HEALTH CARE PROCEDURES & FORMS
TABLE OF CONTENTS
ORAL FEEDING & HYDRATION
LIFTING & TRANSFERRING
Introduction
General Guidelines and General Techniques of Proper Body Mechanics
AMBULATION DEVICES & BRACES
Introduction
Canes Crutches Walkers Braces & Splints
Trunk Supports & Scoliosis Braces
GASTROINTESTIONAL SYSTEM
Structure & Function
Gastrostomy Feeding
Gastrostomy Tubes: Care & Reinsertion
Colostomy & Ileostomy Care: Changing Pouch and Emptying Pouch
Urostomy Care
CIRCULATORY SYSTEM
Structure & Function
Long Term Cardiac/Venous Catheters
RESPIRATORY SYSTEM
Structure & Function
Use of Peak Flow Meter
Postural Drainage
Pulse Oximetry
Oxygen Administration and Oxygen Safety Precautions
Tracheotomy Care
Emergency Tracheotomy Replacement
Tracheostomy Suctioning with Bulb
Tracheostomy Suctioning with Machine
SEIZURE MANAGEMENT
ENDOCRINE SYSTEM
Glucose Monitoring
URINARY SYSTEM
Structure & Function
Clean Intermittent Catheterization
Peritoneal Dialysis (CAPD)
ORAL FEEDING
Students gain a great deal of independence if they can feed themselves, and it is important to
encourage then to learn how. Students with complex medical needs have the same nutritional
needs as other students. If the student demonstrates feeding problems, check doctor’s orders
and physical, occupational and speech therapist’s recommendations.
Note: A student should never be force-fed by any school personnel. All personnel involved in
feeding should be trained in the use of abdominal thrusts.
MAINTAINING ADEQUATE HYDRATION
PURPOSE
To maintain adequate hydration in students at risk for fluid imbalance (i.e., students with oral
motor dysfunction, frequent vomiting or diarrhea), to prevent dehydration, to prevent fluid
retention, to replace fluid loss (i.e. students with fevers, excessive sweating, increased
exercise).
PREPARATION
Explain procedure to student using appropriate developmental approach.
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Wash hands and assemble equipment
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Adaptive drinking devices (if indicated)
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Intake and output log (if indicated)
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Measuring containers (if strict intake and output is necessary)
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Scales and growth charts
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Penlight and tongue blade
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Blood pressure cuff and stethoscope
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Gloves, as needed
PROCEDURE
1. Assess hydration status on a regular basis for those students at risk. Measure weight on
a regular basis, same day of the week, same time of day, with voiding and consistent
dress. Use growth chart to plot curve.
2. Observe for signs of dehydration: e.g., thirst, dry mouth, decreased urinary output, poor
skin turgor, fatigue, weakness, lethargy, numbness, tingling in the extremities, confusion
and shock.
3. Observe for signs of fluid retention: e. g., edema, increased blood pressure, increased
weight, reduced urinary output, and bloated appearance.
4. Notify student’s parent/guardian of altered hydration status.
5. Assist student with drinking if necessary.
6. Allows the student to go to the water fountain on a regular basis.
7. Advise all staff working with student to follow the regime.
8. If intake and output (I&O) are needed due to risk of fluid imbalance or if ordered by physician, chart eating, drinking and output on intake and output log. Advise and instruct all
staff working with the student regarding the intake and output procedure. Show how to
use, record and measure (I&O).
9. Document date, time, what was done and why, and the student’s condition.
10. Offer fluids on a regular basis and encourage adequate hydration status.
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LIFTING AND TRANSFERRING
INTRODUCTION
This section is offered to acquaint school personnel with basic techniques to follow when
changing the position of a student who is unable to sit, stand, or walk without the assistance of
an adult. Before lifting, carrying, or transferring a disabled child, it is recommended that the
personnel involved participate in a practice session where a professional, such as a physical
therapist, demonstrated the correct technique and procedures.
GENERAL GUIDELINES
1. Never try to lift, carry, or transfer a student alone who is too heavy or difficult to manage.
Seek additional assistance.
2. If two adults are moving a student, always discuss and plan the exact movements before
beginning the procedure.
3. Explain the procedure to the child and encourage his/her to assist as much as possible.
4. The equipment involved must be positioned properly and securely and as close to the
student as possible. When a wheelchair is used, the brakes must be locked and the
footrests lifted or removed.
5. Avoid quick movements, since the student’s spastic muscles may tense and he/she may
become frightened.
6. Never forcibly bend or straighten a student’s limbs when moving them about.
GENERAL TECHNIQUES FOR PROPER BODY MECHANICS
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Test the weight load to be lifted before actually lifting it.
Be as close to the student as possible.
Bend at knees while lifting, not at the waist.
Keep the back straight.
Do not lift quickly or with jerky movements.
Do not lift higher than the waist.
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AMBULATION DEVICES AND BRACES
INTRODUCTION
This section will orient the reader to devices and braces used to facilitate mobility or stabilize
muscles and joints of the disabled student.
CANES
Canes are used by students with balance deficits, pain, injury, or weakness on one side of the
body.
Types of canes
• Straight cane
• Quadri-ped cane (Four-legged cane)
• Walkerette cane (Hemi-cane)
Special considerations for school staff:
• Proper height of cane is established by physical therapist or orthotist.
• When one cane is used, it is held in the hand opposite the involved leg. It is advanced as
the involved leg is advanced.
• Two canes are used for additional support.
CRUTCHES
Types of crutches
These ambulation devices offer more support and stability than do canes. Different types of
crutches can be chosen for use with paralysis or weakness in the limbs, for balance deficits or
for problems with coordination.
