Thank you for all the juggling you do!!!
Presented by District Nurses
Cheryl Closser, RN, MSN, PHN
Beth Munns, RN, BA, BSN
Emily Henke, RN, BSN, PHN
Jennifer Rodriguez, RN, BSN, PHN
October 23rd and 24th 2014









Welcome and Introduction
Health Tasks
eSchools
Confidentiality
Medication Administration
Nose Bleeds
Head Injury
Anaphylaxis
Asthma








Diabetes
Vasovagal Syncope
Heart Conditions/AED
Seizures
Immunizations
Questions &
concerns/evaluation
Skills Laboratory
CAIR
Important Health Tasks
Ensuring Confidentiality and Privacy
 Entering Health Information into eSchools
 Administering Medications
 Maintaining the Health Office
 First Aid
 Verifying and Reporting Immunization
Data

Ensuring Confidentiality
Awareness of surroundings when
speaking about students and any medical
conditions.
 Keep paper work and files confidential;
please do not post private information on
walls. Do not allow student access.
 Please review emails before sending.

Entering Information in eSchools
Enter
emergency card
information ASAP! Do not
drop information.
Consistency of entry of
health problems. Example:

notes addressed to staff.

Anaphylaxis vs. Allergies
add your initials
and date to med alert entry.
Ask your nurse about any
med alert doc. Questions.
Notify staff of any urgent
matters i.e. PE restrictions, MD
Please
Generate health problem
list and distribute to
appropriate staff. Example:
food allergy list for kitchen.

Notify nurse of any serious
health conditions.
Medication Administration
Six Critical Rights
Right Student
 Right Medication
 Right Dose
 Right Route
 Right Time
 Right Documentation

Medication Administration
Authorization Form
Fill Out Completely
 Name of Student and Birth Date
 Signatures from parent and doctor with
dates.
 5 of 6 Rights must be on form
 Self administration or Self Carry?

Important Considerations







Changes must be in writing from the physician
Notify School Nurse Immediately of Changes and New
Medication Orders.
Label and Order must match, notify your school nurse if they
do not.
Doctors orders must be brought into school by parent or faxed
All medications this includes over the counter, supplements,
herbs and alternative treatments must be in original container
and be accompanied by a medication authorization form
and/or doctor’s order.
All doctors orders must be placed in health file, med book,
with medication (disaster preparedness), & nurses mailbox
Any problems or questions….contact your school nurse!
Problems

To protect yourself: if you find an
incomplete order, document and date what
you are doing to resolve the problem.
Time
Initials
If student
takes
meds
regularly,
must
mark
reason
for any
missed
dose
For meds dropped or tossed away.
Document on reverse side. Then also
document the medication was given.
Documentation
Complete log in ink, with time, and your
initials, when you assist or observe
student using medication.
 Sign and initial bottom of medication log.
 If student takes meds regularly, document
reason for any missed doses.
 You must have a list of the students who
take medication at school


All prescription medications must be counted and the
number documented on the reverse side of the
Medication Administration Record (MAR).

Two adults count the number of pills (without touching
them) and both adults sign for the medications that have
been brought in.

Call Nurse for Advice if needed
Count pills when
medication is
dropped off





Must be stored in centrally located, locked
cabinet
ALWAYS lock the med cabinet
No student access to med cabinet
Refrigerators for med storage must be locked &
reserved only for meds!
If you do not have a locking refrigerator (for
medications only) at your school site, notify your
site administrator.
Errors and Discontinued Meds

Report errors immediately:
 Site administrator
 School nurse
 Parent/ Guardian
 Document error on MAR
 Fill out incident report

Discontinued/ Outdated
 Attempt to return
 When disposing of
medication place in
sharps container.
Medication Error Sheet
Please complete error sheet and give a
copy to your school nurse and site
administrator.
 If an incident report is required, attach
med error sheet to report and give to
administrator.
 Nurses will also complete reports as we
check the medication binders and give a
copy to the school’s administrators.

