WV COUNCIL OF SCHOOLS RECCOMMENDATIONS ...... 1-25 Body Mass Index (BMI) ...... 1 Dental Inspections/Screening...... 5 Injectable Cortisol ...... 7 Intramuscular (IM) Imtrex ...... 9 Intravenous (IV) Clotting Factor ...... 10 Peritoneal Dialysis ...... 11 Postural Screenings ...... 13 Public School Lice Policy/Procedures ...... 16 Pure Tone Hearing Screening ...... 19 Pulse Oximeters ...... 22 Reinsertion of Gastrostomy Tube (G-tube) ...... 24 Vision Screening ...... 25

POSITION STATEMENTS…………………………………………………………30-31 Immunizations for West Virginia Public Schools……………………………………….30 Insulin Administration at School

INFORMATIONAL GUIDES ...... 33-44 Chest Vests for Airways Clearance ...... 33 Intrathecal Baclofen Therapy ...... 35 Pacemaker and ICD ...... 37 Pressure Garments for Burns ...... 39 Real-time Continuous Glucose Monitoring System ...... 41 Venous Access Devices ...... 43 Mitrofanoff………………………………………………………………………………. Malone Antegrade Continence Enemas (MACE)………………………………………… Assessing Behavioral and Mental Health Needs of Students …………………………….35

EMERGENCY ACTION PLANS (EAPS)/INTERVENTION GUIDES ...... 46-52 Asthma Intervention Guide ...... 46 Diabetes (Insulin Dependent) Guide ...... 48 Severe Allergic Reaction Guide ...... 50 Seizure Intervention Guide ...... 52 Asthma Intervention Guide ...... 46 Diabetes (Insulin Dependent) Guide ...... 48 Severe Allergic Reaction Guide ...... 50 Seizure Intervention Guide ...... 52

SCHOOL NURSE PERFORMANCE EVALUATION TOOLS ...... 55-59

SAMPLE AED POLICY AND PROCEDURE ……………………………………61-74

SKILLS PERFORMANCE CHECKLIST…………………………………………75

APPENDIX EARLY DEFIBRILLATION PROGRAM REGISTRATION GUIDELINE

West Virginia Council of School Nurses

2018 WVCOSN

Region I – Allison St. Clair, Monroe County Region II – Kristi Scaggs, Logan County Region III – Linda Parsons, Kanawha County Region IV – Jenny Friel, Pocahontas County Region V – vacant Region VI – Tiffany Heizeman, Wetzel County Region VII –Rebecca Wise (Secretary), Monongalia County Region VIII – Rhonda Dante (Chair), Hampshire County

2015 WVCOSN RESA I – Amanda Ashley, Raleigh County RESA II – Kristi Scaggs, Logan County RESA III – Melinda Embrey, Kanawha County RESA IV – Jenny Friel, Pocahontas County RESA V – Kristin Stover, Jackson County RESA VI – Carol Cipoletti, Brooke County RESA VII – Rebecca Wise, Monongalia County RESA VIII – Rhonda Dante, Hampshire County

Rebecca J. King - WVDE, Office of Special Programs

We are also grateful to Paula Fields, WVDE-Community Schools Coordinator.

2009 WVCOSN RESA I - Donna (Susie) Poindexter, Wyoming County RESA II - Melinda Gibson, Wayne County RESA III - Delberta Riffe, Putnam County RESA IV - Sarah E. Jordan (Beth), Nicholas County RESA V - Elaine Rinehart, Wirt County RESA VI - Diana Baker, Marshall County RESA VII - Debbie Derico, Upshur County RESA VIII - Sharon Clark, Mineral County

Rebecca J. King - WVDE, Office of Healthy Schools

Special Thanks to the 2010 New WVCOSN Members RESA VI - Carol Cipoletti, Brooke County RESA VII - Debbie Stine, Berkeley County

2006 WVCOSN RESA I - Debbie Kaplan, Raleigh County RESA II - Teresa Ryan, Lincoln County RESA III - Nancy Doss, Boone County RESA IV - Rhonda Tabit, Fayette County RESA V -Alisa Shepler, Ritchie County RESA VI - Diana Barker, Marshall County RESA VII - Nancy Bradshaw, Upshur County RESA VIII - Sharon Clark, Mineral County

Rebecca J. King - WVDE, Office of Healthy Schools

We are also grateful to Mary Jane Rinard of Berkeley County (RESA VII) and Barbara Hart of Marshall County (RESA VI), for contributing in the development of this document. Both were members of the West Virginia Council of School Nurses from 2001-2005.