Special considerations for school staff:
• Proper fit of crutches is established by physical therapist or orthotist.
• Underarm crutches that are too long can cause damage to the nerves in the underarm
area (brachial plexus) which may result in paralysis of arm muscles.
• Special accessories can be added to crutches, such as special tips to prevent slipping,
tote bags, and foam pads on the underarm or grip bars.
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AMBULATION DEVICES AND BRACES (continued)
WALKERS
These devices offer even more stability than do canes or crutches and require less skill or balance to use.
Types of walkers
• Standard walker is a rigid device with four walker tips.
• Mobile walker has wheels on the legs with four wheeled legs.
• Rollator walker had wheels in two legs and tips on the other two for speed control.
Special considerations for school staff:
• A professional should be consulted when selecting a walker.
• The height of the walker should be established by the physical therapist or orthotist.
It should be level with the hips, with the elbows only slightly bent (30 degrees) when
holding the handles. Special accessories can be added to walkers, such as solid
seats, sling seats supports, hand breaks, padded trunk supports, forearm rests or
grip supports.
BRACES AND SPLINTS
These are always prescribes by a physician and fitted by an orthotist or physical therapist. They
are used to provide support to weak muscles/joints, control involuntary movements or to prevent
or correct deformity.
Types of leg braces
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Short leg brace (SLB) is used primarily to keep the ankle/foot in good alignment. Also
called AFO or DAFO Brace.
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Long leg brace (LLB) provides proper alignment of the leg, including the knee, and more
leg control. Also called KAFO brace.
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Rotator cables are used to control internal and external rotation of the leg often attached
to short leg or AFO brace.
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Full complement of bracing is used when full leg control is needed, including hip stability.
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May be further connected to body jacket for trunk control. Also called HKAFO brace or
standing brace.
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Reciprocating gait brace (RGO) is a specialized walking brace with a system of wire
cables attached.
11/11
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AMBULATION DEVICES AND BRACES (continued)
BRACES AND SPLINTS(continued)
Types of splints
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Resting leg splints are used for maintaining good alignment of the leg and preventing
contractures.
Arm splints are used for good alignment, to prevent contractures of the wrist/hand
and to assist with hand/wrist function
Special considerations for school staff:
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All adjustments to braces or splints are made by the physician, the orthotist or the
physical or occupational therapist. Braces on young children require frequent
adjustment due to growth.
The skin under braces and splints should be checked daily unless otherwise ordered by
the physician.
Pressure sores and reddened areas often occur when braces or splints are first worn.
Common pressure points include all bony areas, such as heel, ankle, or wrist. Foam
cushions may be used over these areas.
Monitor students with paralysis or decreased skin sensations (i.e. spina bifida students)
more closely.
If marked reddened areas or blisters are noted, remove braces and restrict mobility.
Notify school nurse, teacher or parent of the problem.
Braces should never be applied over open or reddened areas.
Initial instruction for putting braces on or taking off should be provided by the physical or
occupational therapist.
Place foot into brace first (with knee bent), being sure heel is down before securing
ankle straps. Then go up leg, as needed, to secure calf straps, thigh straps, pelvic belts,
etc.
All straps are to be secured snugly but not excessively tightly.
Make sure toes are straight before putting shoes on.
Avoid wrinkles in the socks under the braces
Locks at the knees and hips must be fastened when student is standing and
unlocked when student sits, unless otherwise directed.
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AMBULATION DEVICES AND BRACES (continued)
TRUNK SUPPORTS AND SCOLIOSIS BRACES
These are always prescribed be the physician and fitted by the orthotist. They help support the
trunk and maintain/improve the alignment of the spinal column.
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Cloth corset is used primarily to offer trunk support to a weak student but allows him to
use any muscle strength he has.
• Molded body jacket offers the most support. It provides constant pressure to the trunk
so a spinal curvature can be corrected or prevented from worsening.
• “Milwaukee brace” is a molded trunk support using cervical and pelvic pressure
• An undershirt, preferably all cotton material, should be worn under the trunk
support/brace to prevent skin irritation and to absorb perspiration.
• The more supportive a brace, the hotter it is to wear. If air holes are drilled in the
molded support¸ it will be cooler but will weaken the jacket. The decision to drill holes or
not is made by the physician or the orthotist.
• The emotional aspects of wearing a trunk support/brace, especially if it is visible, as in
Milwaukee brace, can be difficult to deal with for the young adolescent female, the student will
need patience and support from the family and friends.
Application of trunk support or brace- General Principles
1. Initial instruction for putting the support/brace on or taking it off should be given by the
orthotist or physical therapist.
2. Most trunk supports are applied with the student lying flat.
3. Always apply an undershirt before applying the brace
4. Avoid direct pressure on boney prominences.
5. Never apply over open or reddened areas.
6. Straps should be secured snugly but not excessively tightly, starting, starting at the
bottom of the support/brace and working upwards.
7. If the student complains that the brace does not feel right once applied, take it off and
reapply. points which keeps the spine in alignment from bottom to top.
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GASTROINTESTINAL SYSTEM
Structure and Function:
Structure:
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The upper gastrointestinal tract is where digestion and absorption of most nutrients occurs. The mouth, throat, esophagus, stomach and small intestine are components of this
part of the digestive tract.
The gastrointestinal system breaks down food into basic nutrients that can feed the cells
of the body. Functionally, the gastrointestinal tract is divided into two parts-upper and
lower.
The mouth is where processing of food starts. Chewing is important because digestion
is more effective with smaller particles. The food is swallowed and passes through the
throat, then through the esophagus.
The esophagus is a straight tube about ten inches in length. It descends from the base
of the throat behind the trachea to the stomach.
