Acting with Client-specific Orders

Practice Standard for licensed practical nurses

Introduction

Standards

BCCNM limits and conditions for licensed practical nurse:

Acting with client-specific orders
Specific practice settings

Glossary

Introduction

The Licensed Practical Nurse: Acting with Client-specific Orders standards, limits, and conditions apply to licensed practical nurses (LPNs) when they are acting with client-specific orders.

Acting with client-specific orders refers to licensed practical nurses performing activities that they are competent and allowed to perform with a client-specific order.

Licensed practical nurses may provide care to clients by acting with a client-specific order for an activity that is:

Outlined in the Nurses (Licenced Practical) Regulation,
In alignment with BCCNM standards, limits, and conditions,
Allowed by organizational/employer policies, processes, and restrictions, and
Within the licensed practical nurse's individual competence.

Licensed practical nurses need to know when they are allowed to act within their autonomous scope of practice (without a client-specific order) and when a client-specific order is required before performing an activity.

A client-specific order is an instruction or authorization given by a regulated health professional for a nurse to provide care for a specific client, whether or not the care or service includes a restricted activity or a non-restricted activity. A consultation, referral or professional recommendation is not an order.

Licensed practical nurses also need to know which health professionals are authorized to give a client-specific order that they are allowed to act with. A licensed practical nurse may act with a client-specific order given by:

1.	An authorized health professional who is listed in the Nurses (Licenced Practical) Regulation as authorized to give an order for a restricted activity to be performed by a licensed practical nurse.
	Only these health professionals are authorized to give orders for activities listed in section 7 (restricted activities that require an order) of the Regulation[1] that allow the licensed practical nurse to perform that activity.
	For licensed practical nurses, authorized health professionals include physicians, nurse practitioners, registered nurses, registered psychiatric nurses, dentists, midwives, naturopaths, podiatrists, and pharmacists.
2.	A non-listed health professional who is NOT listed in the Nurses (Licenced Practical) Regulation is not authorized to give orders for restricted activities in section 7 of this regulation.
	However, depending on organizational/employer policies and processes, a non-listed health professional may give orders for activities that are within the licensed practical nurse's autonomous scope of practice.
	Non-listed health professionals have specialized competence within their profession's scope of practice and individual competence that allows them to assess a client and to design or recommend care to meet the client's needs.

