CHAPTER 5: MEDICATION ADMINISTRATION IN SCHOOLS MEDICATION ADMINISTRATION IN SCHOOLS TABLE OF CONTENTS PART A: INTRODUCTION, LEGISLATIVE AUTHORITY AND POLICY ........................ 4 PART B: GENERAL MEDICATION PROCEDURES AND INFORMATION ................... 7 Delivery of Medication to School .............................................................................................................. 8 Medication Storage Guidelines ................................................................................................................. 9 Six Rights of Medication Administration................................................................................................. 10 Routine Counting of Medications ........................................................................................................... 11 Medication Errors ................................................................................................................................... 12 Discontinued Medications ...................................................................................................................... 13 End of the School Year Procedures ......................................................................................................... 14 Medication Disposal ................................................................................................................................ 15 PART C: PRESCRIPTION MEDICATIONS ............................................................. 16 Administration of Prescription Medication Card (blue card).................................................................. 17 Prescription Medication Guidelines ........................................................................................................ 18 Documentation ....................................................................................................................................... 20 PART D: OVER THE COUNTER MEDICATIONS .................................................... 21 Administration of Over the Counter Medication Card (orange card) ..................................................... 22 Over the Counter Medication Guidelines ............................................................................................... 23 Documentation ....................................................................................................................................... 25 PART E: SELF‐ADMINISTERED MEDICATIONS .................................................... 26 Introduction ............................................................................................................................................ 27 Metered Dose Inhaler ............................................................................................................................. 27 Epinephrine auto‐injector (EPI‐PEN) ....................................................................................................... 28 Insulin and diabetic equipment .............................................................................................................. 28 Prescribed pancreatic enzyme supplements .......................................................................................... 29 07/2012 SHS pg. 2 PART F: FIELD TRIP PROCEDURES ..................................................................... 30 Introduction ............................................................................................................................................ 31 Single Day Field Trip ................................................................................................................................ 32 Extended Day/Multi‐Day Field Trip ......................................................................................................... 33 PART G: MEDICATION ADMINISTRATION TECHNIQUES .................................. 355 General Guidelines ................................................................................................................................ 366 Oral Medication (tablets and capsules) ................................................................................................ 377 Oral Medication (liquid) ........................................................................................................................ 388 Metered Dose Inhaler ............................................................................................................................. 39 Nebulized Medication ........................................................................................................................... 411 Eye Medication ..................................................................................................................................... 422 Nasal Medication .................................................................................................................................. 433 Ear Medication ...................................................................................................................................... 444 Topical Medication ................................................................................................................................ 455 Medications via Gastrostomy Tube ...................................................................................................... 466 Rectal Medication (suppository) ........................................................................................................... 477 PART H: EMERGENCY MEDICATIONS .............................................................. 488 Anaphylaxis ............................................................................................................................................. 49 How to Use an EpiPen ........................................................................................................................... 500 Diastat (Diazepam rectal gel) ................................................................................................................ 544 Glucagon ............................................................................................................................................... 556 References ...................................................................................................... 588 07/2012 SHS pg. 3 PART A: INTRODUCTION, LEGISLATIVE AUTHORITY AND POLICY 07/2012 SHS pg. 4 Introduction Some children are able to access a free and public education only because of the effectiveness of medications used to treat illness or disability. In this respect, medication administration at school is considered a supportive service for students. Parents are encouraged to develop a schedule minimizing or eliminating the administration of medications at school. Medication administration during school hours will occur only when a medication schedule cannot be adjusted to provide for administration at home, and is done for the best interest of the child or on an emergency basis. Unlicensed school personnel, who are both authorized by the principal and trained by the school nurse, may assist students in taking prescribed medications during school hours as per Florida Statute 1006.062 and PCSB policy 5330 – Use of Medications. 1006.062 Administration of medication and provision of medical services by district school board personnel.‐ (1) Notwithstanding the provision of the Nurse Practice Act, part I of chapter 464, district school board personnel may assist students in the administration of prescription medication when the following conditions have been met: (a) Each district school board shall include in its approved school health services plan a procedure to provide training, by a registered nurse, a licensed practical nurse, a physician licensed pursuant to chapter 458 or chapter 459, or a physician assistant licensed pursuant to chapter 458 or chapter 459, to the school personnel designated by the school principal to assist students in the administration of prescribed medication. Such training may be provided in collaboration with other school districts, through contract with an education consortium, or by any other arrangement consistent with the intent of this subsection. (b) Each district school board shall adopt policies and procedures governing the administration of prescription medication by district school board personnel. The policies and procedures shall include, but not be limited to, the following provisions: 1. For each prescribed medication, the student’s parent shall provide to the school principal a written statement which grants to the school principal or the principal’s designee permission to assist in the administration of such medication and which explains the necessity for the medication to be provided during the school day, including any occasion when the student is away from school property on official school business. The school principal or the principal’s trained designee shall assist the student in the administration of the medication. 2. Each prescribed medication to be administered by district school board personnel shall be received, counted, and stored in its original container. When the medication is not in use, it shall be stored in its original container in a secure fashion under lock and key in a location designated by the school principal. (2) There shall be no liability for civil damages as a result of the administration of the medication when the person administering the medication acts as an ordinarily reasonable prudent person would have acted under the same or similar circumstances. 07/2012 SHS pg. 5 5530 – Use of Medications The School Board shall not be responsible for the diagnosis and treatment of student illness. The administration of prescribed medication and/or medically‐prescribed treatments to a student during school hours will be permitted only if failure to do so would jeopardize the health of the student, the student would not be able to attend school if the medication or treatment were not made available during school hours, or if the child is disabled and requires medication to benefit from his/her educational program. For purposes of this policy, “medication” shall include all medicines including those prescribed by a physician/health care provider and any over‐the‐counter drugs, herbal preparations, and/or remedies. “Treatment” refers both to the manner in which a medication is administered and to health‐care procedures which require special training, such as catheterization. Before any medication or treatment may be administered to any student during school hours, the Board shall require the written prescription from the child’s physician/health care provider accompanied by the written authorization of the parent. This document shall be kept on file at the school site, and made available to the persons designated by this policy as authorized to administer medication or treatment. School personnel designated by the principal as being responsible for administration of medication shall participate in a scheduled training program provided by the school nurse. No student is allowed to provide or sell any type of over‐the‐
counter medication to another student. Violations of this rule will be considered a violation of the Code of Student Conduct. The principal is responsible for designating 3 school personnel (separate from the school nurse and/or Certified Nursing Assistant) who will be responsible for administering medications in the school. These designated people will not administer medication until after they have successfully completed medication administration training. The Registered Nurse can refuse to delegate any medical task if he or she deems that the designated personnel are not competent to perform the task. It is the responsibility of the designated personnel to assure that prescribed medications are administered. If a student who normally receives medication at school fails to come to the health room at the scheduled time, the person responsible for medication administration should make every effort to locate the student within a 1 hour time frame. 07/2012 SHS pg. 6 PART B: GENERAL MEDICATION PROCEDURES AND INFORMATION 07/2012 SHS pg. 7 Delivery of Medication to School •