The stomach is a curved pouch-like organ that is located under the diaphragm in the
upper left portion the abdomen. The stomach partially digests food and regulates passage of food to the rest of the gastrointestinal tract.
The small intestine is approximately 12 feet long. The duodenum, jejunum, and ileum
are parts of the small intestine. Food passes from the stomach through the small intestine, where most digestion and absorption of nutrients takes place.
The lower gastrointestinal tract consists of the large intestine. This is where water is
reabsorbed and undigested food is consolidated into fecal waste.
The large intestine extends from the end of the small intestine to the rectum. The anus
is the opening to the outside of the body.
Function:
Digestion takes place in two ways:
 Mechanical: chewing and stomach contractions break down food.
 Chemical: food is broken down by digestive acids and enzymes.
The digestive food is absorbed through the lining of the intestine and then enters the
bloodstream where it is carried to the cells.
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GASTROSTOMY FEEDING
Individualized training required prior to performance by Certified Nursing Assistant
PURPOSE:
To provide nourishment to students who are unable to maintain adequate nutrition by mouth.
PREPARATION:
Explain procedure to student to student using appropriate developmental approach
Wash hands and assemble equipment.
Room temperature formula, juice and/or water
Large syringe
Extension tubing, if needed
Measuring cup
Clamp or foley cap, if needed
Gloves
PROCEDURE:
Verify physician’s order regarding type, amount and schedule of feeding.
1. Put on gloves.
2. Position student in an upright or semi-reclining position to prevent aspiration, if
regurgitated.
3. Check for tube placement by injecting with 10ml air and auscultating with a stethoscope
over the umbilicus for an “air rush” (gurgling sound).
4. If unable to verify placement, or if tube appears to be blocked, notify the school nurse
and parent/guardian.
5. Pour liquid into syringe. Allow to flow by gravity over 20-30 minutes. Do not use force or
pressure. Do not let syringe run dry.
6. Irrigate the tube with (30-)50cc room temperature water
7. Clamp tube to avoid introducing extra air into stomach.
8. Maintain student’s position for at least 30 minutes after feeding to prevent regurgitation.
9. Remove gloves
10. Document date, time, type, amount of formula, and student’s response on
Nurse Treatment/Procedure Service Record.
NOTE: Refrigerate any remaining formula. Discard any opened formula after 24 hours.
11/11
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GASTROSTOMY TUBES CARE & REINSERTION
and MIC-KEY BUTTON and PEG CARE
Individualized training required prior to performance by Certified Nursing Assistant
for cleaning stoma site only.
PURPOSE:
To provide the RN/LPN with guidelines to provide care to the Mic-Key Button, PEG or
gastrostomy tube site and reinsert a dislodged Mic-Key Button or gastrostomy tube.
PREPARATION:
 Explain procedure to student using appropriate developmental approach.
 Wash hands
 Assemble equipment:
I.
Cleaning stoma site:
 sterile water
 cotton-tip applicators
 tape
 gloves
II.
Reinsertion of Mic-Key Button or G-tube
 Foley catheter with 5cc balloon (same size as previous catheter)
 Water-soluble lubricant
 5cc syringe with sterile water
 Catheter tip syringe
 Catheter tip plug
 Paper or hypoallergenic adhesive tape
 gloves
PROCEDURE:
 Check physician orders for site care and reinsertion
I. Cleaning Mic-Key Button, PEG or G –tube site:
1. Put on gloves
2. Document date, time, rationale for procedure and condition of skin on
Nursing Treatment/Procedure Service Record.
3. Clean area around tube with soap and water using sterile cotton-tip
applicators. BUTTON:-Same procedure, adding rotation of button 360
degrees with each cleaning. PEG:-Same procedure, adding the lifting
of wings to clean and dry.
II. Emergency Reinsertion of Mic-Key Button or G-tube:
1. Position student on right side to give easy access to G-tube site.
2. Apply water-soluble lubricant to the tip of catheter.
3. Gently insert catheter into stoma about 2”.
4. Check placement by aspirating stomach contents with catheter tip
syringe.
5. Inflate the balloon with appropriate amount of water.
6. Gently pull back on catheter until resistance is met. (Clamp G-tube
and tape to secure tube). (Mic-Key Button to rest on abdomen.)
7. Document, date, time, and rationale for procedure on Nursing
Treatment/Procedure Service Record.
8. Notify parent/guardian.
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COLOSTOMY AND ILEOSTOMY CARE: CHANGING POUCH
Individualized training required prior to performance by non-medical personnel.
PURPOSE:
To maintain comfort and cleanliness and to protect the skin around the stoma.
PREPARATION;
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Explain the procedure using appropriate developmental approach.
Wash hands
Assemble equipment:
 Disposable wet cloth or wipes
 Soap and water
 Pouch appliance
 Skin barrier
 Clamp or rubber band
 Scissors
 Tape
 Gloves
 Plastic bag
PROCEDURE:
1. Verify physician’s order.
2. Observe for leakage.
3. Cut a hole in the skin barrier and pouch as needed. Use the guide provided in the
package or make a pattern (should be 1/16”-1/18” bigger than the stoma). Don’t
fold in half to cut: the fold will create a crease which prevents a good seal.
4. Put on gloves.
5. Have student stand or lie flat.
6. Begin to loosen pouch by holding skin down while pulling up on bag. Remove
used pouch and skin barrier. Discard into plastic bag. Remove any stool on the
stoma with wipe. Gently clean the skin with soap and water, then pat dry.
7. Observe for skin irritation. Apply the skin barrier around the stoma. Apply the
pouch over the stoma. Press it to seal, concentrating on the area closet to the
stoma. Hold in place for 30 seconds.
