responsibilities for monitoring the patient during the procedure and may not leave the patient
unattended or engage in uninterruptible tasks that would compromise continuous monitoring.
7. All patients receiving INTRAVENOUS procedural sedation must have a patent
intravenous access maintained from the beginning of medication administration until recovery
from procedural sedation.
8. Supplemental oxygen and appropriate delivery equipment must be available to all patients
receiving procedural sedation.
9. All patients receiving procedural sedation must be CONTINUOUSLY MONITORED
THROUGHOUT THE PROCEDURE with respect to by the following elements and according to
currently recognized national nursing professional specialty standards:
A. Continuous pulse oximetry.
B. Continuous cardiac monitoring for patients with hypertension, cardiovascular disease
or known dysrhythmia.
C. Intermittent blood pressure monitoring, heart rate, and respiratory rate.
D. Behavioral indicators for level of pain i.e. crying, moaning, etc.
E. Airway patency to assure ventilatory adequacy.
F. Level of consciousness or response to stimuli.
10. Recommended patient elements to be monitored include but are not limited to:
A. Continuous cardiac monitoring in all patients;
B. Monitoring of body temperature;
C. Monitoring of intake and output;
D. Monitoring of the skin which include the color, temperature, turgor, etc.
11. All patients receiving procedural sedation must be MONITORED THROUGHOUT THE
A. according to currently recognized national nursing professional specialty standards;
B. by continuous pulse oximetry; and
C. by intermittent monitoring of blood pressure, heart rate and respiratory rate.
12. In order for the registered nurse to administer procedural sedation, the setting must have
the capabilities for rescuing the patient. The emergency equipment (sized to the patient
population) that is required to be immediately accessible to every patient receiving procedural
sedation includes but is not limited to:
A. Ambu bag, and source for 100% O2,
B. Suction equipment and machine;
C. Airway and intubation equipment;
D. Defibrillator or an automatic external defibrillator and cardiac monitor;
E. Emergency medications and reversal medications;
F. Cricothyroidotomy kit, (i.e. 14 gauge needle, scalpel, kelly clamp, and cricothryroid
13. In order for the registered nurse to administer procedural sedation there must be access
to designated higher level care providers who possess proficiency in airway management,
including endotracheal intubation and pharmacological interventions and ACLS/PALS or
substantially equivalent education. Access is to be defined by the facility=s policies and
procedures which is discussed in item four (4).
14. When the registered nurse is administering procedural sedation, the registered nurse is
expected to consider the potential risk factors, that singly or in combination could increase the risk
of complications associated with procedural sedation. These include but are not limited to:
A. The frail patient and the patient with extremes of age.
B. Inability to communicate or cooperate as in compromised mental status or
C. Significantly developmentally delayed.
D. Severe morbidity or co-morbidity (e.g. cardiac, pulmonary, hepatic, hematological,
renal, central nervous system, musculoskeletal, endocrine and, or multiple
E. Morbid obesity.
F. History of sleep apnea.
G. History of drug, alcohol, tobacco use or abuse.
I. Emergency procedure with lack of patient preparation.
J. Airway anomalies.
K. Previous adverse experience with sedation, analgesia or anesthesia.
L. Unstable vital signs (low blood pressure, tachycardia, or bradycardia).
M. Pulse oximetry of 94 or below on room air.
N. Implantable devices (i.e. epidural pumps, pacemakers, etc).
O. Use of narcotics within 24 hours of procedure.
P. Recent colds, flu or fever.
These risks may be reduced by consultation with the appropriate specialist or anesthesia provider
or both. The patient=s morbidity or co-morbidity may also indicate the need for pre-procedure
testing or diagnostic studies or both, which can reduce the risk of complications. When, in the
professional judgment of the registered nurse, the patient=s risk factors are such that the registered
nurse believes there is substantial jeopardy to the patient, the registered nurse has the right and the
obligation to REFUSE to administer the procedural sedation.