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NO STUDENT SHALL TRANSPORT MEDICATION TO OR FROM SCHOOL. The exception to this is for students who have a completed self‐carry authorization form (for EpiPen, insulin, inhaler or pancreatic enzymes) on file at the school. Medications are not to be transported on a school bus or placed in the student’s backpack for transport. Parents, or their designee, are required to hand‐deliver all medication to the school in order to complete all required paperwork and verify the amount of medication delivered. School personnel will not administer any medication until the completed and signed form is received at the school. Parent should arrange for a separate supply of medication for school use. These medications must be in their original labeled container provided by the pharmacy or manufacturer. Medication should not be transported between home and school on a daily basis, unless the parent daily drops the medication off and signs it in to school and daily picks the medication up and signs it out of school. Upon delivery at school, all medication must be counted by a school staff member trained to administer medication. Counting should take place in the presence of the adult who delivered the medication to school. The total should then be documented on the Administration of Medication card and signed by both staff member and parent. If a dose involves a half‐tablet, each half‐tablet will be counted. If the dose involves 1 ½ tablets, the parent will need to bring in two bottles: one with full tablets and another with half‐tablets. Each bottle will then be counted separately and the medication cards stapled together. 07/2012 SHS pg. 8 Medication Storage Guidelines Schools have a duty to provide safe and appropriate storage of all medications ordered by a health care provider and entrusted to the school’s care. All medications must be kept in the original labeled container provided by the pharmacy or manufacturer. Prescription labels must include the student’s name, name of the medication, the dosage directions, the specific time of administration, date of prescription (must be within one calendar year), the ordering physician’s name, pharmacy name and pharmacy telephone number. ROUTINE DAILY OR OVER‐THE‐COUNTER MEDICATIONS: • Should be stored in a locked drawer or cabinet in a secure area in the clinic or administrative area. • Should be kept cool and dry. CONTROLLED SUBSTANCES (INCLUDING MEDICATIONS FOR ADHD): • Require special attention and storage. • Should be kept under two separate locks and keys, per FDA guidelines and national standards requirements. REFRIGERATED MEDICATIONS (SOME ELIXIRS, INSULIN VIALS): • Should be kept in a locked box in a refrigerator. The refrigerator should be in a secure area with minimal access. They should not be kept in the refrigerator door. • Should not be kept in the same refrigerator as food. • Should maintain a consistent temperature of 36 ‐ 46°F. EMERGENCY MEDICATIONS (EPI‐PEN, GLUCAGON, DIASTAT): • Must be accessible immediately in case of an emergency. ONLY these medications will leave the building in the event of an emergency. • Should be kept in the clinic. It is not recommended to keep emergency medications in the classroom. • May be kept in a secure but unlocked location during the day, but must be locked up after school hours. If stored this way, there should be a sign on the outside of the medication cabinet indicating where the emergency medications are located. 07/2012 SHS pg. 9 Six Rights of Medication Administration *** Always compare the pharmacy label with the Administration of Medication card *** 1. Right Student: Be sure you are giving medication to the correct student. • Ask the student to state his/her name. Do not prompt. • Look at the student’s picture on the Administration of Medication card, if available. • Check with another staff member if you are unsure that the student is who they say. 2. Right Medication: Be sure you give the correct drug. 3. Right Dose: Be sure that the strength and amount (dosage) are correct. 4. Right Time: Be sure the drug is given at the correct time. 5. Right Route: Be sure the correct way of administering the drug is used. 6. Right Documentation: After you have finished assisting with a medication, it is VERY IMPORTANT that you document on the Administration of Medication card immediately. Be sure to write on the correct card and document completely. The Six Rights should be checked 3 times every time a medication is administered: • When taking the medication out of the storage area. • Before giving the medication to the student. • When returning the medication to the storage area. 07/2012 SHS pg. 10 Routine Counting of Medications In the course of any given school day, multiple people can be responsible for giving multiple medications to multiple students. In order to maintain adequate control and accountability of all staff responsible for administering medications to students, it is essential that school personnel maintain an accurate count of all medications dispensed. This is done not only through thorough and complete documentation, but also through biweekly medication counts by the assigned school nurse. Medication counts must be completed on all medications except metered dose inhalers and any medications that students are permitted to carry on their person. SCHOOL PERSONNEL RESPONSIBILITIES: • When accepting medication from a parent, medications MUST be counted in the presence of both the parent and school staff member. Both parties must sign and date the medication card, confirming the amount of medication delivered to school and the current amount present. Do not use your hands to count – use a pill counter or pour the pills into the top of the medication bottle. • When administering a medication to a student, clearly document how much medication was administered (i.e. 1 pill, 2 tsps.). Document how much medication then remains in the bottle after administration. • Count all pills, tablets or capsules after administration but before putting the medication away to verify that the count after dispensing is correct. • Notify the school nurse immediately of any incorrect count. SCHOOL NURSE RESPONSIBILITIES: • On one day every other week, complete a count verification at each assigned school. Double check that the written count is the same as the actual count in the bottle. • If the count is correct, somehow indicate this on the medication card by circling the count, starring the date, etc. Be sure to keep your indicator consistent. • If the count is not correct, double check the math on the medication card as far back as the last verified count. • If you are unable to find the error, complete a Medication Incident Report. 07/2012 SHS pg. 11 Medication Errors Failure to follow any of the Six Rights of Medication Administration constitutes a medication error. This includes any missed doses for any reason except absenteeism. Medication errors are oftentimes used to determine the need for re‐education of staff. SCHOOL PERSONNEL RESPONSIBILITIES: • Identify that an error occurred. • Notify the parent, noting the day and time of notification. Give the parent a description of what occurred. • Notify the principal, noting the day and time of notification. • Notify the school nurse. • Monitor the student for any adverse effects. If the error involved the wrong student, wrong medication, wrong dose, or wrong route, it is advisable to call the Poison Control Center hotline at 1‐800‐222‐1222 for toxicity or expected side effects. Keep the student under observation for possible adverse reactions. Call 911 for any severe adverse reactions, such as difficulty breathing, tongue or facial swelling, difficulty swallowing, vomiting, lethargy or confusion. • Be willing to participate in periodic re‐evaluation and re‐education with the school nurse regarding medication administration, if necessary. SCHOOL NURSE RESPONSIBILITIES: • Notify the student’s health care provider that the error occurred. • Complete a Medication Incident Report. • When the form is complete and signed by all involved, pony the completed form to the School Health Services Coordinator. Do not keep a copy in the student’s health record. • Complete any re‐education or training of the staff, if necessary. Anyone can make an error, even when being careful. There are some steps to take to minimize the possibility of a medication error. • Take your time. Do not allow yourself to be rushed. • Concentrate on what you are doing and avoid distractions. • Work with one student at a time. • Document immediately after giving a medication. 07/2012 SHS pg. 12 Discontinued Medications Many times, a student’s medication needs will change over the course of the school year. Medications, dosages, times or routes may be discontinued by the student’s health care provider. In addition, a student may withdraw from the school. PARENT RESPONSIBILITIES: • Notify the school that the medication for the student has been discontinued. • It is the parent’s responsibility to pick up any unused medication within a reasonable timeframe. No medications will be sent home with a student, regardless of age. SCHOOL PERSONNEL RESPONSIBILITIES: • When a parent notifies the school that a medication has been discontinued, notify the assigned school nurse. • Assist the parent with medication pick‐up and sign out procedures, if necessary. SCHOOL NURSE RESPONSIBILITIES: • Document in PCS Portal that a medication has been discontinued. • If the parent does not come to pick up the medication within 1 week after notifying the school, a letter should be sent to the parent requesting pick‐up within 2 weeks. Document in Portal that a letter was sent. • If the parent does not respond to the letter, place a telephone call to the parent requesting pick‐up of the medication. Notify the parent that the medication will be destroyed if not picked up in the designated timeframe. Document in Portal that a telephone call was made. • If the parent does not respond after a letter and a phone call, follow the procedure for medication disposal. Document the disposal in Portal, and on the medication card. File the medication card with any paperwork to be boxed at the end of the school year. DO NOT file the card in the student’s Cumulative Health Record. 07/2012 SHS pg. 13 End of the School Year Procedures No medications are to remain on school property at the end of the school year. Health Services staff will make every effort to notify parents that medications must be picked up and signed out by the last day of school. No medications will be sent home with a student. PARENT RESPONSIBILITIES: • It is the parent’s responsibility to pick up and sign out any unused medications at the end of the school year. • It is recommended to leave just enough medication at school to finish out the school year. This can be done ahead of time. SCHOOL PERSONNEL RESPONSIBILITIES: • Notify the school nurse of any medication that has been picked up before the last day of school. • Assist parents with medication pick‐up and sign out procedures. • Facilitate placing a notice in the final newsletter of the school year. • If requested, place a SchoolMessenger call to parents reminding them of the need to pick up medications by the last day of school. • All medication must be counted out by a school staff member trained to administer medication. Counting should take place in the presence of the adult who is picking the medication up. The total being sent home with parent should then be documented on the Administration of Medication card and signed by both staff member and parent. SCHOOL NURSE RESPONSIBILITIES: • Place a notice in the final newsletter of the year, stating a need to pick up medications at the end of school. • 2 weeks before school ends, send a letter home to the parents of all students receiving medications at school. The letter must give a specific deadline for pick‐up. Document in PCS Portal that a letter was sent home. • The final week of school, attempt to make phone contact with any parent who has not responded to the written letter. Notify the parent of the deadline. Document any phone contact in Portal. • Request that a SchoolMessenger call be placed to any parents who have not responded to the letter or nurse call. • Any medications remaining at school after the deadline will be properly disposed of. 07/2012 SHS pg. 14 Medication Disposal Health Services staff will make every effort to notify parents of the need to pick up medications remaining at school, including any that were expired or discontinued The destruction of medication will be done only after reasonable attempts to facilitate removal have been made. Parents must also remove any tubing or equipment necessary for medication delivery as well. Any medication that is to be disposed of after reasonable attempts must be documented and cosigned by a witness. The school nurse will be responsible for all medication disposals. The witness can be a Registered Nurse, Licensed Practical Nurse, Certified Nursing Assistant, or school staff member. Keep all medications in the original container.