Standards

1.	Licensed practical nurses require a client-specific order from an authorized health professional to perform any restricted activity listed in section 7 (restricted activities that require an order) of the Nurses (Licensed Practical) Regulation (to the extent the care provided is not within the activities or related limits and conditions listed in section 6 of the Nurses (Licensed Practical) Regulation)).
2.	Licensed practical nurses acting with a client-specific order ensure the ordered activity is:
	a.	Within the scope of practice as set out in the Nurses (Licensed Practical) Regulation,
	b.	Consistent with standards, limits and conditions established by BCCNM,
	c.	Consistent with organizational/employer policies, processes, and restrictions, and
	d.	Within their individual competence.
3.	Licensed practical nurses acting with a client-specific order ensure that they have the competence to:
	a.	Perform the activity safely and ethically,
	b.	Identify potential risks of the activity to the client and how to minimize those risks,
	c.	Manage the intended outcomes of the activity, and
	d.	Recognize unintended outcomes of the activity and implement a plan for dealing with these unintended outcomes.
4.	Before performing an activity with a client-specific order, licensed practical nurses consider applicable employer/organizational policies, processes, and resources, and other relevant human and system factors that may impact their ability to:
	a.	Perform the activity competently and safely within their practice setting, and
	b.	To manage intended and unintended outcomes of the activity.
5.	Licensed practical nurses perform advanced activities with a client-specific order only when they have obtained the additional education, training, and/or clinical experience needed to gain and maintain the competence to perform the activity safely.
6.	Licensed practical nurses acting with a client-specific order ensure that the order:
	a.	Is client-specific,
	b.	Is clear and complete,
	c.	Is documented, legible, dated and signed with a written/electronic signature, and
	d.	Contains enough information for the nurse to carry it out safely.
7.	Licensed practical nurses accept a verbal or telephone client-specific order only when there is no reasonable[2] alternative, according to organizational/employer policies and processes, and when doing so is in the best interest of the client. Nurses repeat the client-specific order back to the ordering health professional to confirm its accuracy and promptly document the order.
8.	Licensed practical nurses conduct assessments to ensure that the client's condition continues to warrant the activity before acting with a client-specific order.
9.	Licensed practical nurses may not change or cancel a client-specific order given by an authorized health professional when the activity is outside of the nurse's autonomous scope of practice or the nurse's individual competence.
10.	Licensed practical nurses communicate and collaborate with the health professional (or their delegate) who gave the client-specific order, follow organizational/employer policies and processes, take action as needed, and document in the client record, when:
	a.	The ordered activity may no longer be appropriate because the client's condition, needs or wishes have changed (e.g., to 'hold' the order),
	b.	They are not able to carry out a client-specific order,
	c.	The client-specific order does not appear to consider a client's individual characteristics, values/beliefs, and preferences,
	d.	The client-specific order does not appear to reflect current evidence or be in the best interest of the client,
	e.	They change or cancel a client-specific order for activities that are within their autonomous scope of practice, or
	f.	The safeguards and resources are not available to manage the outcomes of performing the activity, including reasonably foreseeable unintended outcomes.
11.	Licensed practical nurses follow the standards for Acting within Autonomous Scope of Practice when they change or cancel a client-specific order that is within their autonomous scope of practice and individual competence.
12.	Licensed practical nurses are responsible and accountable for any changes or cancellations they make to a client-specific order that is within their autonomous scope of practice and individual competence.
13.	Licensed practical nurses obtain a client-specific order to perform an activity or provide care or a service that is within their autonomous scope of practice when:
	a.	It is required by organizational/employer policies, processes, or restrictions,
	b.	There are insufficient organizational/employer supports, processes and resources in place (such as decision support tools or clinical practice documents) to enable the nurse to meet BCCNM standards, limits, or conditions related to the activity, care or service, or
	c.	The nurse does not have the individual competence to make a nursing diagnosis or carry out an assessment to determine whether the client would benefit from the activity, care, or service, but is competent to carry out the activity.
14.	Licensed practical nurses ONLY act with a client-specific order from a non-listed health professional when:
	a.	The activity is within the nurse's autonomous scope of practice,
	b.	The nurse is able to meet BCCNM standards, limits, or conditions related to the activity,
	c.	The activity is within the nurse's individual competence, and
	d.	Organizational/employer policies, and processes exist that:
		i. clarify the accountability and responsibility of the nurse and the non-listed health professional, and
		ii. outline the requirements for the non-listed health professional to complete an assessment and to ensure that the ordered activity is in the best interest of the client.