Emergency Care Plan Forms

Please give a copy of the forms i.e.
Seizure Disorder, Diabetes, Anaphylaxis
to parents and/or students with known
diagnosis.

Parents and physician must sign all care
plan forms.
Medication Book Organization
A to Z by last name and include E Care
Plans. Please use alphabetical file tabs.
 If you have a separate emergency plan
binder a copy of the plan must also be
placed in the medication binder.
 If you have a separate binder for diabetic
students, have a reference in main binder.
 Make a list of students taking daily
medication and place in front of binder.

Staff Awareness
Elementary schools may have a red binder
in the staff room with care plans and
physician notes; staff should look at.
 FYI: Teachers/staff should also have a red
binder in their classroom for substitute
teachers with emergency plans. This
should also include a list of students with
med alerts from eSchools. Teachers may
ask you for this information.

Field Trips
Ask teachers to notify you 2 weeks in
advance for field trips.
 Give them a copy of the medication
administration form and the medication
before the trip.
 Instruct teacher to document on back of
form during the trip and assist with official
documentation in med book on return.

Maintaining the Health Office
All equipment is functioning correctly
 Supplies are stocked, organized and
accessible.
 Health office is clean, there should not be
any food in the office. Example: Clean bed after

every use.

Ensure Emergency First Aid bag is ready
to go, along with student medications, logs
and ecards for disasters.
First Aid Considerations
Provide as much privacy as possible.
 Follow universal precautions.
 Document all visits to the Health Office (in
pen) may use paper or computer log.
 Ensure 911 is called if situation warrants,
and notify administration, parents and
school nurse.

Wash hands before and after first aid
treatment
 Wear gloves when in contact with blood
and other body fluids
 Call janitorial staff for clean up of excess
bodily fluids
 Wipe down beds after each use, if
blankets are used wash between uses.
 Keep health office area clear of food and
beverages.

FIRST AID
- Sit upright, lean slightly forward.
- Pinch soft part of nose above
nostrils, 5-10 minutes, repeat if
needed.
- May use ice on bridge of nose if needed.
- To prevent re-bleeding, advise students not to
blow/pick nose or bend down for several hours.
- If nosebleed lasts more than 20 minutes or follows
an accident, fall or head injury don’t hesitate to
call 911.
What is a Concussion?
A concussion is caused by a fall, bump, or blow to the
head & can change the way your brain normally works.

Head injuries must be
taken seriously.

May be difficult to
determine whether
mild or severe.

Call parents and give
head injury form with
signs & symptoms and
when to seek care.

Severe symptoms
usually develop within
24 hours but can
occur several weeks
later.

Doctor’s note required
for students to return
after a concussion.
Ice for head or neck
 Keep still in a darkened room, not alone
 Ask simple questions (what is your name,
what day is today, where are you?)
 Observe body language, personality,
balance
 Monitor student for worsening of
symptoms, report to nurse and parent
 Re-evaluate student at 15 and 30 minutes

Concussion Checklist

http://www.cdc.gov/concussion/pdf/TBI_schools_che
cklist_508-a.pdf
Concussion: Heads Up For Schools
(More information & free resources).









Appears dazed, stunned, and/or confused
Loses consciousness (even briefly)
Memory, behavior or personality changes
Balance problems or dizziness
Double or blurry vision
Headache and/or sensitivity to light or noise
Feels tired, sluggish, hazy, foggy or groggy
Nausea and/or vomiting
Just not feeling right or feeling down
Requires a hospital visit!
Need doctor’s note to return to school.
When is Head Injury a Medical Emergency?
Call 911 if…

Difficulty breathing

Blood or clear fluid in the
ears or nose

One pupil larger than the
other

Loss of consciousness

Mood changes

Increasing confusion

Loss of balance

Worsening headache


Drowsiness or cannot be
awakened
Weakness, numbness,
and/or decreased
coordination

Speech problems
Persistent vomiting or
nausea

Severe head/facial bleeding
Unusual behavior

Seizures



If found unconscious assume the neck is
injured and stabilize. DO NOT MOVE!
Call 911.