15. The practice setting or facility requires that the Performance Improvement or
Risk Management Review Process includes a review of the prescribing, administration and
monitoring of patients receiving procedural sedation including but not limited to:
A) Frequency of patient complications;
B) Type of patient complication;
C) Appropriate identification and management of the patient=s complication; and,
D) Review and modification of the practice setting or facility policies, procedures,
protocols and the training program as dictated by the Performance Improvement or Risk
Management Review outcomes.
16. FOR THE PEDIATRIC PATIENT receiving procedural sedation the following applies:
A. All previously stated conditions relative to the registered nurses knowledge, skill and
educational preparation apply.
B. All previously stated conditions relative to the practice setting or facility=s policies,
procedures and education and credentialing mechanism apply.
C. All previously stated conditions relative to the monitoring of the patient during the
procedure, apply to the pediatric patient EXCEPT the monitoring of the blood pressure
which may be omitted during the procedure if the performance of the blood pressure
reading would interfere with the procedure (an example may be a Magnetic Resonance
D. All previously stated conditions relative to post procedure monitoring apply.
E. Special considerations regarding the pediatric patient includes knowledge of the
metabolism and elimination of the specific medication by age and weight. The registered
nurse administering procedural sedation to the pediatric patient must have specialized
knowledge of the medications utilized to induce procedural sedation and Rescue of the
pediatric patient. Medication which are frequently recognized and utilized to induce
procedural sedation by oral or rectal route may include oral fentanyl lollipop, morphine,
chloral hydrate, phentobarbitol, valium, ativan, versed and demerol.
F. The registered nurse MAY administer procedural sedation to a pediatric patient who is
ASA I and ASA II. The registered nurse may not administer procedural sedation to a
pediatric patient whose pre-anesthesia assessment is classified as an ASA III or IV except
in clinical practice settings that are in acute care institutions AND when the consultation
and recommendations of the certified registered nurse anesthetist or physician with
specialized knowledge, judgment, and skill related to anesthesia are followed.
G. The registered nurse MAY administer nitrous oxide 50% or less to the pediatric patient
in compliance with the American Academy of Pediatrics Guidelines for Monitoring and
Management for Pediatric Patients During and After Sedation for Diagnostic &
Therapeutic Procedures and according to the facility=s waste gas evacuation policies. At a
minimum, the following conditions with regard to the administration of nitrous oxide 50%
or less shall exist:
1. The pediatric patient is able to maintain verbal communication throughout
2. The registered nurse administering nitrous oxide 50% or less must have
the primary responsibility for monitoring the patient during the procedure and may
not leave the patient unattended or engage in uninterruptible tasks that would
compromise continuous monitoring.
3. Pulse oximetry is strongly recommended but not required.
H. The registered nurse MAY administer Ketamine for procedural sedation in critical care
practice settings that are in acute care institutions and when the consultation and
recommendations of the certified registered nurse anesthetist or licensed physician who
has been credentialed by the facility as a qualified anesthesia provider are followed.
I. The registered nurse may NOT administer a combination of demerol, phenergan and
thorazine (i.e. DPT cocktail) intramuscularly to a pediatric patient for the purpose of
sedation, procedural sedation or analgesia.
17. The registered nurse MAY administer procedural sedation as prescribed by a Board
Certified Registered Nurse Practitioner (CRNP) or Certified Registered Nurse Midwife
(CRNM) when the CRNP or CRNM:
A) has an approved collaborative agreement which designates prescription of
procedural sedation is a part of the individual=s practice.
B) is providing care and prescribing procedural sedation to the client population
addressed in the individual=s collaborative agreement.
C) has received additional training to act as the resource for the registered nurse
who is administering the procedural sedation, including Arescuing@ the client.
18. The following situations are NOT considered procedural sedation and are NOT considered
under this declaratory ruling.
A) patients who are sedated for the purpose of immediate intubation such as a patient
receiving Ketamine or Etomidate for emergent intubation.
B) patients who receive sedation for tolerance of mechanical
ventilation, such as an intensive care patient receiving a propofol infusion to
tolerate the ventilator.
C) patients who are receiving sedation solely for the purpose of managing altered
mental status, such as patients receiving haldol or ativan.