BCCNM limits and conditions for licensed practical nurse

Acting with client-specific orders

Activity		BCCNM Limits and Conditions for Licensed Practical Nurse: Acting with Client-specific Orders
1.	Use of restraint	a. Licensed practical nurses apply restraints when a client-specific order from an authorized health professional is in place.
2.	Take an electrocardiogram (ECG)	a. Licensed practical nurses take electrocardiograms (ECGs): i. After successfully completing additional education ii. When a health care professional authorized to read the ECG is immediately available b. Licensed practical nurses are not responsible for reading or interpreting ECG results.
3.	Peritoneal dialysis	a. Licensed practical nurses act with a client-specific order to carry out peritoneal dialysis: i. For clients with stable or predictable states of health ii. After successfully completing additional education
4.	Perform phlebotomy	a. Licensed practical nurses act with a client-specific order and perform phlebotomy: i. To collect blood samples from clients 14 years of age and older ii. After successfully completing additional education iii. By following decision support tools iv. By using a peripheral evacuated system
5.	Perform wound care except conservative sharps wound debridement	a. Licensed practical nurses act with a client-specific order to apply compression therapy, provide negative pressure wound therapy (vacuum assisted closure (VAC), or carry out maggot debridement therapy: i. If a wound care treatment plan is in place ii. After successfully completing additional education iii. By following decision support tools b. Licensed practical nurses *do not* carry out any form of sharps debridement including conservative sharps wound debridement (CSWD).
6.	Apply a cast for a fracture of a bone	a. Licensed practical nurses apply casts for a fracture of a bone: i. With a client-specific order from a medical practitioner or nurse practitioner registered in BC* ii. After successfully completing additional education Licensed practical nurses may only act on a client-specific order to cast a fracture of a bone given by a medical practitioner or nurse practitioner who is registered in British Columbia as per the Nurses (Licensed Practical) Regulation* section 7(3).
7.	Care of clients under anesthesia and sedation	a. Licensed practical nurses work in a team nursing approach to provide care and monitor clients under: i. General anesthesia ii. Intrathecal anesthesia iii. Epidural anesthesia iv. Procedural sedation
8.	Administer by inhalation: Do not administer nitrous oxide Do not monitor clients taking nitrous oxide Do not administer substances for purposes of anesthesia or procedural sedation	a. Licensed practical nurses *do not*: i. Administer nitrous oxide ii. Monitor clients taking nitrous oxide iii. Administer inhaled substances for purposes of anaesthesia or procedural (conscious) sedation
9.	Care of clients requiring mechanical ventilation	a. Licensed practical nurses care for clients requiring mechanical ventilation: i. With stable or predictable states of healthii. After successfully completing additional education b. Licensed practical nurses provide care to clients who use continuous positive airway pressure (CPAP) or bi-level positive airway pressure (BPAP) after successfully completing additional education.
10.	Administer a substance by irrigation: percutaneous tubes	a. Licensed practical nurses act with a client-specific order and irrigate only those percutaneous tubes they are permitted to irrigate at entry-level.
11.	Administer a substance by irrigation: Do not irrigate ostomies	a. Licensed practical nurses *do not* irrigate ostomies.
12.	Intravenous (IV) therapy: establish IV access administer parenteral solutions change IV bags	a. Licensed practical nurses act with a client-specific order to start IVs: i. After successfully completing additional education ii. Using a short peripheral device b. Licensed practical nurses act with a client-specific order to: i. Administer parenteral solutions to clients with stable or predictable states of health ii. Change IV bags infusing via peripheral access (not central venous access)
13.	Do not access central venous access devices (CVAD) or central venous lines* * This may also be referred to as a central venous device (CVD) or central venous catheter (CVC).	a. Licensed practical nurses *do not* access central venous access devices or central venous lines
14.	Care of clients receiving blood or blood products	a. Licensed practical nurses monitor clients receiving blood or blood products in a team nursing approach.
15.	Administer a substance by parenteral instillation: Do not start transfusions of blood or blood products	a. Licensed practical nurses *do not* start transfusions of blood or blood products
16.	Care of clients receiving parenteral nutrition	a. Licensed practical nurses provide care to clients receiving parenteral nutrition in a team nursing approach
17.	Administer a substance by parenteral instillation: Do not start or monitor parenteral nutrition	a. Licensed practical nurses *do not* start or monitor parenteral nutrition
18.	Administer a substance by parenteral instillation: Do not administer radiopaque dyes by parenteral instillation	a. Licensed practical nurses *do not* administer radiopaque dyes via parenteral instillation.
19.	Put an instrument or device into the external ear canal: Do not insert a curette or other instrument	a. Licensed practical nurses *do not* insert a curette or other instrument into the external ear canal to remove: i. Foreign objects ii. Earwax