8. Remove gloves. Wash hands.
9. Document date, time, rationale for procedure, type and amount of stool, and
condition of skin and stoma on Nursing Treatment/Procedure Service Record.
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COLOSTOMY AND ILEOSTOMY CARE: EMPTYING THE POUCH
Individualized training required prior to performance by non-medical personnel.
PURPOSE:
To maintain comfort and cleanliness and to protect the skin around the stoma.
PREPARATION:
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Explain procedure to student using appropriate developmental approach.
Wash hands
Assemble equipment:
 Rinse bottle.
 Basin or toilet
 Disposable wipes
 Gloves
PROCEDURE:
1. Check physician’s orders.
2. Put on gloves
3. Remove the clamp or rubber band to open the lower end of the pouch; open over
basin or toilet.
4. Slide your thumb and index finger down the outside of the pouch, draining
contents into basin or toilet.
5. Observe stool amount and type.
6. Use wipe to clean any remaining drainage from outside and inside the pouch
opening.
7. Hold the pouch opening upright and pour a small amount of water into the pouch.
Gently swish the water around to remove any remaining drainage. Allow to drain
thoroughly.
8. Use wipe to clean and dry the outside of the pouch
9. Close the end of the pouch with clamp or rubber band, allowing room for stool to
collect, and remove excessive air.
10. Document date, time, type and amount of stool and condition of skin and stoma
on Nursing Treatment/Procedure Service Record.
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UROSTOMY CARE
Individualized training required prior to performance by non-medical personnel.
PURPOSE:
To maintain comfort and cleanliness, to prevent infections, and to protect the skin around the
stoma.
PREPARATION:
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Explain the procedure to student using appropriate developmental approach.
Wash hands
Assemble equipment:
 Disposal wet cloth or wipes
 Soap and water
 Pouch appliance
 Skin barrier
 Clamp or rubber band
 Scissors
 Tape
 Gloves
 Plastic bag
PROCEDURE:
1. Verify physician’s order. Observe for leakage.
2. Cut a hole in skin barrier and pouch as needed. Use the guide provided in the package
or make a pattern (should be 1/16”-1/18” bigger than the stoma).
3. Put on gloves
4. Have student stand or lie flat.
5. Begin to loosen pouch by holding skin down while pulling up on bag.
6. Remove used pouch and skin barrier.
7. Empty urine into basin or toilet and pouch into plastic bag.
8. Wash area with mild soap and water and pat dry. Observe for skin irritation.
9. Apply the skin barrier around the stoma.
10. Apply the pouch around the stoma, on top of the skin barrier. Press it to seal,
concentrating on the area closet to the stoma. Hold in place for 30 seconds.
11. Remove gloves. Wash hands.
12. Document date, time, rationale for procedure, type and amount of urine, and condition of
skin and stoma on Nursing Treatment/Procedure Service Record.
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CIRCULATORY SYSTEM
Structure and Function:
The circulatory system delivers oxygen and nutrients to different organs of the body and
transports carbon dioxide and waste products to the lungs and kidneys for elimination.
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Heart: Has four chambers and physiologically is divided into two sides. The atria are the
small collection chambers that collect blood from the veins. The ventricles are the
larger, more muscular chambers that pump blood through the arteries.
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Arteries: Blood vessels with muscular walls that take the blood from the heart to organs
in the body. The largest artery, the aorta, is closest to the heart. As the arteries get
farther away from the heart, they become smaller, with less muscle in their walls.
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Capillaries: Tiny channels, one blood-cell wide, that connect arteries to veins. These
vessels are where the exchange of oxygen and nutrients with carbon dioxide and waste
products occurs in every organ.
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Veins: Thin blood vessels that take blood away from organs toward the heart. Some
veins in arms and legs have one-way valves that keep the blood from pooling in the
hands and feet. As the veins get closer to the heart, they become larger. Central veins
are those veins inside the abdominal or chest cavities. The right side of the heart collects
blood returning from the body via the large veins, the vena cavae, in the right atrium.
The blood then enters the right ventricle through a valve and is pumped to the lungs
through the pulmonary artery, where it loses carbon dioxide and picks up oxygen. The
oxygenated blood from the lungs enters the left atrium through the pulmonary veins. It
then crosses a valve into the left ventricle, which pumps the blood out to the body
through the aorta.
11/11
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LONG TERM CARDIAC/VENOUS CATHETERS
PURPOSE:
When the treatment is long term or repeated, indwelling catheters are inserted.
TYPES:
Central venous catheters, Peripherally-inserted central venous catheters, Implantable venous
devices and Peripherally-placed implantable venous access devices.
COMPLICATION AND NURSING INTERVENTION:
CATHETERS TO BE HANDLED ONLY IN EMERGENCIES
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If the dressing is wet, soiled or loosed, nurse may reinforce it, but parent/guardian is
responsible for changing it.
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Fever, tenderness at site, drainage at site, redness at site – call parent/guardian.
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If catheter breaks or cracks, clamp catheter close to chest immediately. Turn on left side
to prevent complication of possible air embolus. Call parent/guardian and/or physician.
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For shortness of breath, chest pain, dizziness or confusion, turn on left side. Call parent/
guardian and/or physician. Give oxygen per physician’s orders, if available.
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If catheter gets pulled out, apply pressure to site and notify parent/guardian and /or
physician immediately. Document date, time, and action taken.
11/11
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RESPIRATORY SYSTEM
Structure and Function:
Breathing is the use of oxygen as a source for the body, and the exchange of oxygen for carbon
dioxide. The exchange of these gases takes place in the alveoli (tiny air sacs) of the lungs. The
respiratory system can be divided in two parts: the upper and the lower airway.
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The Upper Airway: Air enters the body through the nose and mouth to reach the
pharynx (back of the throat), before passing through the larynx (voice box) to the trachea
(wind pipe).