D) patients receiving continuous or intermittent analgesia for pain control without
sedatives, i.e., topical, intravenous or implanted ports/pumps.
19. The registered nurse may NOT administer procedural sedation utilizing medications
classified as an anesthetic agent to include but not limited to propofol, diprivan,
ketamine or inhalation anesthetics ( see exceptions in item 16 addressing the pediatric
20. The registered nursed may NOT administer procedureal sedation to a patient who se pre-
anesthesia assessment is classified as an ASA IV except:
A) in clinical practice settings that are in acute care institutions; and
B) when the consultation and recommendations of the certified registered nurse
anesthetist or licensed physician who has been credentialed by the facility as a
qualified anesthesia provider are followed.
21. The registered nurse may NOT administer procedural sedation prescribed by a physician
assistant, licensed podiatrist or licensed dentist (for further information regarding the
dentist prescribing please contact the Maryland Board of Dentistry).
22. The registered nurse may NOT administer procedural sedation to the patient (including
pediatric and adult) whose pre-anesthesia assessment is classified as a ASA V.
23. Prior to the procedure beginning, the nurse has the right and responsibility to REFUSE to
administer the medication for procedural sedation when:
A) the medication is one the nurse is prohibited from administering;
B) in the registered nurse's professional judgment the patient's clinical status is
compromised and proceeding would place the patient a unnecessary risk.
C) the initial prescribed dose of the medication is outside the recommended
dosage parameters and may place the patient at risk of deep sedation.
24. When the registered nurse REFUSES to administer procedural sedation given the
circumstances enumerated in item 22, and when the physician performing the procedure
assumes responsibility for administering of the medications, the registered nurse has the
right and the responsibility to REFUSE to monitor the patient and should attempt to
transfer the patient=s care to a certified registered nurse anesthetist or licensed physician
who has been credentialed by the facility as a qualified Anesthesia provider while
continuing to monitor the patient until relieved.
25. During the course of the procedure, the registered nurse has the right and the responsibility
to REFUSE to administer subsequent doses of procedural sedation in amounts that may
convert the patient=s state to deep sedation or cause decompensation of the patient=s vital
signs. In this instance, the registered nurse should attempt to transfer the patient=s care to a
certified registered nurse anesthetist or licensed physician who has been credentialed by the
facility as a qualified anesthesia provider while continuing to monitor the patient until
relieved or until the procedure is completed.
26. The registered nurse must REPORT when he or she has refused to administer or monitor the
patient and document all circumstances of the refusal in accordance with the Performance
Improvement or Risk Management Review Process.
27. Given that all conditions and requirements of this declaratory ruling are met, there is no limit
on the length of time the registered nurse may administer procedural sedation.
28. The registered nurse may NOT obtain informed consent for the administration of procedural
EPISODIC TREATMENTS OR THERAPIES
29. The registered nurses may NOT administer Propofol, an anesthetic agent, except as described
in the Declaratory Ruling addressing the Registered Nurse Administration of Medications
Classified as Anesthetic Agents.
30. In acute care settings a registered nurse MAY administer Ketamine, an anesthetic agent, by
intravenous solution to pediatric patients requiring treatment for bronchospasms when all
conditions and requirements enumerated in the Declaratory Ruling Addressing Administration
of Medication Classified as Anesthetic Agents are met.
31. A registered nurse may NOT administer Ketamine, an anesthetic agent intramuscularly or
intravenously to an adult patient for purposes of procedural sedation.
When procedural sedation is administered by a qualified, specially trained registered nurse
it can NOT be assumed that this registered nurse possesses the same degree of knowledge, skill,
and judgment as that of a certified registered nurse anesthetist or licensed physician or CRNP or
CRNM who has been credentialed by the facility as a qualified anesthesia provider. Therefore, the
critical factors which create the opportunity for the specially trained registered nurse to administer
procedural sedation must be thoroughly and comprehensively assessed and evaluated by the
registered nurse prior to taking action OR no action on the licensed physician or CRNP or CRNM=s
prescriptive order. These critical factors include but are not limited to: the knowledge and skill of
the registered nurse and the prescribing physician regarding medication(s) to induce and reverse the
procedural sedation; the knowledge and skills of the registered nurse and the prescribing
physician to evaluate and monitor the patient during procedural sedation; the knowledge and skill of
the registered nurse and the prescribing physician or CRNP or CRNM to Arescue@ the patient; the
available technology and personnel available within the facility to monitor and rescue the patient; and
the patient=s clinical status, including morbidity, co-morbidity and potential effects of the procedural
sedation medication(s) in relation to these factors and the procedure to be performed.