Recommendations

by the WV Council of School Nurses

2018 RECOMMENDATION

BODY MASS INDEX (BMI) SCREENING AND REFERRALS IN THE SCHOOL SETTING

In reviewing current research and research-based recommendation regarding body mass index (BMI) screenings for children in the school setting, the West Virginia Council of School Nurses feels this is a clinical screening which should be performed by the student’s medical home. The student’s medical home is able to provide the student and parent with individualized medical advice, continued follow-up, community resources including behavioral interventions, education and/or prescribed physical activity and nutritional plans. While the school is able to provide screening with medical home referrals and some education, the ability to follow-up, provide comprehensive science-based prescribed strategies around physical activity, nutrition and behavioral interventions for individual students does not exist. Schools provide evidence-based health strategies and programming for all students, not prescribed medical strategies for individual students. Public schools are educational models with a health component to provide for individualized special health care needs based on the prescribed order of a medical provider during the school day.

The HealthCheck medical provider manual requires the measurement of height and weight for ages 0-21 years with the option to plot measurements on a standard growth chart or use BMI calculations. In 2010, the HealthCheck documentation form began incorporating BMI along with the height and weight measures. The United States Prevention Services Task Force (USPSTF) recently recommended clinicians screen children aged 6 to 18 years for obesity and offer or refer them to comprehensive weight management programs. Comprehensive weight management programs incorporate

counseling and other interventions targeting diet and physical activity along with intensive behavioral interventions to promote improvement in weight status (USPSTF, 2010). Interventions that focused on younger children incorporated a parental involvement component in the program.

Over the past several years, research into weight management in obese children and adolescents has improved in quality and quantity. Despite important gaps, available research supports at least short-term benefits of comprehensive medium- to high-intensity behavioral interventions in obese children and adolescents (Whitlock, 2010).

As public school systems continue to work with the student’s medical home, the medical provider must be made aware of the importance of documenting the student’s height and weight along with BMI calculation on the HealthCheck/comprehensive screening form. If the height, weight and/or BMI are not documented on the HealthCheck or comprehensive screening form, please request the parent complete a school HIPAA/FERPA consent to allow school health/entry personnel to speak directly to the medical provider’s office or have the parent request the proper documentation from the medical provider. The West Virginia Department of Health and Human Resources (WVDHHR)-HealthCheck Program has incorporated the BMI into the 2014 Periodicity Schedule and the HealthCheck documentation form (WVDHHR, 2014)

The Centers for Disease Control and Prevention (CDC) recommends BMI surveillance, as seen with the WVU-Coronary Artery Risk Detection In Appalachian Communities (CARDIAC) Project, instead of census screening completed by schools (CDC, 2007). A representative sample through surveillance data allows the data to be generalized to the entire population with a minimal confidence interval for accuracies. We must work to maintain the measurement of height and weight along with the calculation of BMI within the student’s medical home to ensure a comprehensive medical record with proper interventions and resources as applicable.

Note:

The U.S. Preventive Services Task Force (USPSTF), first convened by the U.S. Public Health Service in 1984, and since 1998 sponsored by the United States Department of Health and Human Services (USDHHS)-Agency for Healthcare Research and Quality (AHRQ), is the leading independent panel of private-sector experts in prevention and primary care. The USPSTF conducts rigorous, impartial assessments of the scientific evidence for the effectiveness of a broad range of clinical preventive services, including screening, counseling, and preventive medications. Its recommendations are considered the "gold standard" for clinical preventive services.