Stop any bleeding with pressure unless
you suspect a skull fracture, no direct
pressure.

Open airway, watch for breathing. CPR if
needed.

Extremely serious form of an allergic
reaction

Can occur within seconds or be delayed.

“Any respiratory system involvement,
difficulty breathing, audible wheezing or
difficulty swallowing”. -EMSA Definition

Act immediately, You can save a
student’s life!
Anaphylaxis Emergency Care Plan

See Handouts in English and Spanish:
http://www.foodallergy.org/document.doc?id=234
http://www.foodallergy.org/document.doc?id=126

Please distribute copies of this plan to
students/families whom have serious
allergies.








Nuts
Shellfish
Latex
Bees
Variety of Foods
Some Chemical
Exposures such as Sulfa
Plants
Other Unknowns
What Kids Could Say:





Look I have small red
bumps

My throat hurts

I can’t swallow

I can’t breathe

I’m scared

I’m dizzy
I’m really itchy all over
I feel like throwing up
My stomach hurts
My heart is beating
really fast
What You May See:

Change of Voice

Coughing

Wheezing

Change of Color

Swelling of any body part

Fainting or Loss of
Consciousness
What to do if Suspected Anaphylactic
Reaction
 Determine if anaphylaxis is suspected.
More of a danger not to give it than to give it.
 If symptoms have occurred CALL 911 immediately,
stay with student. Have student sit and stay calm.
 Prepare to administer EpiPen. EpiPen acts
immediately but effects last only 10-15 minutes.
Make sure 911 is called.
Two strengths:
Above 66 lbs. = 0.3 mg (yellow)
Below 66 lbs. = 0.15 mg (green)
How to Administer Epi-Pen:
 Form a fist around the Epi-pen. Pull off the Safety Cap.
 Never put thumb, fingers, or hand over the black/orange
tip.
 Swing and jab the tip firmly into the OUTER THIGH at a
90 degree angle. (Can be injected through clothing.)
 You will hear a click. Hold the EpiPen in place for 10
seconds. Remove & massage the injection area for
several seconds. (After the injection, they may feel their
heart pounding. This is a normal.)
 Check the black/orange tip: If the needle is exposed the
dose was delivered, if not repeat above steps.
Always Call 911:
 Give epi-pen first if alone, then call 911.
 Know time you gave Epi-pen, may only last 10-15
minutes. Do not give Benadryl first, takes 30-60 min.
 If symptoms return give 2nd Epi-pen 10-15 minutes
after initial dose.
 If insect sting, remove stinger/apply ice to sting area.
Scrape stinger out, do not pull out.
 Give used Epi-pen to paramedics

Observe for signs of shock cover with
blanket if cold.

Watch breathing. If stops breathing begin
CPR.

Document the incident

Send a copy to your school nurse
 School Personnel are required to have
current CPR certification to administer an
Epi-pen.
 Store at room temperature
 Keep record of expiration datesolution must be colorless, replace if
brown
Auvi Q Demonstration
SEIZURE
TRAINING
FOR SCHOOL PERSONNEL
Information from Epilepsy Foundation
 Discuss
what a Seizure is.
 Review types/signs of Seizures.
 Seizure Triggers or Precipitants
 What to do during a Seizure.
 Recognize when a Seizure is a Medical
Emergency.
What is a Seizure?
A brief, excessive discharge of electrical activity in
the brain that alters one or more of the following:
 Movement
 Sensation
 Behavior
 Awareness
 Most
Seizures are NOT medical Emergencies!
Types and Signs of Seizures

Generalized Seizures: (seizures involving the entire brain)
*Tonic-Clonic (generally last 1 to 3 minutes, sudden, loss of
consciousness, convulsions, stiffening and/or jerking of
extremities)
*Absence Seizures(generally last 1 to 10 seconds, lapse of
awareness, blank stare, pause in activity)