The registered nurse is responsible and accountable for all actions or lack of action that he or s
he takes when administering an anesthetic or monitoring the patient receiving procedural sedation
or both. In addition, the registered nurse is always held to the fundamental principle of nursing
which is, do no harm.
The registered nurse is required to have the same knowledge base for the medication(s)
administered to induce procedural sedation as for any other medication that he or she administers.
This knowledge base includes but is not limited to:
1) Effects, side effects, and contraindications of each drug to be administered.
2) The amount of the medication to be administered at any one time (including initial
dose, subsequent doses and total amount of the medication(s) administered for the
3) Ability to anticipate and recognize potential complications of each drug and
combination of drugs.
4) Ability to recognize emergency situations and institute appropriate nursing
Should all of the Board=s stipulated conditions contained in this Board ruling NOT be
met, then the registered nurse has the right and responsibility to REFUSE to administer medication
and/or monitor the patient receiving procedural sedation or both prior to the initiation of the
Because this specialized procedure requires specialized education, training and nursing judgment,
the registered nurse is held accountable to REFUSE to perform this specialized act or any other act
of nursing which is beyond the parameters of the licensee's education, capabilities and experience.
1. Association of Operating Room Nurses. Standards, Recommended Practices, and
Guidelines: Managing the Patient Receiving Conscious Sedation/Analgesia. 1998,
2. American Academy of Pediatrics. Guidelines for Monitoring and Management of
Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures. January
3. American Society of Peri-Anesthesia Nurses Standards. Advanced Life Support (ACLS)
Pediatric Life Support/PALS and ACLS/PALS Equivalent Programs.
4. Nechyba, Christian, MD and Gunn, Veronica L. MD, Editors. The Harriet Lane
Handbook: A Manual For Pediatric House Officers. 16th Edition. C.V. Mosby. St. Louis 2002.
5. American Society for Gastroentestinal Endoscopy:
A) Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologist. February
B) Technology Assessment Status Evaluation - Monitoring Equipment for Endoscopy.
C) Guidelines for Training in Patient Monitoring and Sedation and Analgesia. October
D) Sedation and Monitoring of Patients Undergoing Gastrointestinal Endoscopic
Procedures. October 2000.
6. American Association of Nurse Anesthetist:
A) The Certified-Registered Nurse Anesthetist in Alternative Practice Settings. Policy
No. 2.1. May 1988.
B) Qualified Providers of Conscious Sedation. Policy No. 2.2. June 1996.
C) The Separation of Operator/Anesthetist Responsibilities. Policy No 2.3.
D) Suggested Guidelines for Registered Professional Nurses Engaged in The
Administration of IV Conscious Sedation. Addendum to Policy No. 2 .2.
E) Administration of Nitrous Oxide by Qualified Anesthesia Providers. Policy No. 2.4.
F) Scope and Standards For Nurse Anesthesia Practice. October 1999.
G) Standards For Office Based Anesthesia Practice. October 1999.
H) Code of Ethics. October 1999.
I) Preparedness For Treatment of Malignant Hyperthermia. October, 1999.
J) Latex Allergy Protocol. October 1999
7. American Society of Anesthesiologist:
A) Basic Standards for Pre-Anesthesia Care. October 1987.
B) Standards For Basic Anesthesia Monitoring: October 1986 and Amended/Revised
C) Standards For Post Anesthesia Care. October 1988 and Amended/Revised October 1994.
D) Guidelines for Ambulatory Anesthesia and Surgery. October 1973 and Amended/Revised
E) Guidelines for Non-Operating Room Anesthesiology Locations. October 1994.