SUPPLIES NEEDED: 1. Permanent marker 2. Liquid, such as water, coffee or soda 3. Something inedible, such as cat litter, dirt, sand or coffee grounds 4. A piece of fruit with a soft skin, such as an orange, banana or apple 5. Duct or packing tape 6. An opaque container PROCEDURE: 1. With a permanent marker, mark out any identifying information on the medication bottle for safety. 2. For pills, tablets, capsules: Add water, coffee or soda to the bottle to begin dissolving the contents. 3. For liquids: Add something inedible, such as litter, dirt, sand or coffee grounds. 4. For metered dose inhalers: Disconnect the medication canister from the mouthpiece. Break off the tab that holds the canister into the mouthpiece. 5. For injectables: Empty into the toilet or sink. Place the empty containers into the sharps container. EpiPens can be injected into a piece of fruit. 6. Close all bottle lids and secure with duct or packing tape. 7. Place the bottles inside an opaque (not see‐through) container, such as a coffee can, laundry detergent bottle or large food can from food services. 8. Tape that container closed with the duct or packing tape. 9. Dispose of this container in the regular trash. Do not put it in the recycle bin. 10. On the medication card, document the date and time of disposal, the name of the medication disposed of, and how much was disposed. Both individuals should sign the card. 11. For full sharps containers: See Public Folders Æ Health Services Æ Sharps Containers. 07/2012 SHS pg. 15 PART C: PRESCRIPTION MEDICATIONS 07/2012 SHS pg. 16 Administration of Prescription Medication Card (blue card) •
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Blue cards should be ordered through the Warehouse #98333. School Health Services does not keep a supply of medication cards. These cards are to be used for prescription medications only. The card only requires the parent signature, since the label on the bottle will provide the health care provider’s order. The top of the card must be filled out completely and include: student name, date the card is being filled out, student grade and teacher (if elementary school). If possible, the student’s picture should be attached to the card. The parent should fill out: name of the medication, dosage, reason for the medication, medication expiration date and specific time the medication is to be given. Health Services cannot accept orders that do not state a SPECIFIC chronological time (i.e. order must read “at noon” and not “daily”). Parent must also sign and date the card and provide a valid working telephone number. The medication card should be kept in a 3‐ring binder in the clinic. It is NOT to be kept in the same folder or baggie as the medication. A new medication card is required each school year. A new medication card is required for any change in medication, dosage or time. All staff administering medications must complete the signature verification at the bottom of the medication card. 07/2012 SHS pg. 17 Prescription Medication Guidelines •
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Parent or parent designee must deliver all medications to school. Schools should not accept medications brought in by students or bus assistants. Keep all prescription medications in their original pharmacy container. All prescriptions must have readable and currently dated pharmacy label. The label should include: ¾ Student’s name ¾ Name of the medication ¾ Dosage instructions ¾ Specific time of administration during the school day ¾ Date the prescription was filled (must be within 1 calendar year) ¾ Health care provider name ¾ Pharmacy name and telephone number If the pharmacy label does not include a specific time of administration (i.e. must say “at noon” instead of “daily”), the school should not accept the medication. Parents should be directed to request a second label from the pharmacy with the appropriate time(s) to be given during the school day. If there is any question concerning the medication, contact the parent, school nurse, health care provider or pharmacy before administering the medication. School staff is not to administer prescription narcotics to students at school. Narcotics can have many side effects that would hinder a student’s ability to learn. These students are usually ill enough to remain at home. If there is a question about whether a medication is a narcotic, contact the school nurse or School Health Services. There are no legal restrictions preventing a parent from themselves administering a medication in the school setting to his or her child. Emergency medications (EpiPen, Glucagon, and Diastat) are the only medications that should leave the building in the event of an emergency. 07/2012 SHS pg. 18 PARENT RESPONSIBILITIES: • Parent or parent designee must hand‐deliver medication to school in the original labeled container. • Medication in plastic bags, food storage containers, medication dividers or other non‐
pharmacy containers will not be accepted. • It is recommended to provide the school with a maximum of a 30 day supply of medication. • Parent must count the medication in the presence of school personnel and sign the medication card for verification. SCHOOL PERSONNEL RESPONSIBILITIES: • Do not accept medication without a completed medication card. • Do not accept medication with incomplete, missing or unreadable pharmacy labels. • Do not accept medication without a specific time of administration. • Count the medication in the presence of the parent. Cosign the medication card to verify the count. • Notify parent, either in writing or over the phone, when medication supply is running low. Document any parent contact on the medication card. • Notify the school nurse of any new prescription medication accepted into the school. SCHOOL NURSE RESPONSIBILITIES: • Verify that all blue card information matches the prescription label. If they do not match, contact the parent and/or health care provider for clarification. This includes verifying that the prescription states a specific time of administration. • Keep an accurate and up‐to‐date list of all medication in the school, using the template provided by School Health Services. Update the list as needed. 07/2012 SHS pg. 19 Documentation •
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Fill out all spaces of the medication card completely. The first time a trained designee administers a medication, they must sign their full legal name at the bottom of the card for signature verification. After that initial time, personnel can sign using their initials only if desired. Each day of the month, with the exception of weekends, must have proper documentation on the medication card. ¾ If a student is absent, write the date and “Absent” on the appropriate line, carry the medication count down to the next line and sign. ¾ If there is no school, write the date and “No School” on the appropriate line, carry the medication count down to the next line and sign. The medication card must be kept in the 3‐ring binder. If a medication dose is omitted, it is acceptable to administer it up to 1 hour after the scheduled time. Notify the parent as soon as possible. This will NOT be considered a medication error. Any parent requests to hold medication must be received in writing with specific dates and times to be held. Keep a copy of the request with the medication card and give the original to the school nurse. Document on the medication card appropriately. Errors must be initialed and crossed out with a single strike line. Do not use correction tape or fluid. Document in blue or black ink. Do not use pencil. Document immediately after administering the dose. If an entry is missed, document “Late Entry” next to the date when the entry is written on the medication card. 07/2012 SHS pg. 20 PART D: OVER THE COUNTER MEDICATIONS 07/2012 SHS pg. 21 Administration of Over the Counter Medication Card (orange card) •
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Orange cards should be ordered through the Warehouse #98334. School Health Services does not keep a supply of medication cards. These cards are to be used for over the counter or non‐prescription medications only. The card requires both a parent signature and a health care provider order with signature. The top of the card must be filled out completely and include: student name, date the card is being filled out, student grade and teacher (if elementary school). If possible, the student’s picture should be attached to the card. The HEALTH CARE PROVIDER must fill out the name of the medication, dosage, reason for medication, and time interval for the medication to be given. The health care provider must also sign and date the card and give the office telephone number. The parent must sign and date the card and provide a valid working telephone number. The medication card should be kept in a 3‐ring binder in the clinic. It is NOT to be kept in the same folder or baggie as the medication. A new medication card is required each school year. A new medication card is required for any change in medication, dosage or time. All staff administering medications must complete the signature verification at the bottom of the medication card. 07/2012 SHS pg. 22 Over the Counter Medication Guidelines •