20.	Suction nasal passages beyond the point where they normally narrow	a. Licensed practical nurses act with a client-specific order to suction the nasal passages beyond the point where they normally narrow after successfully completing additional education.
21.	Put an instrument or device in the nasal passages beyond the point where they normally narrow: Do not insert nasogastric (NG) Do not insert orgastric tubes (OG) Do not carry out nasopharyngeal washes	a. Licensed practical nurses *do not*: i. Insert nasogastric (NG) tubes ii. Insert orogastric (OG) tubes iii. Carry out nasopharyngeal washes
22.	Put an instrument or device beyond the pharynx: Do not insert laryngeal mask airways (LMAs)	a. Licensed practical nurses *do not* insert laryngeal mask airways (LMAs).
23.	Insert coude tip catheters	a. Licensed practical nurses act with a client-specific order to insert coude tip catheters after successfully completing additional education.
24.	Put an instrument or a device, or finger beyond the labia majora: remove vaginal packing insert or remove pessaries	a. Licensed practical nurses act with a client-specific order to remove vaginal packing after successfully completing additional education. b. Licensed practical nurses act with a client-specific order to insert or remove pessaries after successfully completing additional education.
25.	Put an instrument or a device, or finger beyond the labia majora: Do not insert vaginal packing Do not carry out pelvic or vaginal examinations Do not perform cervical cancer screening Do not insert an instrument, substance or medication into or beyond the cervix	a. Licensed practical nurses *do not*: i. Insert vaginal packing ii. Carry out pelvic or vaginal examinations iii. Perform cervical cancer screening iv. Insert an instrument, substance or medication into or beyond the cervix
26.	Put an instrument or a device beyond the anal verge: tubes into the rectum	a. Licensed practical nurses act with a client-specific order to insert tubes into the rectum: i. After successfully completing additional education ii. By following decision support tools
27.	Put an instrument or a device beyond the anal verge: Do not insert or advance scopes for rectal/bowel examination	a. Licensed practical nurses *do not* insert or advance scopes for rectal/bowel examinations.
28.	Care of clients with tracheostomies	a. Licensed practical nurses provide tracheostomy care to clients: i. With well-established tracheostomies ii. After successfully completing additional education
29.	Put an instrument or a device or finger into an artificial opening into the body: digital examination of colostomies suprapubic catheters gastrostomy tubes	a. Licensed practical nurses act with a client-specific order to carry out digital examination of colostomies for clients: i. With well-established stomas ii. After successfully completing additional education b. Licensed practical nurses act with a client-specific order to insert suprapubic catheters and gastrostomy tubes for clients: i. With well-established stomas ii. After successfully completing additional education
30.	Do not perform fetal heart monitoring	a. Licensed practical nurses *do not* carry out fetal heart monitoring using an intermittent Doppler, or any related activities including palpation and auscultation of the fetal heart.
31.	Apply electricity: Do not apply electricity to destroy tissue or affect the heart or nervous system (except AED)	a. Licensed practical nurses *do not* apply electricity to destroy tissue or affect the heart or nervous system except automated external defibrillators (AEDs)
32.	Do not apply laser that cuts or destroys tissue	a. Licensed practical nurses *do not* apply laser that cuts or destroys tissue.
33.	Administer intravenous (IV) medications	a. Licensed practical nurses act with a client-specific order to administer IV medications after successfully completing additional education. b. Licensed practical nurses change IV bags containing potassium chloride (KCL) infusing via peripheral access (not central venous access), when the IV bag has been compounded commercially or by a pharmacy.
34.	Administer medications: Do not administer medications by these routes	a. Licensed practical nurses *do not* administer: i. IV push medications ii. IV medications through a central venous access device iii. Intrathecal medications iv. Intra-osseous medications v. Medications into epidural spaces vi. Medications into perineural spaces vii. Inhaled substances or medications for purposes of anaesthesia or procedural sedation
35.	Treat clients with known asthma who are in respiratory distress	a. Licensed practical nurses treat respiratory distress in a known asthmatic: i. In a team approach ii. With a client-specific order from an authorized health professional
36.	Compound, dispense, or administer Schedule II drugs (Drug Schedules Regulation)	a. Licensed practical nurses compound, dispense or administer Schedule II drugs to treat a disease or disorderwith a client-specific order from an authorized health professional.
37.	Do not administer allergy challenge testing or desensitization treatments	a. Licensed practical nurses *do not* administer allergy challenge testing or desensitization treatments.
38.	Medical aesthetics[3]	a. Licensed practical nurses successfully complete additional education before providing medical aesthetic procedures. b. Licensed practical nurses administering injectable drugs or substances or implantable devices for medical aesthetic purposes only do so: i. with a client-specific order from an authorized health professional, and ii. when the ordering health professional, or another health professional who has assumed responsibility for the care of the client, is present within the facility when the procedure is being performed and immediately available for consultation.