F) Practice Guidelines For Sedation and Analgesia by Non-Anesthesiologists: Report of Task
Force. October 1999. pp. 1-8.
8. Vanderbilt Medical Center, Anesthesiology Educational Guide:
A) The Patient Evaluation Process. October 1999.
B) Laboratory Tests and Their Preoperative Indications. October 1999.
C) Guidelines for Perioperiative ElectroCardiology. October 1999.
D) Guidelines for Preoperative Chest Radiography. October 1999.
E) Guidelines On Pulmonary Function Tests. October 1999.
9. Joint Commission on Accreditation of Hospitals and Organizations:
A) Standards of Conscious Sedation. January 1999.
B) Standards and Intents for Sedation and Anesthesia Care. January 2001.
10. How to Comply with TX. 8, the New Resuscitation Standard. Briefings on JCAHO.
Vol. 11, No 8. August, 2000.
11. ________, The Practice of Anesthesiology. Chapter One.
12. ______, Nurses Uneasy about IV Sedation for Long Cases. OR Manager. March, 2000.
13. Health Occupations Article, Title 8, The Nurse Practice Act.
14. Declaratory Ruling 96-1, Re: Registered Nurse Administration of Conscious Sedation For
Short Term Therapeutic, Diagnostic, and Surgical Procedures.
15. Advisory Opinion-Conscious Sedation. Arizona State Board of Nursing, October, 1997.
16. Position Statement-Registered Nurse Management of Patients Receiving IV Conscious
Sedation for Short Term Therapeutic, Diagnostic or Surgical Procedures. Arkansas Board of
Nursing, November, 1994.
17. Position Statement-Registered Nurse Administration of Medication for the Purpose of
Induction of Conscious Sedation for Short Term Therapeutic, Diagnostic or Surgical
Procedures. California Registered Nurse Board of Nursing, 1995.
18. Guidelines-Registered Nurse Administration, Management and Monitoring of the Patient
Receiving IV Conscious Sedation During Therapeutic, Diagnostic or Surgical Procedures.
Connecticut Board of Nursing
19. Guidelines-Registered Nurse Administration, Management and Monitoring of the Patient
Receiving Conscious Sedation During Therapeutic, Diagnostic or Surgical Procedures.
Delaware Board of Nursing.
20. Advisory Opinion-Role of the Registered Nurse in the Management of Patients Receiving
IV Conscious Sedation for Short Term, Therapeutic, Diagnostic or Surgical Procedures.
Kentucky Board of Nursing
21. Declaratory Ruling regarding Registered Nurse Administration Management and
Monitoring of the Patient Receiving IV Conscious Sedation. Louisiana Registered Nurse Board
22. Position Statement-Role of the Registered Nurse in the Administration of IV Conscious
Sedation During Short Term, Therapeutic, Diagnostic or Surgical Procedures. Massachusetts
Board of Nursing, November 1999.
23. Position Statement-Role of the Registered Nurse in the Administration, Monitoring of IV
Conscious Sedation. Mississippi Board of Nursing. April, 2000.
24. Position Statement-Registered Nurse Administration, Management and Monitoring of
Patients Receiving IV Conscious Sedation. Missouri Board of Nursing.
25. Advisory Opinion-Analgesia/Conscious Sedation. Nebraska Board of Nursing.
26. Advisory Opinion-Conscious Sedation. New Mexico Board of Nursing.
27. Guidelines-Administration, Management and Monitoring of IV Conscious Sedation by
Non-Anesthetists RNs. New York Board of Nursing.
28. Position Statement-The Role of the Registered Nurse in the Management of Patients
Receiving IV Conscious Sedation. North Carolina Board of Nursing, June, 2000.
29. Position Statement-The Role of the Registered Nurse in the Management of Patients
Receiving Conscious Sedation/Analgesia. For Therapeutic, Diagnostic or Surgical Procedures.
North Dakota Board of Nursing, May 2000.
30. Guidelines-Administration, Management and Monitoring of IV Conscious Sedation.
Oklahoma Board of Nursing.
