Editing Management of Care (section)

== Scope of Practice ==

Scope of practice defines what a given license permits a person to do. It is established by each state's nurse practice act and interpreted by that state's board of nursing. Facility policy may narrow a scope but can never widen it, and a provider's order can never authorize a nurse to perform an act outside the nurse's legal scope.

=== The three roles tested on licensure examinations ===

'''Registered nurse (RN).''' The RN is accountable for the full nursing process: the initial and ongoing comprehensive '''assessment''', nursing '''diagnosis''', development and revision of the '''plan of care''', initial patient and family '''teaching''', and '''evaluation''' of whether interventions worked. The RN is also accountable for the delegation decision itself and for supervising those to whom care is delegated. The RN cares for the unstable, the newly admitted, and the unpredictable. Tasks commonly reserved for the RN on examinations include intravenous push medications, blood product administration, initiation and titration of vasoactive drips, total parenteral nutrition, care planning, triage, and the admission assessment.

'''Licensed practical or vocational nurse (LPN/LVN).''' The LPN is a licensed nurse who practices under the direction of an RN or an authorized provider. The LPN '''collects data''' and contributes focused observations to the assessment the RN owns; the LPN does not perform the initial comprehensive assessment. The LPN '''reinforces''' teaching the RN has already initiated; the LPN does not perform initial teaching. The LPN cares for '''stable patients with predictable outcomes'''. Skills commonly within LPN scope include administering most oral, topical, subcutaneous, and intramuscular medications, sterile dressing changes and complex wound care, urinary catheterization, nasogastric tube feeding and maintenance, tracheostomy care and suctioning, ostomy care, capillary blood glucose testing, and monitoring patients who have already been stabilized.

'''Assistive personnel (AP/UAP/CNA).''' Assistive personnel are unlicensed. They may perform '''standard, unvarying tasks on stable patients that require no nursing judgment''': hygiene and bathing, feeding a patient with no swallowing impairment, oral care, ambulation and transfers, positioning and turning, routine range of motion, bed making, measuring and recording vital signs on a stable patient, intake and output, weights, specimen collection, and stocking. Assistive personnel may report findings but may not interpret them.

=== The three verbs that are never delegated ===

A dependable examination heuristic is that the RN never delegates '''assessment, teaching, evaluation, or nursing judgment''' to anyone, and never delegates the care of an '''unstable''' patient. If a question stem contains "assess," "teach," "evaluate," "plan," or describes a patient whose condition is changing, the answer is the RN. If the stem describes a routine, predictable task on a stable patient, an LPN or assistive personnel may be correct.

'''Application note.''' Students lose points by reasoning about who is physically capable of a task rather than who is legally accountable for it. An experienced assistive personnel may be far better at obtaining a blood pressure than a new graduate RN, and that is irrelevant. The question is who is accountable for deciding what the blood pressure means.