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Parent or parent designee must deliver all medications to school. Schools should not accept medications brought in by students or bus assistants. Keep all over the counter medications in their original, unopened manufacturer container. All bottles or boxes containing over the counter medications must be labeled with the student’s name and grade. If there is any question concerning the medication, contact the parent, school nurse, or health care provider before administration. No legal provisions exist to allow students to carry over the counter medications on their person. Therefore, students are not permitted to self carry such medications on school property. There are no legal restrictions preventing a parent from themselves administering a medication in the school setting to his or her child. The school nurse or trained personnel should provide non‐medical treatments before offering over the counter medication. Question the student about hunger, hydration and lack of sleep. Offer appropriate non‐medical interventions such as a snack, water and rest time. Before administering the over the counter medication, attempt to contact the parent by telephone to determine if any prior doses of medication were given at home. When giving over the counter medications, be sure to check the expiration date on the bottle. Do not administer expired medications. If expired, notify the parent as soon as possible. Any student requiring over the counter medication more than 3 times in 1 month, or more than 3 consecutive days in a row, should be referred to the school nurse. Sunscreen should be applied at home by the parent before school whenever possible. If sunscreen is to be administered by school personnel, it will be treated as any other over the counter medication. Florida State Statute 1001.43 allows for student to wear sunglasses, hats or other protective wear while outdoors during school hours. FDA‐regulated non‐prescription herbal products will be treated the same as other non‐
prescription medications. Those products not regulated by the FDA will not be administered by school personnel. Parents have the right to come to school and administer such products to their children. 07/2012 SHS pg. 23 PARENT RESPONSIBILITIES: • Parent or parent designee must deliver medication to school in the original unopened manufacturer container. • Medication in plastic bags, food storage containers, medication dividers or other non‐
original packaging will not be accepted. • Parent must count the medication in the presence of school personnel and sign the medication card for verification. SCHOOL PERSONNEL RESPONSIBILITIES: • Do not accept medication without a completed medication card. • Do not accept medication that is not in its original unopened packaging. • Count the medication in the presence of the parent. Cosign the medication card to verify the count. • Notify the school nurse of any new over the counter medication accepted into the school. SCHOOL NURSE RESPONSIBILITIES: • Verify that all orange card information is complete and makes sense based on the age of the student and the manufacturer’s recommended dosing. If there is any question or concern, notify the student’s health care provider. • Keep an accurate and up‐to‐date list of all medication in the school, using the template provided by School Health Services. Update the list as needed. 07/2012 SHS pg. 24 Documentation •
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Fill out all spaces of the medication card completely. The first time a trained designee administers a medication, they must sign their full legal name at the bottom of the card for signature verification. After that initial time, personnel can sign using their initials only if desired. The medication card must be kept in the 3‐ring binder. Errors must be initialed and crossed out with a single strike line. Do not use correction tape or fluid. Document in blue or black ink. Do not use pencil. Document immediately after administering the dose. 07/2012 SHS pg. 25 PART E: SELF‐ADMINISTERED MEDICATIONS 07/2012 SHS pg. 26 Introduction Students with certain chronic health conditions (asthma, life‐threatening hypersensitivity to food or insects, diabetes and pancreatic insufficiency) may require special circumstances. These students often need certain life‐saving medications. Because these conditions will affect the student for the rest of their lifetime, it is essential that these students become self‐
sufficient in their emergency care management. To that end, these students are permitted to carry and administer their life‐saving medications if deemed appropriate by the parent, health care provider, principal and school nurse. This right is granted by law in Florida Statute 1002.20. The medications covered under this law include: metered dose inhalers, epinephrine auto‐injector (EpiPen), insulin and diabetic management supplies, and prescribed pancreatic enzyme supplements. Pinellas County School Board policy 5330.01 – Self‐Administered Medication also recognizes the student’s right to carry these medications. Self administration of these medications requires authorization by both the parent and health care provider. It is the responsibility of the school nurse to assess the safety of the student with regards to self administration. Other than the specific Authorization to Self Carry form, no other paperwork will be required for students who self administer. No other medications are allowed to be carried by students except those detailed below. The school nurse has the right and the duty to revoke the self administration privilege for any student the nurse assesses as unsafe or ineffective. 1. METERED DOSE INHALER for asthma F.S. 1002.20(3)(h): Asthmatic students whose parent and physician provide their approval to the school principal may carry a metered dose inhaler on their person while in school. The school principal shall be provided a copy of the parent’s and physician’s approval. The parent and health care provider are to complete PCSB form 2‐3060: Authorization to Carry and Self Administer Metered Dose Inhaler for Asthma. The original completed authorization form will be kept in the 3‐ring binder that contains all medication cards. A copy will be provided to the principal. Medication must be labeled with the student’s name. Students may use their inhaler anywhere on school property. The school nurse is required to train 3 school personnel who can assist the student with inhaler administration in the event the student is unable to self administer. 07/2012 SHS pg. 27 2. EPINEPHRINE AUTO‐INJECTOR (EPIPEN) for life‐threatening allergic reactions F.S. 1002.20(3)(i): A student who has experienced or is at risk for life‐threatening allergic reactions may carry an epinephrine auto‐injector and self‐administer epinephrine by auto‐injector while in school, participating in school‐sponsored activities, or in transit to or from school or school‐sponsored activities if the school has been provided with parental and physician authorization. The parent and health care provider are to complete PCSB form 2‐2366: Authorization for Emergency Injection for Severe Allergy. The original completed authorization form will be kept in the 3‐ring binder that contains all medication cards. A copy will be provided to the principal. Medication must be labeled with the student’s name. Students may use their EpiPen anywhere on school property, while participating in school sponsored functions, or in transit to or from school activities. The school nurse is required to provide student specific training to staff who have contact with the hypersensitive student, including training at least 3 staff members to administer the EpiPen in the event the student is unable to self administer. 3. INSULIN AND DIABETIC EQUIPMENT FOR DIABETES MANAGEMENT F.S. 1002.20(3)(j): Diabetic students whose parent and physician provide their written authorization to the school principal may carry diabetic supplies and equipment on their person and attend to the management and care of their diabetes while in school, participating in school‐sponsored activities, or in transit to or from school or school‐sponsored activities…The written authorization shall identify the diabetic supplies and equipment that the student is authorized to carry and shall describe the activities the child is capable of performing without assistance, such as performing blood‐glucose level checks and urine ketone testing, administering insulin through the insulin‐delivery system used by the student, and treating hypoglycemia and hyperglycemia. In accordance with Section 504 of the Rehabilitation Act of 1973, the Individuals with Disabilities Education Act (IDEA) of 1990, and the 2003 Nursing Guidelines for the Delegation of Care for Students with Diabetes in Florida Schools, students with diabetes are legally allowed to check blood glucose levels and respond to the results anywhere on school property, while participating in school sponsored functions, or in transit to or from school activities. The parent and physician are to complete PCSB form 2‐2966: Authorization for Diabetes Management in School. The original completed authorization form will be kept in the 3‐ring binder that contains all medication cards. A copy will be provided to the principal. Medication and supplies must be labeled with the student’s name. The school nurse is required to provide training to school staff on the signs and symptoms of hypo‐ and hyperglycemia and emergency diabetes care. In addition, the school nurse will provide student specific training to staff that have close contact with the diabetic student. 