Partial Seizures: (seizures involving only part of the brain)
*Simple/Complex Partial (awareness maintained and/or impaired,
psychic/sensory symptoms, inability to respond)
Seizure Triggers and Precipitants


Flashing lights and hyperventilation can trigger seizures in some
students with epilepsy
Factors that might increase the likelihood of a seizure in students with
epilepsy include:









Missed or late medication (#1 reason)
Stress/anxiety
Lack of sleep/fatigue
Hormonal changes
Illness
Alcohol or drug use
Drug interactions (from prescribed or over the counter medicines)
Overheating/overexertion
Poor diet/missed meals
What to do during a Seizure?









Remain calm
Time seizure
Ensure safety
Clear the area
Cushion head, remove glasses
Turn on side, loosen any tight clothing
Nothing in mouth; don’t hold down
Protect privacy
After: reassure and stay with them
When is a Seizure an Emergency?
Call 911 When:

Convulsive (tonic-clonic) seizure > 5 minutes






Please refer to individual student health plan & consult
with your nurse.
Repeated seizures without
regaining consciousness
Injured or other medical condition
First-time seizure
Breathing difficulties
Possible pregnancy
Contact Information
Epilepsy Foundation Information and
Referral. (800) 332-1000
www.epilepsyfoundation.org
What is Asthma?
Asthma Triggers








Allergens (mold, dust, pollen, animals etc.)
Chemicals (sulfites, aspirin, etc.)
Emotions (stress, crying, excitement)
Exercise
Irritants (perfume, cleaning fluids, smoke)
Respiratory Infections (cold, flu, sinus)
Seasonal/Time (day vs. night)
Smoking
Image Retrieved from:http://www.momscleanairforce.org/2013/05/20/asthma-cartoon
Wheezing
 Frequent Cough
 Chest Tightness
 Shortness of Breath
 Difficulty Walking or Talking
 Check their Peak Flow Meter
if they have one.

Three Types: Please call nurse if unsure of
the type of inhaler provided.
1.
2.
3.
Rescue
Maintenance
Steroid Reversing Medication
Rescue Inhaler

Rescue Inhaler/Symptom Relieving:
FOR SCHOOL
Example: Albuterol/Ventolin/Pro Air HFA
Maintenance Inhaler

Maintenance/Preventative: Home Use
Example: Advair, Q Var, Dulera
No inflammation=no muscle irritation=no tightening of the breathing tubes.
Steroid Flare Up Reversing
Medication
Example: Prednisone
Symptom Relieving:
Rapid Heart Rate
 Tremors
 Nervousness
 Headache

1.
Help to sit upright; stay calm and reassure
2.
Follow Emergency Action Plan &/or Doctors order for use of
rescue inhaler
3.
Get help from school nurse or notify parent if student has any of
the following:
•
Inhaler not helping
•
Breathing hard and fast
•
Can’t walk or talk well
4.
Call 911 if not breathing, unconscious, lips blue, struggling to
breathe (hunched over or ribs show), or other signs of distress
Notify Parent or Guardian

Remove the cap and hold the inhaler upright.

Shake the inhaler

Tilt your head back slightly and breathe out.

Press down on the inhaler to release the medicine as you start to
breathe in slowly.

Breathe in slowly for 3 to 5 seconds.

Hold your breath for 10 seconds to allow medicine to go deeply into
your lungs.

Repeat puffs as directed. Wait 1 minute between puffs to allow the
second puff to get into the lungs.
Asthma Action Plan

Please have parents and/or doctor
complete the plan for students that have
significant difficulty with their asthma.
Vasovagal Syncope
Student faints in response to trigger (sight
of blood, heat, lack of food or water, fear
of injury, standing for a long time, etc.)
 If a student loses consciousness call 911
 Student should be checked by MD.
especially if it is a first occurrence.
 If known history and student uninjured
he/she should rest for 15 to 30 minutes.