As air enters the nose, larger dust particles are filtered out by the hairs in the nostrils.
The air then passes through the nose, where a large area of moist mucus membrane
adds moisture and warms the air to body temperature. When air reaches the back of the
throat, bacteria and viruses are again filtered by the tonsils and adenoids.
Air then passes through the larynx and down into the trachea. This passage of air
through the larynx during inhalation (breathing in) and exhalation (breathing out) is
essential for normal speech production.
Mucus comes from the tissues that line both the upper and lower airway, When this fluid
is not warmed and humidified in a natural way, the mucus can dry and partially or
completely solidify, causing a blockage in the airway.
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The Lower Airway: The trachea divides into the two main air tubes (the right bronchus
and the left bronchus). Each bronchus subdivides into smaller bronchi that enter each
lobe of the lungs. The bronchi then subdivide further into smaller ducts that enter each
individual alveolus (air sac). It is here that the actual exchange of oxygen and carbon
dioxide takes place.
The lungs occupy most of the chest cavity. They are elastic structures, continuously
filling and shrinking with each breath of air.
The main muscles of breathing are the diaphragm and the intercostal muscles, located
between the ribs during normal breathing. The breathing (respiratory) rate for an adult is
about 12-16 times a minute, for a baby about 24-36 times a minute, and 16-20 times a
minute for a school-age child. In any person, these rates will vary depending on
exercise, excitement and illness.
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USE OF PEAK FLOW METER
Individualized training required prior to performance by non-medical personnel.
PURPOSE:
To assist student and physician in monitoring respiratory status.
PREPARATION:
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Explain procedure to student using appropriate developmental approach.
Wash hands and assemble equipment:
 Peak Flow Meter
PROCEDURE:
1. Verify physician’s order.
2. Slide marker or arrow on the Peak Flow Meter to the bottom of the numbered scale (zero
or the lowest number on the scale).
3. Have student stand erect, take a deep breath, close lips tight around mouthpiece, and
blow out as hard and as quickly as possible. The force of the air causes the marker to
move along the numbered scale. Note the number on a piece of a paper.
4. Repeat the entire routine three times. (You know you have done the routine correctly
when the numbers from all three tries are very close together.
5. Record the highest of the three readings. Do not calculate an average.
6. Measure the Peak Flow Rate close to the same time each day. The doctor can help
determine the best time. Keep a chart of the Peak Flow Rates on Nursing
Treatment/Procedure Service Record
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POSTURAL DRAINAGE
Individualized training required prior to performance by non-medical personnel.
PURPOSE:
To facilitate the clearance of mucus from the airway to promote optimal respiratory effort.
PREPARATION AND TEACHING:
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Explain procedure to student using appropriate developmental approach.
Wash hands
Assemble equipment
 Wedge or pillows
 Tissues
 Percussion Suction equipment (if ordered)
PROCEDURE:
Percuss and vibrate only over the ribs. Avoid the spine, breastbone, stomach, lower ribs, and
back to prevent trauma to the spleen, liver, and kidneys.
1. Verify physician’s order.
2. Wash hands after removing rings.
3. Using wedge or pillows, position student. Do not perform postural drainage precussion
on bare skin.
4. Percuss indicated areas with cupped hand, fingers together and wrist loose.
5. Encourage deep breathing and coughing occasionally during procedure. The procedure
should take 15-30 minutes. Allow student to rest at intervals to prevent fatigue.
6. Suction, if ordered and necessary.
7. Provide tissues, as needed.
8. Dispose of used supplies and wash hands.
9. Document procedure and amount of drainage on Nursing Treatment/Procedure Service
Record.
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PULSE OXIMETRY
Individualized training required prior to performance by non-medical personnel.
PURPOSE:
To determine oxygen saturation and to guide oxygen therapy.
PREPARATION:
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Explain the procedure to the student using appropriate developmental approach.
Wash hands
Assemble equipment:
 Pulse Oximeter
 Pulse Oximeter sensor tape
PROCEDURE:
1. Verify physician’s orders and care plan actions to be taken.
2. Refer to operating manual for instructions on the use of the machine.
3. Place sensor around foot, hand, finger, toe or earlobe.
4. Tape the sensor securely in place.
5. Take appropriate action following individualized care plan.
6. Document date, time, results, and action taken on Nursing Treatment/Procedure Service
Record.
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OXYGEN ADMINISTRATION
Individualized training required prior to performance by non-medical personnel
PURPOSE:
To provide a safe environment for the student receiving oxygen.
PREPARATION:
 Explain the procedure to the student using appropriate developmental approach.
 Wash hands
 Assemble equipment:
 “Oxygen in Use” signs are posted on campus.
 Oxygen tank and delivery system. (Check the tanks to make sure there is
enough oxygen and document on Nursing Treatment/Procedure Service
Record.)
 Back-up oxygen tank and delivery system, if indicated.
PROCEDURE:
Obtain physician’s order for oxygen administration. Order needs to include method of delivery
(mask, cannula, tracheostomy, etc.), the flow rate, time to be given, and if oxygen is to be selfadministered.
Prior to student’s arrival:
1. Write a care plan to include responsibilities of parent, school and outside agencies
involved, include a plan for failure of the system.
2. In-service staff regarding oxygen administration and designate, in writing, at least two
staff members, other than school nurse, who can be responsible for the operation of the
equipment and identify empty or nonfunctional apparatus.
3. Notify the Risk Management Office, if requested by school principals, that oxygen will be
in use on the school premises. Assist them with any safety inspections or measures
they feel are necessary.