07/2012 SHS pg. 28 4. PRESCRIBED PANCREATIC ENZYME SUPPLEMENTS FOR CYSTIC FIBROSIS F.S. 1002.20(3)(k): A student who has experienced or is at risk for pancreatic insufficiency or who has been diagnosed as having cystic fibrosis may carry and self‐administer a prescribed pancreatic enzyme supplement while in school, participating in school‐sponsored activities, or in transit to or from school or school‐sponsored activities if the school has been provided with authorization from the student’s parent and prescribing practitioner. The parent and health care provider are to complete PCSB form 2‐3162: Authorization to Carry & Self‐Administer Pancreatic Enzyme. The original completed authorization form will be kept in the 3‐ring binder that contains all medication cards. A copy will be provided to the principal. Medication must be labeled with the student’s name. Students may administer their enzyme supplement anywhere on school property, while participating in school sponsored functions, or in transit to or from school activities. The school nurse is required to provide student specific training on the signs and symptoms of pancreatic insufficiency to school staff who have close contact with the student. 07/2012 SHS pg. 29 PART F: FIELD TRIP PROCEDURES 07/2012 SHS pg. 30 Introduction Field trips often create challenging situations regarding students who require medication administration. It is important to plan ahead for students with chronic health problems going on a field trip. Field trip planning is a collaborative effort between administrators, the field trip teacher and the school nurse. Both the school nurse and school staff must be aware of any special medical issues of the students attending the trip. Students with chronic health conditions CANNOT be excluded from going on a field trip that occurs during a regular school day. The school may request that the student’s parent chaperone the trip but they cannot require that the parent attend for student attendance. It is highly recommended that the organizing teacher speak with the school nurse regarding the field trip details and discuss any concerns or questions. Copies of field trip forms that indicate special health care needs should be forwarded to the school nurse as soon as possible after the return deadline for nurse review and planning. Whenever possible, students should be encouraged to self‐carry inhalers, EpiPens, or pancreatic enzymes if the student is deemed appropriate to do so. Medications that cannot be self administered require a staff member trained in medication administration. Nurses must train staff to administer medications on field trips. Trained school board personnel must accompany a student needing medication on the bus. Those students should also be assigned to a trained person’s group while on the field trip. If medications need to be given while on a field trip, the same rules that govern medication administration in school will apply. All medications will be kept safely with the designated school board employee in their original container and label. It is not permissible to transfer medications to any other container for field trip use. It is acceptable to administer medication 1 hour early or 1 hour later if the student will be out of the building at the scheduled administration time. If given 1 hour early or 1 hour later due to a field trip, this should be noted on the medication card. Volunteers or parent chaperones who are not school board employees may NOT administer medications unless otherwise indicated below. Diabetic students: A nurse must attend the field trip for any diabetic student who requires insulin injection by a nurse or parent and whose parent is unable to attend the field trip. A nurse should also attend the field trip of any diabetic student who is very young, newly diagnosed, or otherwise unstable if the parent is unable to attend. Students who successfully self‐manage their diabetic care while at school will not need a nurse to attend, provided that the field trip teacher has received training on the signs and symptoms of hypo‐ and hyperglycemia and emergency diabetic care. 07/2012 SHS pg. 31 Single Day Field Trip A single day field trip refers to a field trip that both begins and ends within normal school hours. Only prescription medication will accompany students for single day field trips. •
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On the day of the field trip, the school nurse or designated school personnel will make a copy of the prescription medication card. 2 school board employees trained in medication administration will count the amount in the bottle, document that amount on the copy of the medication card, and both will sign. The original pharmacy bottle with label will then be transferred to the field trip teacher, along with the copy of the medication card. The original card is to remain at the school at all times. While on the field trip, a trained school board employee will give the medication at the appropriate time, amount and route. Documentation should occur immediately after administration. Upon return to school, the medication is to be returned to the clinic promptly. 2 trained school board employees will count the amount remaining, document that amount on the original medication card, and both will sign. The field trip documentation should be attached to the back of the original card. A notation should be made on the original card stating student attended a field trip on that particular day. 07/2012 SHS pg. 32 Extended Day/Multi‐Day Field Trip An extended day field trip refers to a field trip that begins before and/or extends after the normal duty day for school staff, but does not involve an overnight stay. A multi‐day field trip refers to a field trip that involves any overnight stay, regardless of the amount of overnights. General Guidelines: • No medications, either prescription or over the counter, can be given to a student without specific written physician orders and written parental consent. • No additional orders are required unless the student requires different medications or additional doses of medications other than those required in school. Medications such as these will require written orders and consent. • Parents are to provide all medications for extended or multi‐day field trip use in an original labeled pharmacy container with specific dosing instructions and times. Medications are not to come from the student’s school supply. It is recommended to supply only the doses required to cover the field trip. • Student must have a completed medication administration card on file with the school before the field trip begins. Only prescription medication will accompany students for extended day field trips. Both prescription and over the counter medications may accompany students for extended or multi‐day field trips. Extended Day Field Trips: • On the day of the field trip (or the day before if the trip is to begin before school hours), the school nurse or designated personnel will make a copy of the medication card. • 2 school board employees trained in medication administration will count the amount in the bottle, document that amount on the copy of the medication card, and both will sign. • The original pharmacy bottle with label will then be transferred to the field trip teacher, along with the copy of the medication card. The original card is to remain at the school. • While on the field trip, a trained school board employee will give the medication at the appropriate time, amount and route. Documentation should occur immediately after administration. • Upon return to school (or first thing next morning if the trip returns after school hours) the medication is to be returned to the clinic promptly. 2 trained school board employees will count the amount remaining, document that amount on the original medication card, and both will sign. • The field trip documentation should be attached to the back of the original card. • A notation should be made on the original card stating student attended a field trip on that particular day. 07/2012 SHS pg. 33 Multi‐Day Field Trip: • For prescription medications: ¾ Parent must complete prescription medication card including signature and date. ¾ Parent is to provide all medications – school is not to use the school’s supply. ¾ Prescription medications are to be brought to the school by the parent in the original labeled pharmacy container, following all guidelines for Delivery of Medications to School as outlined in Part B above. ¾ Medications are to be brought in 1 week before the field trip for the school nurse to review. ¾ The procedure then continues as outlined above under Extended Day Field Trips. ¾ The parent must pick up any remaining prescription medications at the end of the field trip, following the guidelines for sign‐out procedures as outlined in End of the Year Procedures in Part B above. Medication will not be sent home with a student regardless of age. • For over the counter medications: ¾ Parent and health care provider must complete the over the counter medication card, including all signatures and telephone numbers. ¾ Over the counter medications are to be brought to the school by the parent in the original unopened container with the student’s full name written on the box. Dosing and instructions on the box must be clearly visible. All guidelines as outlined in Part B: Delivery of Medications to School will be followed. ¾ Medications are to be brought in 1 week before the field trip for the school nurse to review. ¾ On the day of (or day before) the trip, the procedure continues as outlined above under Extended Day Field Trips EXCEPT that field trip teacher may transfer over the counter medications to the previously identified chaperone after the medications have been signed out of the school. Chaperones who are not school board employees may not sign out medications. ¾ The parent must pick up any remaining prescription medications at the end of the field trip, following the guidelines for sign‐out procedures as outlined in End of the Year Procedures in Part B above. Medication will not be sent home with a student, regardless of type of medication or age of the student. ¾ On multi‐day school sponsored field trips only, a parent may designate a chaperone who is not a school board employee to administer ONLY over the counter (OTC) medications to their student. This requires completion of PCSB form 2‐3084 (Optional Multi‐Day School Sponsored Field Trip Parental Permission for OTC Medication Administration to Student by Designee). In this instance, no paperwork from the health care provider is required. 07/2012 SHS pg. 34 PART G: MEDICATION ADMINISTRATION TECHNIQUES 07/2012 SHS pg. 35 General Guidelines •