Heart Conditions and AEDs
AED can save a child’s life that has a
heart condition.
 AED awareness training annually at your
school sites.
 AT least one person on site at all times
that is CPR certified.
 Register at Coastal Valley EMS
 Place device in visible location for anyone
to use.

Monthly AED Readiness Check
Date
Functional(green light)
Adult Padpak Exp date
Ped Padpak Exp date
Signature
What is Diabetes?

Body does not make or properly use
insulin.

Insulin is needed to:
•

Move glucose from blood into cells for energy
If insulin isn’t working, high blood glucose
results:
•
•
•
Energy levels are low
Dehydration
Complications
Retrieved from: www.diabetes.org
Type 1
 Insulin
dependent
diabetes
 Insulin producing
cells (pancreas)
destroyed by body
 Must take insulin daily
by injection or insulin
pump.
Type 2
 Most
common in
adults.
 Pancreas can still
make insulin.
 Diet, weight, lifestyle,
and genetics causes.
 Early diagnosis
controlled with
medications at home.
Signs and Symptoms of
Diabetes
Increased urination
 Increased thirst
 Increased tiredness
 Acanthosis Nigricans=dark pigmentation
of skin around neck

http://www.bing.com/images/search?q=nigricans+albicans&qpvt=nigricans+albicans&FORM=IGRE
 Medication/insulin
 Blood
sugar monitoring
 Carbohydrate Counting
 Exercise
 24/7 Job
http://www.bing.com/images/search?q=juggling+type+1+diabetes&qs=n&form=QBIRMH&pq=juggling+type+1+diabetes&sc=0-12&sp=-1&sk=
Diabetes Medical Management
Plan
Basis for all school-based diabetes care
plans.
 Developed by student’s personal health
care team and guardian.
 Signed by a member of student’s personal
health care team.
 Individualized

 Basal
dose is the background insulin that
works for 24 hours
 Bolus dose is extra insulin given for
carbohydrates
 Correction dose is used to decrease high
blood sugar
 Ketones are acids produced by the body
when it burns fat for fuel. Bad for
diabetics.
 I:C is the insulin to carbohydrate ratio
 Insulin
and Activity make blood sugar go
down
 Food makes blood sugar go up
 Stress, illness, and injury affect blood
sugar and it can go up or down.
 Many
older students are independent!
 Some students will need school staff to
observe or assist with care.
 All students with diabetes will need
help in the event of an emergency
situation.
 Always check the health plan
 Never leave student alone
In Range (set by doctor)
 Administer insulin per plan
 Document
 Back to class
Too high=
Hyperglycemia
Too low=
Hypoglycemia
Goal is to lower blood sugar within range
 Check blood glucose
 Allow use of the bathroom
 Allow access to water
 Insulin dose if stated in plan
 Check ketones if in plan
 Call home
 May NOT PLAY or DO PE if ketones present
 Ketones can lead to diabetic keto-acidosis
emergency

 Develop
over time, usually one high blood
sugar is not a cause for an alarm.
 Pumpers can develop faster
 Time to check can vary based on health
care plan.
 Always check if have
Nausea
Vomiting
Abdominal
Pain
Flu like symptoms
 Two
ways to check ketones; blood or urine
 Pee on a keto stick
 Any color on the stick is a call home
 Darker the color the more serious
 Dark and vomiting call 911 if unable to
reach parent this can become very
dangerous and serious
 Blood
sugar too low – usually less than
80
 Quick onset
 Requires immediate treatment
 May lead to unconsciousness if not
 Most students will be able to recognize the
signs and symptoms of hypoglycemia but
not always…
Hypoglycemia Signs and
Symptoms
Mild
 Extreme Hunger
 Tremors
 Lethargic
 Increased heart rate
 Pale skin
 Sweating
 Change in Personality
 Shakiness
 Dizziness
 Headache
 Lethargic
 Dilated Pupils
 Clammy Skin
 Anxiety
Moderate to Severe