Public Law Section 915 mandates that USDHHS-AHRQ convene the USPSTF to conduct scientific evidence reviews of a broad array of clinical preventive services, develop recommendations for the health care community, and provide ongoing administrative, research, technical, and dissemination support.

The mission of the USPSTF is to evaluate the benefits of individual services based on age, gender, and risk factors for disease; make recommendations about which preventive services should be incorporated routinely into primary medical care and for which populations; and identify a research agenda for clinical preventive care. For more information, please go to http://www.ahrq.gov/clinic/uspstfab.htm.

Devised: 11/01/10

Revised: 8/2018

References

Centers for Disease Control and Prevention. (2007). Body Mass Measurement in Schools Executive Summary. CDC Retrieved on November 1, 2010 form http://www.cdc.gov/HealthyYouth/obesity/BMI/pdf/BMI_execsumm.pdf.

Nihiser AJ, Lee SM, Wechsler H, McKenna M, Odom E, Reinold C,Thompson D, Grummer-Strawn L. (December, 2007). Body Mass Index Measurement in Schools. Journal of School Health. 2007;77:651-671. Retrieved on November 1, 2010 form http://www.ashaweb.org/files/public/JOSH_1207/josh_Final_249_07Nov27.pdf.

U.S. Preventive Services Task Force. (January 2010). Screening for Obesity in Children and Adolescents. Agency for Healthcare Research and Quality, Rockville, MD. Retrieved on October 13, 2010 from http://www.ahrq.gov/clinic/uspstf/uspschobes.htm.

West Virginia Department of Health and Human Resources. (2014). Periodicity Schedule. Office of Maternal Child and Family Health, HealthCheck Program, Charleston, W.V. Retrieved on November 1, 2015 from http://www.dhhr.wv.gov/HealthCheck/providerinfo/Documents/HC%20periodicity%20sc hedule%2002-15.pdf.

Whitlock, Evelyn. (January 2010). Effectiveness of Weight Management Interventions in Children: A Targeted Systematic Review for the USPSTF. Pediatrics 2010;125:e396-e418. Retrieved on November 1, 2015 from http://www.ncbi.nlm.nih.gov/pubmed/20083531.

DISCLAIMER :

The “Recommendation” of the West Virginia Council of School Nurses (WVCOSN) is not representative of West Virginia State Code or West Virginia State Board of Education recommendation or policy. This is a recommendation based on consensus, evidence-based practice reviews and current research from the

WVCOSN. The WVCOSN is set forth by W.Va. Code §18-5-22.

The certified school nurse is responsible for utilizing nursing judgment and skill to determine the safest delivery of health care on an individual case-by-case situation in the West Virginia public school setting while protecting the welfare and health of the student. Every situation is unique and requires a collaborative team approach lead by the certified school nurse, which includes, but not limited to, the student, parents/guardians, school administrator, experts in the field and the student’s primary health care provider, at the local level.

2018 RECOMMENDATION

DENTAL INSPECTIONS/SCREENINGS

It is the recommendation of the West Virginia Council of School Nurses that dentists conduct proper dental inspections/screenings for all children. W.Va. Code §30-4-15 defines the scope of practice of the dentist as examining, evaluating and diagnosing diseases, disorders and conditions of the oral cavity.

It is within the scope of practice of the certified school nurse to perform a nursing assessment of the oral cavity and recommend to the parent/guardian that further evaluation is needed when a student presents with signs or symptoms or need for examination of the oral cavity. It is the role of the certified school nurse to promote and/or provide oral health education in the school setting.

A letter communicating the results of the oral cavity assessment should be given to the parent or guardian, as soon as possible, when further evaluation is warranted. A method should be developed for tracking referrals and for encouraging follow-ups as needed. The West Virginia Education Information System (WVEIS) provides a method for recording and tracking dental screening results.