Specific practice settings

	Practice Setting	BCCNM Limits and Conditions for Licensed Practical Nurses: Specific Practice Settings
1.	Ambulatory Care LPNs working in ambulatory care settings need to know when they are allowed to act within their autonomous scope of practice (without a client-specific order) and when a client-specific order may be required before performing an activity	a. Licensed practical nurses working in ambulatory care clinics or offices where surgical procedures are performed: i. Require a unit orientation that is consistent with LPN entry-level competencies ii. Assist with surgical procedures: After successfully completing additional education When an authorized health professional is immediately available b. Licensed practical nurses *do not* administer: i. IV push medications i. IV medications through a central venous access device (CVAD), or a central venous line iii. Intrathecal medications iv. Intra-osseous medications v. Medications into epidural spaces vi. Medications into perineural spaces vii. Inhaled substances or medications for purposes of anaesthesia or procedural (conscious) sedation c. Licensed practical nurses work in a team nursing approach to provide care and monitor clients under: i. General anesthesia ii. Intrathecal anesthesia iii. Epidural anesthesia iv. Procedural sedation d. Licensed practical nurses work in a team nursing approach to care for clients recovering from epidural anesthesia after successfully completing additional education.
2.	Antenatal Care LPNs working in antenatal care settings need to know when they are allowed to act within their autonomous scope of practice (without an order) and when a client-specific order may be required before performing an activity	a. Licensed practical nurses working in antenatal clinics require a unit orientation consistent with LPN entry-level competencies. b. Licensed practical nurses provide antenatal care: i. To healthy clients with an uncomplicated pregnancy ii. In a team approach with medical practitioners, midwives, registered nurses and/or nurse practitioners
3.	Emergency Room LPNs working in emergency rooms need to know when they are allowed to act within their autonomous scope of practice (without an order) and when a client-specific order may be required before performing an activity	a. Licensed practical nurses working in emergency rooms require a unit orientation that is consistent with LPN entry-level competencies. d. Licensed practical nurses *do not* triage clients in emergency rooms (ERs). c. Licensed practical nurses work in a team nursing approach to provide care for clients with stable or predictable states of health.
4.	Hemodialysis LPNs working in hemodialysis settings need to know when they are allowed to act within their autonomous scope of practice (without an order) and when a client-specific order may be required before performing an activity.	a. Licensed practical nurses working in hemodialysis settings carry out hemodialysis: i. For clients with stable or predictable states of health ii. After successfully completing post-basic education through an in-house program offered by a health authority affiliated with BC Renal iii. By following decision support tools established by a health authority affiliated with BC Renal iv. When a registered nurse is immediately available v. Using an arteriovenous (AV) fistula or AV graft b. Licensed practical nurses working in hemodialysis settings manage, access and maintain central venous lines and central venous access devices (CVAD) used specifically for hemodialysis by: i. Changing dressings on central venous access lines specific to dialysis access only ii. Measuring visible central venous access lines specific to dialysis access only iii. Carrying out dialysis through a central venous access line specific to dialysis access only c. Licensed practical nurses working in hemodialysis settings administer solutions, substances and Schedule I, IA, II and III drugs (Drug Schedules Regulation) by any route, including intravenous and IV push, as part of routine hemodialysis procedures. d. Licensed practical nurses working in hemodialysis settings *do not* administer: i. Intrathecal medications ii. Intra-osseous medications iii. Medications into epidural spaces iv. Medications into perineural spaces v. Inhaled substances or medications for purposes of anaesthesia or procedural (conscious) sedation e. Licensed practical nurses working in hemodialysis settings monitor clients receiving blood or blood products in a team nursing approach. f. Licensed practical nurses working in hemodialysis settings *do not* start transfusions of blood or blood products.