4. Make arrangements with Transportation Department if transporting the student. Inservice their staff, as needed.
5. If school is to administer oxygen, the system must be checked each AM, upon student’s
arrival at school.
6. Nursing Treatment/Procedure Service Record to be kept in classroom and completed by
designated person.
7. Obtain new physician’s order yearly and contact family and doctor, as needed.
Oxygen administration by nasal cannula or mask:
 Wash hands
 Attach tubing securely to oxygen source.
 Set liter flow on the flow meter as prescribed. Never change this setting without an
order.
 Check cannula prongs/mask to make sure that oxygen is coming out.
 Determine that nasal cannula/mask fits properly and is flowing well. For nasal cannula:
insert nasal cannula prongs gently into the student’s nose. Make sure both prongs are in
the nostrils. Loop tubing over each ear and then under the chin.
 Wash hands
 Monitor student continuously for respiratory distress. Initiate emergency procedures
as indicated.
 Document oxygen administration and any observations on Nursing Treatment/Procedure
Service Log.
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OXYGEN SAFETY PRECAUTIONS
1. Do not smoke or allow open flames, heaters, or radiators near oxygen.
2. Never permit oil, grease or highly-flammable material to come in contact with oxygen
cylinders, liquid oxygen, valves, regulators or fittings.
3. Do not lubricate with oil or other flammable substances, and do not handle equipment
with greasy hands or rags.
4. Never put anything over gas cylinder.
5. Post name and contact information for oxygen supply company.
6. Return any defective equipment to the authorized company for replacement.
7. Have spare oxygen readily accessible, based on the student’s needs. This should be
stored safely in a secure place.
8. Extra tubing and tank equipment (e.g., wrenches) must be kept in an easily accessible
place.
9. If using oxygen gas, be sure that the tank is securely placed in its stand and cannot fall
or be knocked over.
10. Be careful that the oxygen tubing does not become kinked, blocked or disconnected.
11. Use only the flow meter prescribed by the student’s physician.
12. The local fire department should be notified that oxygen is in use in the school.
13. Post “Oxygen in Use” signs on school campus.
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TRACHEOSTOMY CARE
For RN/LPN (licensed nursing staff only)
PURPOSE:
To provide instructions for the care of the student with a tracheotomy, including: 1) skin care, 2)
changing ties, 3) emergency tracheotomy tube replacement.
PREPARATION:
Explain procedure to student using appropriate developmental approach. Wash hands and
assemble equipment after verifying physician’s orders.
SKIN CARE EQUIPMENT:
 Gloves sterile
 Cotton-tip applicators
 Clean dressing
 One-half strength peroxide wipes (1:1 hydrogen peroxide and sterile normal saline or
sterile water)
PROCEDURE:
1. Apply gloves.
2. Remove old tracheotomy dressing and observe for skin irritation.
3. Moisten sterile applicators with one-half strength hydrogen peroxide.
4. Using a rotating motion, clean from stoma outward.
5. Rinse with sterile applicators moistened with sterile normal saline or sterile water.
6. Insert clean dressing around stoma, under tracheotomy tube, using one hand to stabilize
tracheotomy tube.
7. Wash hands.
8. Document procedure on Nursing Treatment/Procedure Service Record.
CHANGING TIES EQUIPMENT:
 Twill tape or bias seam tape
 Bandage scissors
 Gloves
PROCEDURE:
Two medically trained people must be present.
1. Position student on back with neck extended.
2. One person holds tracheotomy in place via neck plates, while other changes ties.
3. Cut and remove ties.
4. Put on new ties.
a. Fold end of the tie and cut a small slit, ½” cut from end of tie.
b. Thread the tie through the flange hole.
c. Pull other end of the tie through the slit.
5. Repeat steps in #4 for other side.
6. First person bends child’s head forward while holding tube in place.
7. Second person ties a knot in the tie on the side of the neck; alternate know from one
side to
the other. The tie should be tight enough to get only one small finger between the tie and
child’s neck.
8. Wash hands.
9. Document procedure on Nursing Treatment/Procedure Service Record.
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TRACHEOSTOMY CARE (continued)
Tracheotomy tube change is done at school only in emergency situations.
EMERGENCY TRACHEOSTOMY TUBE REPLACEMENT EQUIPMENT:
 Gloves
 Tracheotomy ties
 Two sterile tracheotomy tubes – one in original size and one in next smaller size.
PROCEDURE: Two medically trained people must be present.
*Note: This is an EMERGENCY procedure. After three unsuccessful attempts at suctioning:
1.
2.
3.
4.
5.
Call for assistance.
Position student with neck hyper-extended to visualize the stoma optimally.
Open sterile package.
Cut old ties and gently remove tube.
Remove sterile tracheotomy from the package, holding tube by phalanges, not by the
piece which fits into stoma, avoid contaminating the tube.
6. Insert obturator into tube to make insertion easier. Obturator is not left in place after
insertion because it blocks the airway. Some brands do not have obturators.
7. Spreading stoma open with the index and middle fingers of one hand, gently inserted the
new tube. The tube should be directed back and then down. Remove the obturator as
soon as the tube is in place.
8. Hold the tube in place and apply ties.
9. Suction if necessary.
10. If you are unable to insert the tracheotomy tube: Reposition head and try again. If the
new tube will not enter, try to insert tracheotomy tube of the next smaller size. If you
cannot insert smaller tube, reposition head and try again. If still unsuccessful, start
rescue breathing using mouth-to- stoma technique and call 911. If too much resistance
is felt, cover stoma with gauze and do mouth-to-mouth technique. Check for pulse. If no
pulse start CPR .