It is NOT the role of the certified school nurse to perform massive dental screenings. A total of 98% of West Virginia children have medical insurance and should be receiving a comprehensive physical exam (i.e. HealthCheck) annually with a dental screening. The health provider’s dental screening results shall be valid up to one year and meet the requirements of dental screening, as indicate in West Virginia State Board

of Education Policy 2525. The school nurse also needs to be aware of community services available to assist students in obtaining follow-up treatment.

Devised: 2006

Revised: 08/2018

DISCLAIMER:

2018 RECOMMENDATION

Intramuscular (IM) Imitrex

It is the recommendation of the West Virginia Council of School Nurses that intramuscular Imitrex should not be administered by school nurses in the school setting. However, students who have orders for self-administration of Imitrex intramuscularly from a licensed prescriber and permission of the parent/guardian may self-administer in the school setting. The school nurse should assess and develop a comprehensive emergency plan for management of the student after self-administration of Imitrex intramuscularly in the school setting.

DISC LAIMER:

The “Recommendation” of the West Virginia Council of School Nurses (WVCOSN) is not representative of West Virginia State Code or West Virginia Board of Education recommendation or policy. This is a recommendation based on consensus, evidence-based practice reviews and current research from the WVCOSN N. The WVCOSN is set forth by W.Va. Code §18-5-22.

Devised: 2006 Revised: 08/2018

2018 RECOMMENDATION

Intravenous (IV) Clotting Factor

It is the recommendation of the West Virginia Council of School Nurses that intravenous (IV) Clotting Factor should not be administered by school nurses or other school personnel. However, students who have been trained and deemed competent by a hemophilia specialist to self-administer IV Clotting Factor may do so with proper physician authorization and parent/guardian permission. The school nurse should collaborate with the hemophilia specialist/physician to develop a comprehensive emergency plan for management of the student requiring administration of IV Clotting Factor in the school setting.

DISCLAIMER:

The “Recommendation” of the West Virginia Council of School Nurses (WVCOSN) is not representative of West Virginia State Code or West Virginia Board of Education policy/recommendation. This is a recommendation based on consensus, evidence-based practice reviews and current research from the WVCOSN. The WVCOSN is set forth and defined by W.Va. Code §18-5-22.

Devised: 2006

Revised: 08/2018

2018 RECOMMENDATION

PERITONEAL DIALYSIS

It is the recommendation of the West Virginia Council of School Nurses, that Continuous Ambulatory Peritoneal Dialysis (CAPD) not be performed in the school setting. Infection is the most common problem for those on CAPD. It would be extremely difficult to find an appropriate place within our school buildings where CAPD could be performed safely without an increased risk for infection. The School Nurse should collaborate with the provider to develop an emergency plan for the student.

Devised: 2009

Revised: 08/2018

References

Gokal, R., Khanna R., R. TH. Krediet and K.D. Nolph. (2000). Kluwer Academic Publishers: Testbook of Peritoneal Dialysis. pp. 364.

National Kidney and Urologic Diseases Information Clearinghouse. (May 2006). Treatment Methods for Kidney Failure: Peritoneal Dialysis. Retrieved on December 2009 from http://kidney.niddk.nih.gov/kudiseases/pubs/peritoneal/#how.

DISCLAIMER:

2018 RECOMMENDATION

POSTURAL SCREENINGS

Postural (scoliosis) screening is NOT mandated by West Virginia State Law, but has been commonly performed in many counties. Mass screening for scoliosis requires a considerable amount of time. This condition only affects 2-3% of the population of the entire United States.

The United States Preventive Services Task Force (USPSTF), a division of the Agency for Health Care Research and Quality (AHCRQ), did not find good evidence that screening asymptomatic adolescents detects idiopathic scoliosis at an earlier stage than detection without screening. The accuracy of the most common screening test—the forward bending test with or without a scoliometer—in identifying adolescents with idiopathic scoliosis is variable, and there is evidence of poor follow-up of adolescents with idiopathic scoliosis who are identified in community screening programs.