5.	Medical Aesthetics “Medical aesthetics" refers to elective non-surgical outpatient clinical procedures that include the performance of a restricted activity (activities listed in sections 6 and 7 of the Nurses (Licensed Practical) Regulation and are primarily intended to alter or restore a person's appearance.	a. Licensed practical nurses successfully complete additional education before providing medical aesthetic procedures. b. Licensed practical nurses administering injectable drugs or substances or implantable devices for medical aesthetic purposes only do so: i. With a client-specific order from an authorized health professional, and ii. When the ordering health professional, or another health professional who has assumed responsibility for the care of the client, is present within the facility when the procedure is being performed and immediately available for consultation.
6.	Mental Health and Substance Use LPNs working in settings where mental health disorder is the primary diagnosis need to know when they are allowed to act within their autonomous scope of practice (without an order) and when a client-specific order may be required before performing an activity.	a. Licensed practical nurses working in settings where substance use or a mental health disorder is the primary diagnosis require an orientation that is consistent with LPN entry-level competencies. b. Licensed practical nurses work in a team nursing approach to provide care for clients whose primary diagnosis is substance use or a mental health disorder after successfully completing additional education.
7.	Perioperative LPNs working in perioperative settings need to know when they are allowed to act within their autonomous scope of practice (without an order) and when a client-specific order may be required before performing an activity.	a. Licensed practical nurses work in a scrub or circulating role in the operating room (OR): i. After successfully completing formal post-basic education ii. When a registered nurse is immediately available b. Licensed practical nurses *do not* administer: i. IV push medications ii. IV medications through a central venous access device (CVAD), or a central venous line iii. Intrathecal medications iv. Intra-osseous medications v. Medications into epidural spaces vi. Medications into perineural spaces vii. Inhaled substances or medications for purposes of anaesthesia or procedural (conscious) sedation c. Licensed practical nurses working in a perioperative setting work in a team nursing approach to provide care and monitor clients under: i. General anesthesia ii. Intrathecal anesthesia iii. Epidural anesthesia iv. Procedural sedation
8.	Postpartum Care LPNs working in postpartum care need to know when they are allowed to act within their autonomous scope of practice (without an order) and when a client-specific order may be required before performing an activity.	a. Licensed practical nurses working in postpartum settings require a unit orientation consistent with LPN entry-level competencies that includes: i. Infant resuscitation as part of a cardiopulmonary resuscitation (CPR) course for health professionals ii. The Neonatal Resuscitation Program (NRP) modules 1-4 and 9 iii. Newborn and maternal assessment, including breastfeeding, consistent with the Perinatal Services British Columbia (PSBC) Newborn Clinical Pathway (PSBC Newborn Guideline 13: Newborn Nursing Care Pathway) and the Postpartum Clinical Pathway (Perinatal Services BC: Perinatal Services BC Obstetrics Guideline 20 Postpartum Nursing Care Pathway) b. Licensed practical nurses provide care for mothers and newborns: i. With stable or predictable states of health ii. When a registered nurse, nurse practitioner, midwife and/or medical practitioner is immediately available c. Licensed practical nurses take heel pricks after successfully completing additional education.