Yawning
Irritability/frustration
Behavior/personality changes
Extreme tiredness/fatigue
Sudden crying
Restlessness
Confusion
Inability to swallow
Dazed Appearance
Seizures, convulsions
Unconsciousness/coma
jerking movements







Blood sugar (BS) check
 If no meter, treat for a low with…
Rule of 15
 Student eats / drinks 15 grams of a fast acting
carbohydrate
• 4 oz. of juice
• 3-4 glucose tablets
• 1-2 TBSP honey
• 6 oz. regular soda --NOT DIET SODA
• 3 tsp. sugar in water
Re-check BS in 10-15 min
Repeat with 15 more grams if still low
Recheck in 10-15 min
If symptoms continue, call home
Do Not Over Treat or allow student to over treat
 Student
unable to swallow or unconscious
 Inject glucagon ASAP! Call 911
 Position student on side will vomit
 Call parent or guardian and nurse
 Stay with the student
 Student should respond to the glucagon in 1020 minutes
 When student is awake and able to swallow give
juice while waiting for EMS
 If student found unconscious assume low BS
 Naturally
occurring pancreatic hormone
 It raises blood glucose level by releasing
liver glycogen.
 Treatment for severe hypoglycemia.
 Can save a life!
 Cannot harm a student – cannot overdose.
 There are different doses, check the doctor’s
order.
88
 Place:
As designated in DMMP accessible to
school personnel.
 Store at room temperature
 Expiration date: Monitor
 After mixing, dispose of any unused portion
within one hour.
89
1.
Flip cap off glass vial
containing dry powder
2.
Remove cap from syringe
3.
Put on gloves if available
90
4.
Inject entire fluid in syringe
into the bottle containing
powder
5.
Shake gently or roll to mix
until all powder is dissolved
and solution is clear.
91
6.
Inspect. Solution should
be clear and colorless.
7.
Draw prescribed amount
of glucagon back into
syringe.
92
8.
Clean site if possible.
9.
Inject at 90° into the tissue under
cleansed area (may administer through
clothing as necessary



buttocks
thigh
arm
93
10.
11.
12.
13.
14.
15.
May take 10-20 minutes for student to
regain consciousness
Check blood glucose
Give sips of fruit juice or regular soda,
once student is awake and able to drink
Advance diet as tolerated
Document as per DMMP
Do not recap syringe. Discard sharp in
appropriate container
94
 The
time to complete recovery from a severe
hypoglycemic episode varies according to how low
the blood glucose level was and for how long prior
to treatment
 Some signs and symptoms, such as headache,
may persist for several hours, although the blood
glucose level is satisfactory
 Continued monitoring is important
 Student may need to be transported via EMS or
go home with parent/guardian
95
 Student
does not remember being
unconscious, incoherent or has a headache
 Blood
200)
glucose becomes very high (over
 Nausea
or vomiting may occur
96
Glucagon Training Documentation
Send copy to HR
 Keep a copy for your own records

Diabetes Monitoring Log

For the supervision of diabetic students at
school.

Let your nurse know if you have a student
that requires supervision.
Legal Considerations

In the State of California unlicensed
assistive personnel may administer insulin.
Maintaining and Reporting
Immunization Information





Review immunization records and ensure
requirements are met
Shots for School
Complete state reports for K and 7th grade
Annually send report to Public Health Dept. for K
and notify your nurse when complete. Send
proof to Special Services.
Notify nurse of any questions or concerns
Immunization Guidelines





Conditional vs Unconditional Admission
30 day grace period while waiting for records
Waiver Forms
Homeless may attend without immunizations.
http://eziz.org/assets/docs/IMM-1080.pdf
CAIR
Please review form; add email and school
 Promise of CONFIDENTIALITY
 Password and User Name
 District Nurses to follow up
 CAIR web information
 Jrodriguez@srcs.k12.ca.us