11. Once trach tube is inserted observe student for respiratory distress: cyanosis, anxiety,
poor inspiratory effort. If necessary, start rescue breathing using mouth-to-stoma
technique and call 911. If too much resistance is felt, cover stoma with gauze and do
mouth-to-mouth technique
Check for pulse. If no pulse, start CPR, continue until relieved or child is responsive.
a. Observe student until condition is stable and there is no further danger or
paramedics arrive.
b. Wash hands.
c. Document procedure on Nursing Treatment/Procedure Service Record.
Notify parent/guardian and physician immediately.
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TRACHEOSTOMY SUCTIONING WITH BULB
Individualized training required prior to performance by non-medical personnel.
PURPOSE:
To provide the nurse with guidelines for removing secretions from the airway in order to
establish and maintain airway patency.
PREPARATION:



Explain procedure to student using appropriate developmental approach.
Wash hands
Assemble equipment
 Bulb syringe
 Tissues
 Gloves
PROCEDURE:
1. Gather supplies.
2. Squeeze the bulb of the bulb syringe with your thumb.
3. Place the tip of the bulb syringe at trach opening, and release bulb slowly.
4. Remove the bulb syringe from the trach opening, and then squeeze the bulb to push out
the secretions onto tissue.
5. Repeat as needed to clear trach.
6. After use, wash the bulb syringe in hot soapy water, rinse it well with clean water, and let
air dry.
7. Document date, time, reason, procedure done, and student’s response on Nursing
Treatment/Procedure Service Record.
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TRACHEOSTOMY SUCTIONING WITH MACHINE
RN/LPN (licensed nursing staff only)
PURPOSE:
To provide guidelines for removing secretions from the airway in order to establish and maintain airway patency.
PREPARATION:

Explain procedure to student using appropriate developmental approach.

Wash hands

Assemble equipment
1. Portable suction machine
2. Clean, disposable catheter (size determined by physician) and clean gloves
3. Clean, disposable connecting tube
4. Same size trach and one of next smaller size
5. Tissues or paper towel
6. Bandage scissors
7. Gloves
PROCEDURE:
1. Verify physician’s order.
2. Plug in suction machine, and check functioning and patency of the connecting tube.
3. Open clean catheter and apply gloves.
4. Open and fill rinsing container with sterile normal saline or sterile water.
5. Measure the catheter against a spare tracheostomy tube to determine correct insertion length.
6. Tell student to take some deep breaths.
7. Lubricate catheter with sterile normal saline or sterile water.
8. Insert measured length of catheter into the tracheostomy tube without applying suction.
9. Withdraw catheter slowly and apply suction by putting thumb over opening in catheter Suctioning should require no
more than 5 seconds. Avoid suctioning more than 10 seconds.
10. Clear secretions in catheter after each use with sterile normal saline or sterile water.
11. Allow student to take a few breathes for at least 30 seconds before repeating the process.
12. Repeat, as necessary, until desired results are obtained.
13. Suspect a mucus plug if the student continues to be in distress. Cut ties, remove trach tube and reinsert a trach of
the same size. If unable to insert, try trach one size smaller.
If unsuccessful, begin CPR and call 911.
14. Clean catheter and connecting tube with sterile normal saline or sterile water.
15. Turn suction machine off.
16. Discard disposable equipment and gloves. Wash hands
17. Document date, time, reason for procedure done and student’s response on Nursing Treatment/Procedure
Service Record.
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SEIZURE MANAGEMENT
Individualized training required prior to performance by non-medical personnel.
PURPOSE:
To provide guidelines regarding care of the student with seizures, maintain adequate airway,
and protect student from injury during seizure.
PREPARATION:
 Prepare Seizure Care Plan for student
 Have special equipment such as oxygen and suction on hand, only if ordered by the
student’s physician.
PROCEDURE:
 Identify students with history of seizures. Prepare Seizure Care Plan for those students.
Verify physician’s orders and any special instructions.

Instruct appropriate staff working with student about diagnosis, orders and special
instructions.

In case of seizure activity:
1. Clear immediate environment of hard, sharp or harmful objects. Stay with student,
provide for privacy, ease student to floor. Call for assistance, if needed.
2. Place student on left side, to prevent aspiration and to allow tongue to fall forward.
3. Use oxygen (if ordered) and suction as needed for respiratory distress.
4. Do not restrain student, and do not force anything into the mouth. Loosen restrictive
clothing and remove glasses.
5. Call parent/guardian
6. If a seizure is prolonged and the student does not regain consciousness (Status
Epilepticus), stops breathing, or is seriously injured, have staff call 911. Perform CPR or
mouth-to-mouth resuscitation as indicated.
7. Following the seizure, allow the student to rest, assist with change of clothing if
necessary, provide reassurance and emotional support.
8. Wash hands.
9. Document seizure activity, activity prior to seizure, duration, etc. on Seizure Log (PCS
Form- 2-2328) which should be kept in the classroom with the student.
NOTE: If student has never had a seizure, has a seizure in water, fail to regain consciousness,
is pregnant, or is a known diabetic, or if seizure activity lasts more than 5 minutes or is followed
immediately by another seizure, call 911 and parent/guardian.
Children with known repetitive seizure disorders may not require emergency level response,
depending upon physician’s orders for school care.
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GLUCOSE MONITORING
Individualized training required prior to performance by non-medical personnel.
PURPOSE:
To facilitate diabetes management and to check blood glucose level.
PREPARATION:



Explain the procedure to the student using appropriate developmental approach.
Wash hands
Assemble equipment.
 Glucose monitoring machine.
 Test strips
 Alcohol prep or cotton ball/alcohol
 Lancet or auto-click device
 Cotton balls or tissue
 Sharp container
 Gloves
PROCEDURE:
Verify physician’s orders and care plan for actions to be taken.
Wash hands and put on gloves.