Practice Setting

BCCNM Limits and Conditions for Licensed Practical Nurses: Specific Practice Settings

Ambulatory Care

LPNs working in ambulatory care settings need to know when they are allowed to act within their autonomous scope of practice (without a client-specific order) and when a client-specific order may be required before performing an activity

a. Licensed practical nurses working in ambulatory care clinics or offices where surgical procedures are performed:

i. Require a unit orientation that is consistent with LPN entry-level competencies

ii. Assist with surgical procedures:

After successfully completing additional education
When an authorized health professional is immediately available

b. Licensed practical nurses do not administer:

i. IV push medications

i. IV medications through a central venous access device (CVAD), or a central venous line

iii. Intrathecal medications

iv. Intra-osseous medications

v. Medications into epidural spaces

vi. Medications into perineural spaces

vii. Inhaled substances or medications for purposes of anaesthesia or procedural (conscious) sedation

c. Licensed practical nurses work in a team nursing approach to provide care and monitor clients under:

i. General anesthesia

ii. Intrathecal anesthesia

iii. Epidural anesthesia

iv. Procedural sedation

d. Licensed practical nurses work in a team nursing approach to care for clients recovering from epidural anesthesia after successfully completing additional education.

Antenatal Care

LPNs working in antenatal care settings need to know when they are allowed to act within their autonomous scope of practice (without an order) and when a client-specific order may be required before performing an activity

a. Licensed practical nurses working in antenatal clinics require a unit orientation consistent with LPN entry-level competencies.

b. Licensed practical nurses provide antenatal care:

i. To healthy clients with an uncomplicated pregnancy

ii. In a team approach with medical practitioners, midwives, registered nurses and/or nurse practitioners

Emergency Room

LPNs working in emergency rooms need to know when they are allowed to act within their autonomous scope of practice (without an order) and when a client-specific order may be required before performing an activity

a. Licensed practical nurses working in emergency rooms require a unit orientation that is consistent with LPN entry-level competencies.

d. Licensed practical nurses do not triage clients in emergency rooms (ERs).

c. Licensed practical nurses work in a team nursing approach to provide care for clients with stable or predictable states of health.

Hemodialysis

LPNs working in hemodialysis settings need to know when they are allowed to act within their autonomous scope of practice (without an order) and when a client-specific order may be required before performing an activity.

a. Licensed practical nurses working in hemodialysis settings carry out hemodialysis:

i. For clients with stable or predictable states of health

ii. After successfully completing post-basic education through an in-house program offered by a health authority affiliated with BC Renal

iii. By following decision support tools established by a health authority affiliated with BC Renal

iv. When a registered nurse is immediately available

v. Using an arteriovenous (AV) fistula or AV graft

b. Licensed practical nurses working in hemodialysis settings manage, access and maintain central venous lines and central venous access devices (CVAD) used specifically for hemodialysis by:

i. Changing dressings on central venous access lines specific to dialysis access only

ii. Measuring visible central venous access lines specific to dialysis access only

iii. Carrying out dialysis through a central venous access line specific to dialysis access only

c. Licensed practical nurses working in hemodialysis settings administer solutions, substances and Schedule I, IA, II and III drugs (Drug Schedules Regulation) by any route, including intravenous and IV push, as part of routine hemodialysis procedures.

d. Licensed practical nurses working in hemodialysis settings do not administer:

i. Intrathecal medications
ii. Intra-osseous medications

iii. Medications into epidural spaces

iv. Medications into perineural spaces

v. Inhaled substances or medications for purposes of anaesthesia or procedural (conscious) sedation

e. Licensed practical nurses working in hemodialysis settings monitor clients receiving blood or blood products in a team nursing approach.

f. Licensed practical nurses working in hemodialysis settings do not start transfusions of blood or blood products.

Medical Aesthetics

“Medical aesthetics" refers to elective non-surgical outpatient clinical procedures that include the performance of a restricted activity (activities listed in sections 6 and 7 of the Nurses (Licensed Practical) Regulation and are primarily intended to alter or restore a person's appearance.

a. Licensed practical nurses successfully complete additional education before providing medical aesthetic procedures.

b. Licensed practical nurses administering injectable drugs or substances or implantable devices for medical aesthetic purposes only do so:

i. With a client-specific order from an authorized health professional, and

ii. When the ordering health professional, or another health professional who has assumed responsibility for the care of the client, is present within the facility when the procedure is being performed and immediately available for consultation.

Mental Health and Substance Use

LPNs working in settings where mental health disorder is the primary diagnosis need to know when they are allowed to act within their autonomous scope of practice (without an order) and when a client-specific order may be required before performing an activity.

a. Licensed practical nurses working in settings where substance use or a mental health disorder is the primary diagnosis require an orientation that is consistent with LPN entry-level competencies.

b. Licensed practical nurses work in a team nursing approach to provide care for clients whose primary diagnosis is substance use or a mental health disorder after successfully completing additional education.

Perioperative

LPNs working in perioperative settings need to know when they are allowed to act within their autonomous scope of practice (without an order) and when a client-specific order may be required before performing an activity.

a. Licensed practical nurses work in a scrub or circulating role in the operating room (OR):

i. After successfully completing formal post-basic education

ii. When a registered nurse is immediately available

b. Licensed practical nurses do not administer:

i. IV push medications

ii. IV medications through a central venous access device (CVAD), or a central venous line

iii. Intrathecal medications

iv. Intra-osseous medications

v. Medications into epidural spaces

vi. Medications into perineural spaces

vii. Inhaled substances or medications for purposes of anaesthesia or procedural (conscious) sedation

c. Licensed practical nurses working in a perioperative setting work in a team nursing approach to provide care and monitor clients under:

i. General anesthesia

ii. Intrathecal anesthesia

iii. Epidural anesthesia
iv. Procedural sedation

Postpartum Care

LPNs working in postpartum care need to know when they are allowed to act within their autonomous scope of practice (without an order) and when a client-specific order may be required before performing an activity.