The USPSTF found fair evidence that treatment of idiopathic scoliosis during adolescence leads to health benefits (decreased pain and disability) in only a small proportion of people. Most cases detected through screening will not progress to a clinically significant form of scoliosis. Scoliosis needing aggressive treatment, such as surgery, is likely to be detected without screening.

The USPSTF found fair evidence that treatment of adolescents with idiopathic scoliosis detected through screening leads to moderate harms, including unnecessary brace wear and unnecessary referral for specialty care. As a result, the USPSTF concluded that the harms of screening adolescents for idiopathic scoliosis exceed the potential benefits.

The National Association of School Nurses (NASN) does not have a position statement or policy brief on postural screening in schools. Therefore, the WV Council of School Nurse recommends school nurses DO NOT perform mass postural screenings due to the outcomes of evidence-based research by USPSTF.

Note:

Devised: 2006

Revised: 08/2018

References

Adams, Susan RN, BSN and McCarthy, Ann Marie RN, PhD, FAAN. (October 2005). Evidence-Based Practice and School Nursing. The Journal of School Nursing, Volume 21, Number 5.

U.S. Preventive Services Task Force. (June 2004). Screening for Idiopathic Scoliosis in Adolescents: Recommendation Statement. Agency for Healthcare Research and Quality, Rockville, MD. Retrieved on December 13, 2006 from http://www.ahrq.gov/clinic/3rduspstf/scoliosis/scoliors.htm.

DISCLAIMER:

2018 RECOMMENDATIONS

PUBLIC SCHOOL LICE POLICY/PROCEDURE

Head lice (pediculosis capitus) are small parasitic insects that live on the scalp and neck hairs of their human hosts. Physically they have remained unchanged for 2000 years. No disease is associated with head lice and in‐school transmission is considered to be rare. When transmission occurs, it is generally found among younger‐age children with increased head‐to‐head contact (Frankowski & Bocchini, 2010). Complications related to infestation are rare; pruritis (itching) is the most common problem.

The West Virginia Council of School Nurses (WVCOSN) recognizes the importance of regular school attendance and the maintenance of a learning environment conducive to the academic success of children. “No-nit policies that exclude children until all nits are removed may violate a child’s civil liberties and are best addressed with legal counsel for schools. The American Academy of Pediatrics and the National Association of School Nurses discourage no-nit policies that exclude children from school (AAP, 2015). A study of attendance records found that 12 to 24 million school days are lost annually in the United States due to exclusion of students for nits. Exclusion for any reason has been correlated with truancy as well as with poor academic performance. According to the American Academy of Pediatrics (AAP), “screening for nits alone is not an accurate way of predicting which children will become infested.” In a study of 1729 students who were screened for head lice, 91 were found to have nits. They found that those children who had more than 5 nits within 1 cm or ¼ of an inch of the scalp were more likely to develop an infestation and then only 1/3 of those in that group actually developed an active case of lice (Williams, 2001). The presence of nits does not indicate active infestation; exclusion of these children for nits alone would have resulted in them missing school unnecessarily and could result in poor academic performance. 14

According to the AAP, head lice screening programs in schools do not have a significant effect on the incidence of head lice and are not cost effective. A more appropriate management tool in controlling head lice outbreaks within the classroom would be a parent education program.

The WVCOSN recommendation for the treatment of head lice includes:  The school nurse, the most knowledgeable professional in the school community regarding pediculosis management, will train school personnel responsible for detecting head lice.  Lice or nits less than ¼ inch or 1 cm from the scalp, then the parent or guardian shall be called and made aware of the situation.  The parent or guardian will be educated as to the appropriate health information for treatment and prevention of pediculosis.  The student will be permitted to return to the classroom when they are lice free.  The student will be rescreened as necessary to detect the presence of live lice.  Classroom screening is NOT warranted.

Conclusion: Data does not support the exclusion of children for nits or lice. No disease process is associated with head lice; therefore pediculosis should not disrupt the education process. Students found with live head lice should be referred to parents or guardians for proper treatment and reevaluated as necessary to prevent a recurrence. Therefore, it is the recommendation of the West Virginia Council of School Nurses that “No-Nit” polices be eliminated and students be allowed to return to the classroom with lice.