31. Position Statement-Registered Nurse Administration of Conscious Sedation During
Therapeutic, Diagnostic or Surgical Procedures. Oregon Board of Nursing, November, 1997.
32. Position Statement-Role and Scope of Responsibilities of the RN to administer
medications fore Pre-Operative Sedation and Conscious Sedation as Ordered by a Licensed
Physician or Dentist. South Carolina Board of Nursing.
33. Position Statement-The Role of the Registered Nurse in the Management of Clients
Receiving IV Conscious Sedation for the Short Term, Therapeutic, Diagnostic or Surgical
Procedure. South Dakota Board of Nursing.
34. Position Statement-Administration of IV Conscious Sedation by the Registered Nurse.
Texas Board of Registered Nurse Examiners.
35. Policy Statement-Registered Nurses Performing Procedural Sedation. The Nursing Care
Quality Assurance Commission, State of Washington.
1. Laura Kress, RN, MAS, Nurse Manager, Inpatient and Outpatient Endoscopy Units, Johns
Hopkins Hospital, Baltimore, Maryland.
2. JoAnn Walker, RN, BS, CNOR, St. Agnes Health Care, Department of Education and
Development, Baltimore, Maryland.
3. Mary Ann Smith, RN, CGRN, Clinical Coordinator, Shore Health System, Digestive Health
Center, Easton, Maryland.
4. Mary Ann Sipple, RN, Nurse Manager, PACU & Endoscopy Units, Western Maryland Health
Systems, Memorial Hospital and Medical Center, Cumberland, Maryland.
5. Marijo Cosmas, RN, MS, CRNP, Vascular and General Surgical Services, Calvert Memorial
Hospital, Prince Frederick, Maryland.
6. John Hitchens, CRNA, Jarrettsville, Maryland,
7. Robin Mattheiss, CRNA, Lutherville, Maryland.
8. Noel McElwee, CRNA, Baltimore, Maryland..
9. Lisa LaCivita, BSN, CRNA, Annapolis, Maryland.
10. Mary A. Rogers, BSN, RN, Nurse Manager, CGRN, Endoscopy, North Arundel Hospital, Glen
11. Ann Sessoms, RN, MSN, CCRN, Clinical Specialist/Critical Care, Peninsula Regional Medical
Center, Salisbury, Maryland.
12. Barbara Christensen, RN, Nurse Manager-Cardiac Cath Lab, Washington Adventist Hospital,
Takoma Park, Maryland.
13. Kathleen Shiring, RN, CRN, Clinical Nurse III-Educator for Interventional Radiology, Anne
Arundel Medical Center, Annapolis, Maryland.
14. Karen Carlson, RN, CRN, Nurse Manager Radiology, Suburban Hospital, Bethesda, Maryland.
15. Kathy Reisig, RNC, Pediatric Patient Care Coordinator, St. Joseph Medical Center, Towson,
16. Betty Nethkin, RN, Director of Nursing MCH, St. Joseph Medical Center, Towson, Maryland.
17. Elizabeth Lins RN, Assistant Unit Manager, Surgical Intensive Care Unit, Johns Hopkins Hospital,
18. Deborah Cowell RN, MSN, Clinical Nurse Specialist, Critical Care, North Arundel Hospital, Glen
19. Deborah Timms, RN, Clinical Nurse Coordinator, Emergency Department, Shore Health System,
20. Margaret Garrett, RN, Esq. Senior Counsel, Johns Hopkins Hospital, Baltimore, Maryland.
21. Deborah Dang RN, MS, Director of Nursing Practice, Education and Research, Johns Hopkins
Hospital, Baltimore, Maryland.
22. Julie Stanik-Hutt, CRNP, Assistant Professor of Nursing, Johns Hopkins University, School
of Nursing, CRNP Program, Baltimore, Maryland.
23. Carol Ann Huff, M.D. , Assistant Professor, Medicine - Oncology, John Hopkins University and
Director of Hemotologic Malignancy Program, Johns Hopkins Hospital, Baltimore, Maryland.
24. Sandra Dearholt, RN, MS, Coordinator of Nursing Practice, Johns Hopkins Hospital, Baltimore,