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Respect the student’s individuality. Every student will want to take their medication a certain way. Learn what each student wants and accommodate as much as possible. Always safeguard the student’s confidentiality and privacy. Whenever possible, medications should be administered in the clinic. Medications can be given from 1 hour before to 1 hour after the scheduled time. For example, if a medication is scheduled at 12:00 pm, the student can take the medication anytime between 11:00 am and 1:00 pm. Optimally, the medication should be given at the scheduled time, but giving it within the 1 hour before or after window does not constitute a medication error. Follow all label directions and instructions carefully. Always wash your hands before and after administration. Training is required prior to any administration by non‐medical personnel. Be sure to tightly close all caps and lids to prevent contamination of the medication. Do not give any medication that is discolored or smells abnormal. Review all medication orders completely. 07/2012 SHS pg. 36 Oral Medication (tablets and capsules) GENERAL INFORMATION: • No tablet or capsule will be crushed at school unless approved in writing by the student’s health care provider. If a medication is to be crushed, the parent must provide both a pill crusher and the food to mix the crushed pill into. • If tablets are to be split in half, the parent must do this before bringing the medication to school. School board employees will not split pills. • If the student desires, capsules can be pulled apart with the contents mixed in soft food provided by the parent. Discard the empty capsule. • Always give oral medication while the student is sitting upright or standing. • If the student vomits after giving the medication, DO NOT REDOSE. Call the parent immediately. Document the vomiting and parent call on the medication card. • If the student refuses to take the medication, call the parent. Document the refusal and parent call on the medication card. SUPPLIES NEEDED: • Medication • Medicine cup • Water, unless otherwise indicated • Soft food for mixing, if needed PROCEDURE: 1. Wash hands. 2. Open medication bottle and pour the necessary number of pills into the medicine cup or bottle lid. 3. Assist the student in taking the medication, if necessary. 4. Follow the medication with water unless otherwise indicated on the order. 5. Recap the bottle. 6. Check the mouth to be certain the medication was swallowed. 7. Dispose of all used supplies. 8. Wash hands. 9. Document appropriately. 07/2012 SHS pg. 37 Oral Medication (liquid) GENERAL INFORMATION: • Always measure liquids into a calibrated hollow medication spoon, medicine cup or syringe and pour on a hard surface to keep it level. • If giving the medication via syringe, squirt the syringe between the cheek and the teeth to prevent choking. • Hold the bottle with the label facing up so any spilled liquid doesn’t obscure any printed information. • Wash the measuring device after each use with soap and water, and air dry. • If the student vomits after giving the medication, DO NOT REDOSE. Call the parent immediately. Document the vomiting and parent call on the medication card. • If the student refuses to take the medication, call the parent. Document the refusal and parent call on the medication card. MEASURING SPOON METRIC EQUIVALENT ¼ teaspoon 1 ¼ cc or mL ½ teaspoon 2 ½ cc or mL ¾ teaspoon 3 ¾ cc or mL 1 teaspoon 5 cc or mL 1 Tablespoon 15 cc or mL 1 ounce 30 cc or mL SUPPLIES NEEDED: • Medication • Approved measuring device • Paper towel • Water, unless otherwise indicated PROCEDURE: 1. Wash hands. 2. If indicated, shake the bottle to mix contents. 3. Pour the liquid into the approved measuring device. 4. Give the medication to the student. 5. Follow the medication with water unless otherwise indicated. 6. Wipe the bottle lip with paper towel before replacing the cap. 7. Dispose of all used supplies. 8. Wash hands. 9. Document appropriately. 07/2012 SHS pg. 38 Metered Dose Inhaler GENERAL INFORMATION: • A metered dose inhaler (MDI) is used to deliver a number of common asthma medications that help open the airway and ease breathing. • Young children who have trouble using an MDI correctly may use a spacer. • Older students may carry and self administer their inhaler only if there is an authorization form signed by the parent and health care provider on file at the school. • Review the medication order carefully to know how many puffs the student requires. • Wash the mouthpiece after each use and air dry thoroughly. • If it has been more than 2 weeks since the MDI was last used, prime the canister by squirting 2 puffs into the air. • If the student refuses to take the medication, call the parent. Document the refusal and parent call on the medication card. SUPPLIES NEEDED: • Cartridge containing the medication • Mouthpiece • Spacer, if indicated PROCEDURE WITHOUT A SPACER: 1. Wash hands. 2. Remove the cap and look to see that nothing is blocking the mouthpiece. 3. Hold the inhaler upright with the mouthpiece at the bottom and shake it. Place the index finger on the top of the metal canister and thumb on the bottom of the plastic mouthpiece. Prime the inhaler if needed. 4. Tilt the student’s head back slightly, and instruct the student to breathe out completely. 5. Place the inhaler in the student’s mouth and have the student close their lips around the mouthpiece. 6. Press down on the inhaler as soon as the student starts to breathe in. 7. Student should breathe in slowly and steadily over 3 to 5 seconds. 8. Have the student hold their breath for 10 seconds to allow the medication to settle into the lungs. 9. Student should breathe out slowly. 10. Wait 1 minute and repeat steps 3‐9 for each puff ordered. 11. Replace the cap. 12. Rinse the mouth with water after use. 13. Wash hands. 14. Document appropriately. 07/2012 SHS pg. 39 PROCEDURE WITH A SPACER: 1. Wash hands. 2. Remove caps from MDI and spacer device. 3. Shake inhaler. Prime the inhaler if needed. 4. Insert the inhaler into the open end of the spacer, opposite the mouthpiece. 5. Student should breathe out completely. 6. Place mouthpiece of spacer between the teeth and have student seal lips tightly around it; OR hold the mask gently over the nose and mouth with no gaps between the mask and the skin. Instruct the student to keep the chin up. 7. Press the canister to release the medication. The medication will be trapped in the spacer. 8. Instruct the student to breathe in as slowly and as deeply as possible. 9. Remove the spacer from the mouth and have student hold their breath for 10 seconds; OR if using a mask have the student breathe in and out normally for 20 seconds. 10. Wait 1 minute and repeat steps 3‐9 for each puff ordered. 11. Replace the caps on the MDI and spacer. 12. Rinse the mouth with water after use. 13. Wash hands. 14. Document appropriately. 07/2012 SHS pg. 40 Nebulizer Medication GENERAL INFORMATION: • A nebulizer turns liquid asthma medication into a mist for easy inhalation. • It takes approximately 10‐15 minutes to complete a nebulizer treatment. • The air filter on the nebulizer machine should be cleaned as necessary and air dried. • Clean the medication container and mouthpiece/mask with soap and water and air dry. There is no need to clean the connection tubing. Do not use any parts that are cracked, broken or grossly discolored. • Each student must have their own tubing, medication container and mouthpiece/mask clearly labeled and individually stored. • If the student refuses to take the medication, call the parent. Document the refusal and parent call on the medication card. SUPPLIES NEEDED: • Nebulizer machine • Nebulizer parts: connection tubing, medication container and mouthpiece/face mask • Liquid medication • Saline (if necessary) PROCEDURE: 1. Wash hands. 2. Plug in the nebulizer machine. Make sure the air filter is clean. 3. Attach the connection tubing from the machine to the bottom of the medication container. 4. Place the medication (and saline, if needed) into the nebulizer medication container. Screw the top on tightly. 