Cleanse finger tip with alcohol swab and let dry.
Place strip in machine to activate it and check code # to code on the test strip container
(if applicable)
5. Obtain the blood sample by puncturing the side of fingertip with lancet/auto-click device.
6. Follow manufacturer’s instructions.
7. Read results, dispose of lancet/auto-click tip in sharp container and used supplies.
8. Remove gloves and wash hands.
9. Take appropriate action following individualized care plan.
10. Document date, time, signature, procedure, outcome and action taken on Nursing Treatment/Procedure Service Report.
1.
2.
3.
4.
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URINARY SYSTEM
STRUCTURE AND FUNCTION:
The urinary system filters waste material from the blood and removes it from the body as urine.
Kidneys: Two bean-shaped organs, one at each side of the spine at the back of the upper
abdomen, which regulate the amount of water in the body. Ninety percent of what the kidneys
removed from the blood is recycled back into the blood, after filtering out waste.
Bladder: Reservoir for storing the urine until it is ready to be discharged from the body.
Urethra: Tube leading from the bladder to the outside opening of the body through which the
urine is discharged.
Blood Vessels: Renal arteries carry blood from the main artery to the kidneys where waste is
filtered out; the renal veins take cleansed blood away from the kidneys.
Ureters: Narrow tubes that conduct the waste liquid (urine) from the kidneys to the bladder.
Meatus: The external opening. In girls, between the labia, just above the vagina. In boys, at the
tip of the penis.
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CLEAN INTERMITTENT CATHETERIZATION
Individualized training required prior to performance by Certified Nursing Assistant
PURPOSE:
To ensure periodic emptying of the bladder and relieve urinary retention.
PREPARATION:



Explain procedure to student using appropriate developmental approach.
Wash hands
Assemble equipment.
 Catheter – type and size per physician’s order.
 Sealable container to store a reusable catheter if used.
 Water soluble lubricant
 Soap, water and cotton balls or pre-moistened disposable wipes.
 Container for urine collections, if student is unable to use toilet.
 Paper towel to lay equipment on.
 Gloves
PROCEDURE
1. Verify physician’s order.
2. Wash hands.
3. Assemble equipment in an appropriate private location, preferably in a bathroom.
4. Put on gloves.
5. Using cotton balls saturated with liquid soap and water or wet wipes and cleanse the
genital area.
6. FEMALE:
a) Position student in a sitting position. If a sitting position is not possible, the
student should be on her back, feet flat on bed with knees flexed and apart. The
urine collection container should be within close reach.
b) With one hand, gently separate the labia exposing the meatus.
c) Place cotton ball or wet wipe above meatus. With a single downstroke, cleanse
the meatus.
d) Repeat this procedure two times using a clean cotton ball or wipe.
e) With the opposite hand, lubricate the catheter tip with water soluble lubricant.
f) Place opposite end of catheter in the urine receptacle or commode.
g) Hold catheter in place until urine stops flowing.
7. MALE:
a) Position the student, on his back with legs flat and extended.
b) Retract foreskin as indicated and cleansed in a circular motion from meatus outward
toward shaft with each wipe.
c) Holding the catheter three inches from the tip, insert catheter into urinary meatus, slightly
past point where urine returns. If strong resistance is met, do not force the catheter.
Remove it and notify student’s parent/guardian and/or physician immediately.
d) Remove catheter, pausing if urine begins to flow again
8. If catheter is one time only use, dispose of properly. If to be used again, wash the
catheter with warm soapy water. Rinse with running, clear water and air dry. If receptacle was used, discard urine, rinse container with disinfectant. If student complains of fever, chills, or flank or urinary tract pain, or you observe hematuria (blood in urine), foulsmell, cloudiness or decreased output, notify student’s parent/guardian and/or physician.
Dispose of used supplies, properly and wash hands.
9. Document date, time, signature, procedure, outcome and action taken on Nursing
Treatment/Procedure Service Record.
10. Assist student with diaper changing and dressing.
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CONTINUOUS AMBULATORY PERITONEAL DIALYSIS (CAPD)
RN/LPN (licensed nursing staff only)
PURPOSE:
To remove water and waste products and help maintain the body’s chemical balances.
Prior to student’s arrival:
Obtain physician’s order for CAPD and completed medical treatment form.
Write a care plan to include responsibilities of parents, school, and outside agencies involved.
PREPARATION
 Explain the procedure to the student using appropriate developmental approach.
 Wash hands
 Assemble equipment. Maintain sterile technique during solution and equipment
preparation to avoid introducing pathogens into student’s cavity during treatment.




Dialysis Administration Set
Dialysate
Masks
Sterile Gloves
PROCEDURE:
1.
2.
3.
4.
Take and record vital signs - temperature, pulse and blood pressure.
Put on mask.
Prepare the dialysis administration set.
Place drainage bag below the student to facilitate gravity drainage, and connect the
outflow tubings to student.
5. Connect the dialysis infusion lines to the bags of dialysate and hang the containers on
an IV pole at the student’s side.
6. Place student in supine position and have student put on mask.
7. Prime tubings with solution, keeping the clamps closed, and connected one infusion line
to the abdominal catheter.
8. Open the clamps on the infusion lines and infuse the prescribed amount over 5-10
minutes. When bag is empty, promptly close the clamps.
9. Apply sterile gloves and disconnect the inflow line per company’s instructions.
10. After solution has dwelled in the peritoneal cavity for the prescribed length of time, allow
the solution to drain from peritoneal cavity into the collection bag.
11. Dispose of used supplies.
12. Wash hands.
13. Document date, time, signature, procedure, outcome and action taken on Nursing
Treatment/Procedure Service Record.
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