a. Licensed practical nurses working in postpartum settings require a unit orientation consistent with LPN entry-level competencies that includes:

i. Infant resuscitation as part of a cardiopulmonary resuscitation (CPR) course for health professionals

ii. The Neonatal Resuscitation Program (NRP) modules 1-4 and 9

iii. Newborn and maternal assessment, including breastfeeding, consistent with the Perinatal Services British Columbia (PSBC) Newborn Clinical Pathway (PSBC Newborn Guideline 13: Newborn Nursing Care Pathway) and the Postpartum Clinical Pathway (Perinatal Services BC: Perinatal Services BC Obstetrics Guideline 20 Postpartum Nursing Care Pathway)

b. Licensed practical nurses provide care for mothers and newborns:

i. With stable or predictable states of health

ii. When a registered nurse, nurse practitioner, midwife and/or medical practitioner is immediately available

c. Licensed practical nurses take heel pricks after successfully completing additional education.

Glossary

Additional education: Additional education is structured education (e.g., workshop, course, program of study) designed for the nurse to attain the competencies required to carry out a specific activity. Additional education:

builds on the entry-level competencies,
identifies the competencies expected of learners on completion of the education,
includes both theory and application to practice, and
includes an objective evaluation of learners' competencies on completion of the education.

Advanced activities: Activities that are within a nurse's scope of practice but require additional education, training and/or clinical experience that build on the foundational knowledge, skills, and judgement attained during entry-level nursing education.

Competence: The integration and application of current knowledge, skills, attitudes, and judgment required to perform safely, ethically, and appropriately within an individual's practice.

Competencies: The knowledge, skills, attitudes, and judgment required to provide safe, competent, and ethical care within an individual's practice or in a designated role or setting.

Decision support tools (DSTs): Evidence-based documents used by nurses to support clinical judgment and decision-making by guiding the assessment, diagnosis and treatment of client-specific clinical problems. DSTs come in various forms and are created by organizations or specialists in a specific area of health care.

Formal post-basic education: Structured education that builds on the entry-level LPN competencies. Formal post-basic education is delivered:

by an educational institution that teaches a BCCNM-recognized practical nursing education program or equivalent, or
through a collaborative arrangement between an employer that employs LPNs in post-basic areas and a school that teaches a BCCNM-recognized practical nursing education program or equivalent.

Team approach: When the care needs of a client include activities that are outside LPN scope of practice or the individual competencies of the LPN, the LPN seeks out other members of the health care team to jointly review the client's care needs and determine how the care needs will be met between them. Where relevant, the registered nurse or registered psychiatric nurse may be the most appropriate team member for the LPN to seek consultation and collaboration with regarding client care needs.

Team nursing approach: When the nursing care needs of a client include activities that are outside LPN scope of practice or the individual competencies of the LPN, the LPN seeks out the registered nurse or registered psychiatric nurse to jointly review the client's care needs and determine how the care needs will be met between them.

Footnotes

[1] To the extent the activity is not within the activities or related limits and conditions listed in section 6 of the Regulation.

[2] “Reasonable" refers to the common understanding that registrants of BCCNM would have as to what is appropriate in the situation.

[3] “Medical aesthetics" refers to elective non-surgical outpatient clinical procedures that include the performance of a restricted activity (activities listed in sections 6 and 7 of the Nurses (Licensed Practical) Regulation and are primarily intended to alter or restore a person's appearance.

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Acting with Client-specific Orders

Int​rodu​ction

Sta​ndards

BCCNM limits and conditions for licensed practical nurse

Acting​​​ with client-specifi​c orders

Specific practice settings

​​Glossary​

​​Foot​​​notes​

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Introduction

Standards

Acting with client-specific orders

Glossary

Footnotes

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