5. Connect the medication container to the mouthpiece or mask. 6. Have the student place the mouthpiece between the teeth, or fit the mask over the student’s face. 7. Turn on the machine. 8. Keep the medication container upright or it will not mist. Encourage the student to breathe slowly and deeply. Towards the end of the treatment, you may need to tap the sides of the medication container so all of the medication becomes nebulized. 9. The administration is over when all of the medication is gone or when no more mist comes out. 10. Wash hands. 11. Document appropriately. 07/2012 SHS pg. 41 Eye Medication GENERAL INFORMATION: • Eye drops and ointments are administered on the lower lid, NOT directly to the eye itself. This avoids contamination of the eye or the container. • If the student is willing and able to administer their own eye drops, he or she should be allowed to do so with supervision. • Do not administer eye medication if the student is crying. • Review the medication order carefully, as many times only one eye needs to be medicated. • If the student refuses to take the medication, call the parent. Document the refusal and parent call on the medication card. SUPPLIES NEEDED: • Gloves • Eye medication • Clean tissue or cotton ball PROCEDURE: 1. Wash hands. 2. Put on gloves. 3. Remove any eye discharge with a clean tissue or warm water. Use a clean tissue for each eye. 4. Have the student lie down with their head extended over a pillow or blanket roll, or sit with the head tilted back and looking upwards. 5. Gently pull down on the lower lid to create a pocket. 6. Place the hand holding the medication on the student’s cheek or forehead to stabilize as needed. 7. Give the dose as specified on the prescription. If the medication is an ointment, apply a thin line of ointment evenly along the length of the lower eyelid. 8. Have the student gently close the eye and count to 10, looking in all directions to distribute the medication. 9. Wipe any excess medication from around the eye with a clean tissue or cotton ball. 10. Repeat on the other eye, if necessary. 11. Replace the dropper or cap. Never rinse the eyedropper. 12. Dispose of all used supplies. 13. Remove gloves and wash hands. 14. Document appropriately. 07/2012 SHS pg. 42 Nasal Medication GENERAL INFORMATION: • Nasal medication can include a nasal inhaler, nose drops or nasal spray. • Student must be observed closely for choking, as nasal medication has the potential to enter the throat. • If in dropper form, do not allow the dropper to touch the inside of the nose. Rinse the dropper thoroughly between uses and allow to air dry. • Review the medication order carefully to verify which nostril requires the medication. • If the student refuses to take the medication, call the parent. Document the refusal and parent call on the medication card. SUPPLIES NEEDED: • Gloves • Clean tissue • Medication • Dropper (if needed) PROCEDURE: 1. Wash hands. 2. Put on gloves. 3. Ask student to blow their nose. 4. Have the student lie down with their head hyper extended over a pillow or blanket roll, unless medication is a nasal inhaler. Student must be upright for inhaler use. 5. Administer the medication. ¾ For a nasal inhaler, insert the inhaler into one nostril while gently pressing the other nostril closed. Shake the inhaler between uses. ¾ For a nasal spray or drops, follow the manufacturer directions for use. 6. The student should breathe normally for 1 minute while remaining on their back. 7. Replace any cap or lid. 8. Dispose of all used supplies. 9. Remove gloves and wash hands. 10. Document appropriately. 07/2012 SHS pg. 43 Ear Medication GENERAL INFORMATION: • Hold the bottle in hands to warm the contents before use. This will decrease pain and dizziness. • Always position the student with the ear to be medicated pointing upwards. • Review the medication order carefully, as many times only one ear needs to be medicated. • If the student refuses to take the medication, call the parent. Document the refusal and parent call on the medication card. SUPPLIES NEEDED: • Gloves • Clean tissue or cotton ball • Medication PROCEDURE: 1. Wash hands. 2. Put on gloves. 3. Have the student lie down or tilt the head so the affected ear is facing up. 4. Use a clean tissue or cotton ball to remove any drainage present on the outer ear. 5. If the drops are a “suspension” (have a cloudy appearance), shake the bottle gently. If the drops are a “solution” (have a clear appearance), give without shaking. 6. Place the wrist holding the medication on the student’s cheek or head to stabilize as needed. 7. For a child (up to teenaged), gently pull the earlobe down and back to help straighten out the ear canal. For an adult (teenager and older), pull the earlobe up and out. 8. Give the dose as specified on the prescription by squeezing the bottle the required number of times. 9. Gently massage the area in front of the ear to help the medication enter the canal. 10. Keep the student on their side with the ear pointed upward for 5 minutes to prevent loss of medication. 11. After 5 minutes, repeat on the other ear if necessary. 12. Replace the cap. 13. Dispose of all used supplies. 14. Remove gloves and wash hands. 15. Document appropriately. 07/2012 SHS pg. 44 Topical Medication GENERAL INFORMATION: • Never use your fingers to apply topical medication. Always use cotton tipped applicators, a tongue depressor or clean gauze to apply. Use a new applicator for each area. • Avoid touching the students eyes or lips with the medication. • Stress the importance of hand washing to the student. • If the student refuses to take the medication, call the parent. Document the refusal and parent call on the medication card. SUPPLIES NEEDED: • Gloves • Soap and water (if necessary) • Medication • Cotton tipped applicators, tongue depressor or gauze • Bandage or gauze to cover the wound, if necessary PROCEDURE: 1. Wash hands. 2. Put on gloves. 3. Clean the area with soap and water if needed. Pat dry. 4. Apply the medication in a thin, even layer using a cotton tipped applicator, tongue depressor or clean gauze. 5. Cover the area with gauze or a bandage, if ordered. 6. Dispose of all used supplies. 7. Remove gloves and wash hands. 8. Document appropriately. 07/2012 SHS pg. 45 Medications via Gastrostomy Tube GENERAL INFORMATION: • Requires individualized training of CNAs before administration. • Students unable to take medication by mouth may receive them via gastrostomy tube. • Student should be positioned in a sitting or semi‐reclined position. • If the tablet must be crushed, it should be dissolved in 30cc of water. • Do not crush enteric‐coated or sustained/extended release tablets. These medications will require a liquid substitute. • If the student refuses to take the medication, call the parent. Document the refusal and parent call on the medication card. SUPPLIES NEEDED: • Gloves • Medical tape, if necessary • Liquid medication or finely crushed pills dissolved in water in an appropriate syringe • Extension tubing, if necessary • 50‐60cc warm water (or per health care provider order) in a 60cc oral, enteric, or catheter‐tipped syringe PROCEDURE: 1. Wash hands. 2. Put on gloves. 3. If needed, resecure any tape securing the gastrostomy tube. 4. Verify that all ports are closed to ensure an airtight seal. 5. Verify tube placement by attaching a syringe to the port and lowering the syringe to verify stomach contents. 6. Verify tube patency by flushing with 30cc of water. If the tube is blocked, call the parent immediately. Do not attempt to force the liquid into the tube. 7. Draw up the required amount of liquid medication into an appropriate syringe, or crush the tablet and add to 30cc water to dissolve. 8. Attach the medication syringe to a port on the tubing. Ensure an air tight connection. 9. Administer the medication by gravity. May need gentle pressure with the syringe plunger to start the flow. 10. Flush immediately with 20‐30cc of warm water (or per physician order) to clear the tube. 11. Disconnect the extension tubing if needed. Rinse the tubing with water and air dry completely. 12. Dispose of all used supplies. 13. Remove gloves and wash hands. 14. Document appropriately. 07/2012 SHS pg. 46 Rectal Medication (suppository) GENERAL INFORMATION: • Be certain that the person inserting the suppository does not have a long fingernail on the finger used for insertion. • Position the student on the left side with the lower leg straight and upper leg bent forward toward the stomach. • If the order requires a ½ suppository, the parent must cut before bringing to school. • If the student refuses to take the medication, call the parent. Document the refusal and parent call on the medication card. SUPPLIES NEEDED: • Gloves • Suppository • Water or a water soluble lubricant PROCEDURE: 1. Wash hands. 2. Put on gloves. 3. If the suppository is soft, hold under cool water or place in the refrigerator for a few minutes to harden it. 4. Remove the wrapper. 5. Wet the suppository with a water‐soluble lubricant (NOT petroleum jelly) or water. 6. Remove the student’s undergarments and position properly. 7. Lift the upper buttock to expose the rectal area. 8. Insert the suppository, pointed end first, with the finger about 1 inch into the rectum. Do not go further than the first joint in your finger. The suppository must pass beyond the rectal sphincter or it will pop out. 9. Hold the buttocks together for 10 seconds. 10. The student should remain lying down for 5 minutes to avoid having the suppository come out. 11. Dispose of all used supplies. 12. Remove gloves. Assist the student with dressing. 13. Wash hands. 14. Document appropriately. 07/2012 SHS pg. 47 PART H: EMERGENCY MEDICATIONS 07/2012 SHS pg. 48 Anaphylaxis WHAT IS ANAPHYLAXIS? Anaphylaxis is a life‐threatening allergic reaction that can occur quickly (as fast as within a couple of minutes). Symptoms of anaphylaxis vary, but include reactions in many different body systems. Anaphylaxis can be caused by a number of triggers, including but not limited to certain foods, stinging and biting insects, medications, and latex. If someone you're caring for shows signs or symptoms of anaphylaxis, inject the health care professional‐prescribed EpiPen or EpiPen Jr. immediately, then promptly call 911 and seek immediate medical attention. Failure to inject the EpiPen at the first signs of anaphylaxis can be life threatening. COMMON CAUSES OF ANAPHYLAXIS: • Stingers and bites: bees, hornets, yellow jackets, wasps, fire ants • Foods: peanuts, tree nuts (walnuts, pecans), fish, shellfish, cow’s milk, eggs, soy • Drugs: antibiotics, especially penicillin; some non‐steroidal anti‐inflammatory drugs (NSAIDs) • Latex: can be found in art supplies, balloons, balls, bandages, chewing gum, disposable diapers, disposable gloves, elastic in clothing, glue, rubber bands, plastic storage bags SYMPTOMS OF ANAPHYLAXIS: • Skin reaction: hives, itching, flushing, swelling of the lips and tongue • Airway reaction: itching and tightness in the throat, hoarseness, difficulty breathing, chest tightness, wheezing, coughing • Gastrointestinal reaction: nausea, vomiting, diarrhea, cramping, abdominal pain • Cardiovascular reaction: chest pain, rapid heart rate, dizziness, fainting • Nervous system reaction: uneasiness or impending feeling of doom, headache, dizziness, confusion *** IF NO EPIPEN AUTO‐INJECTOR IS AVAILABLE, CALL 911 IMMEDIATELY, THEN THE PARENT, AND GIVE EMERGENCY SUPPORTIVE CARE. *** 07/2012 SHS pg. 49 How to Use an EpiPen GENERAL INFORMATION: • EpiPen is used to treat anaphylaxis and prevent anaphylactic shock. • Anaphylaxis usually occurs within seconds or minutes after a hypersensitive person is exposed to an allergen. It is possible that a delayed reaction may occur up to 24 hours later. • Activate EMS as soon as possible based on an assessment of the student’s situation. • The student MUST be transported to the hospital for further medical attention. • NEVER put thumb, fingers or hand over the orange tip. • NEVER press or push the orange tip with thumb, fingers or hand. The needle comes out of the orange tip. SUPPLIES NEEDED: • EpiPen auto‐injector PROCEDURE: 1. Assess student for symptoms. 2. CALL 911. 3. Remove the EpiPen from the carrier tube by flipping open the cap. 4. Grasp the EpiPen in fist with the orange tip pointing down. 5. Using the other hand, pull off the blue safety release. 6. Hold the orange tip near the outer thigh. DO NOT INJECT INTO THE BUTTOCK. 7. Swing and firmly push against the outer thigh until the unit clicks. The EpiPen should be perpendicular to the thigh. It is designed to work through clothing, including jeans. 8. Hold the EpiPen against the thigh for 10 seconds to allow for complete drug delivery. 9. Remove the EpiPen from the thigh. The orange cover will extend to cover the needle. 10. Massage the injection area for 10 seconds. 11. Place the used EpiPen in a plastic bag to give to EMS upon arrival. 12. Call the parent. 13. Remain with the student until EMS arrives. Copy the Student Clinic Card for EMS use. 14. Dispose of all used supplies. 15. Wash hands. 16. Document appropriately. 17. Inform the school nurse of the incident. The school nurse will obtain a new EpiPen and authorization form from the parent. 07/2012 SHS pg. 50 07/2012 SHS pg. 51 07/2012 SHS pg. 52 07/2012 SHS pg. 53 Diastat (Diazepam rectal gel) GENERAL INFORMATION: • Diastat is used to treat prolonged seizure activity. • Review the order carefully to understand how long the student must be seizing before administering Diastat. • Activate EMS as soon as possible. • If Diastat is administered, the student MUST be transported to the hospital. • Remove all other students from the surrounding area. • Respect the student’s privacy as much as possible. SUPPLIES NEEDED: • Gloves • Lubricant • Medication in a pre‐filled locked syringe PROCEDURE: 1. CALL 911. 2. Wash hands. 3. Put on gloves. 4. Position the student on left side and remove undergarments. Extend the student’s lower leg and bend the upper leg toward the stomach. 5. Push up with thumb and pull to remove the cap from Diastat. 6. Lubricate the tip with the lubricating jelly. 7. Separate buttocks to expose the rectum. 8. Gently insert the syringe tip into the rectum. The rim should be snug against the rectum. 9. Slowly count to 3 while gently pushing the plunger until it stops. 10. Slowly count to 3 before removing the syringe. 11. Slowly count to 3 while holding the buttocks together. 12. Dispose of the syringe and redress the student. Diastat container may be thrown into the trash, or can be given to EMS upon arrival. 13. Remove gloves and wash hands. 14. Keep student on their side and remain with them until EMS arrives. Copy the Student Clinic Card for EMS use. 15. Document appropriately. 16. Notify the school nurse of the incident. The school nurse will obtain a new Diastat and authorization form from the parent. 07/2012 SHS pg. 54 Glucagon 07/2012 SHS pg. 55 GENERAL INFORMATION: • Glucagon is given to counteract severe hypoglycemia (low blood sugar). • Act quickly. Prolonged unconsciousness may be harmful. • Activate EMS as soon as possible based on an assessment of the situation. • Student MUST be transported to the hospital for further medication attention. • Turn the student on his/her side to prevent choking, as glucagon may cause vomiting. • The contents of the syringe are inactive. The contents of the syringe must be mixed with the contents of the bottle. • Do not prepare glucagon until ready to use. • Give glucagon if: ¾ Student is unconscious ¾ Student is unable to eat food containing fast‐acting sugar ¾ Student is having a seizure ¾ Repeated administration of food containing fast‐acting sugar products (regular soft drink, fruit juice) does not improve the student’s condition • Review the medication order carefully to be certain how much Glucagon to give SUPPLIES NEEDED: • Gloves • Glucagon kit • Alcohol wipes PROCEDURE: 1. Wash hands. 2. Put on gloves. 3. Remove the flip‐off seal from the glucagon bottle. 4. Wipe the rubber stopper on the bottle with an alcohol wipe. 5. Remove the needle cover from the syringe. 6. Inject the entire syringe into the glucagon bottle. Remove the syringe from bottle. 7. Swirl the bottle gently until the Glucagon dissolves. DO NOT USE THE SOLUTION UNLESS IT IS CLEAR WITH A WATER‐LIKE CONSISTENCY. 8. Using the same syringe, hold the bottle upside down and gently withdraw all of the solution from the bottle. 9. Cleanse the area for injection with an alcohol wipe. Glucagon should be injected into a large muscle in the buttocks, thigh or arm. 10. Insert the needle into the loose skin and inject all of the glucagon solution. THERE IS NO DANGER OF OVERDOSE. 11. Withdraw the needle and press an alcohol swab against the skin. 12. Glucagon should awaken the student within 15 minutes. 07/2012 SHS pg. 56 13. Dispose of the needle into a sharps container. DO NOT RECAP THE NEEDLE. 14. Remain with the student until EMS arrives. Copy the Student Clinic Card for EMS use. 15. Dispose of all used supplies. 16. Wash hands. 17. Document appropriately. 18. Notify the school nurse of the incident. The school nurse will obtain a new Glucagon kit from the parent. 07/2012 SHS pg. 57 References The 2011 Florida Statutes. http://www.leg.state.fl.us/Statutes/ American Academy of Pediatrics Policy Statement: Guidelines for the Administration of Medication in School. http://pediatrics.aappublications.org/content/124/4/1244.full.pdf+html?sid=26a5958e‐48db‐
4511‐832a‐50ed1108d045 Florida Department of Health: Nursing Guidelines for the Delegation of Care for Student with Diabetes in Florida Schools 2003. http://www.doh.state.fl.us/family/school/reports/DiabetesGuidelines2003.pdf Florida Department of Health: School Health Administrative Guidelines. April 2007. http://www.doh.state.fl.us/family/school/attachments/sh_index.htm#Administrative%20Guide
lines http://justnebulizers.com/caring‐for‐your‐nebulizer http://pi.lilly.com/us/rglucagon‐ppi.pdf http://wps.prenhall.com/chet_wilson_drugguides_1/6/1576/403558.cw/index.html http://www.aafa.org/display.cfm?id=8&sub=16&cont=57 http://www.diastat.com http://www.drugs.com/cg/how‐to‐use‐a‐nebulizer.html http://www.epipen.com http://www.mayoclinic.com/health/anaphylaxis/ds00009/desection=causes http://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000006.htm http://www.nursingtimes.net/nursing‐practice‐clinical‐research/the‐administration‐of‐drugs‐
via‐enteral‐feeding‐tubes/205180.article http://www.safemedication.com/safemed/MedicationTipsTools/HowtoAdminister/HowtoUseR
ectalSuppositoriesProperly.aspx 07/2012 SHS pg. 58 Johnson, Philip E., J. Michael Hayes, Vera Farkas Reinstein, Steven M. Simmons, and Jean Benson. Medication Use in Schools. Florida Society of Health‐System Pharmacists: 2003. National Association of School Nurses Position Statement: Medication Administration in the School Setting. http://www.nasn.org/PolicyAdvocacy/PositionPapersandReports/NASNPositionStatementsFull
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