Devised: 2006

Revised: 8/2018

References

American Academy of Pediatrics. (May 2015). Head Lice. Retrieved from file:///C:/Users/bking/AppData/Local/Microsoft/Windows/INetCache/Content.Outlook/8 SGMH4WY/AAP%20Lice%20Guidance%202015.pdf.

Centers for Disease Control and Prevention. (September 2015). Head Lice Information for Schools. Retrieved from http://www.cdc.gov/parasites/lice/head/schools.html.

Frankowski, B.L,, & Bocchini, J.A.. (2010). Clinical Report‐Head Lice. Pediatrics. 126(2) 392- 403. Retrieved from http://pediatrics.aappublications.org/cgi/content/abstract/126/2/392doi:10.1542/peds.2010 ‐1308.

National Association of School Nurses. (January 2011). Position Statement. Pediculosis Management in the School Setting. Retrieved from http://www.nasn.org/Default.aspx?tabid=237.

Pollack, Richard J. PhD. (August 9, 2000). Head Lice Information. Harvard School of Public Health. Retrieved on January 25, 2006 from http://www.hsph.harvard.edu/headlice.html#harm.

Williams LK, Reacher A, Mac Kenzie WR, Hightower AW, Blake PA. (2006). Lice, nits and school policy. Pediatrics 2001: 107:1011-1015. Retrieved from http://www.co.washington.wi.us/uploads/docs/CHN_AAP_LiceNitsSchoolPolicy.pdf.

: DISCLAIMER

The “Recommendation” of the West Virginia Council of School Nurses (WVCOSN) is not representative of

West Virginia State Code or West Virginia State Board of Education recommendation or policy. This is a recommendation based on consensus, evidence-based practice reviews and current research from the

WVCOSN. The WVCOSN is set forth by W.Va. Code §18-5-22.

2018 RECOMMENDATION

PURE TONE HEARING SCREENING

According to West Virginia Code §18-5-17, pure tone hearing screening is a compulsory pre-enrollment screening for all children entering public school for the first time in this state. An audiologist, speech pathologist or support personnel under the supervision of an audiologist should perform this hearing screening. The length and type of supervision is to be determined by the supervising audiologist. The Regional Education Services Agencies (RESA) has coordinated service delivery through audiologists who have developed “Hearing Screening Guidelines” in accordance with guidelines recommended by the American Speech and Hearing Association (1997).

Audiometers used for screening must meet ANSI (American National Standards Institute 1996) S3.6-1996 requirements for either limited range audiometers or wide range audiometers and must be calibrated annually (1). Any other method of testing such as noisemakers, whispering, hand-held devices, speech stimuli, or group screening is not recommended as appropriate procedures.

A normal pure tone hearing screening is when a child can hear at the intensity of 20dB HL at the frequencies of 1000Hz, 2000Hz and 4000Hz, and at 25dBHL at 500Hz. A child who does not pass at the appropriate dB should be retested a second time after they have been re- instructed and the headset has been readjusted. (2). Referral to an audiologist should be made if the child does not hear a 20dB tone at 1000Hz, 2000Hz, and 4000Hz and a 25dB tone at 500Hz.

Documentation of hearing results can be either pass or refer (1). Students who do not pass the screening and recheck must be referred to an audiologist for follow-up evaluation. A 17

letter communicating the results of the screening and recommendations should be given to the parent or guardian and the student’s physician as soon as possible. A method should be developed for tracking referrals and for encouraging follow-up as needed. The West Virginia Education Information System (WVEIS) provides a method for recording and tracking hearing results.

It is the recommendation of the West Virginia Council of School Nurses that counties shall employ an audiologist, speech pathologist or support personnel under the supervision of an audiologist to perform hearing screenings. An audiologist must train all persons/school personnel who perform hearing screenings. Approximately 98% of West Virginia children have medical insurance and should be receiving a comprehensive physical exam (i.e. HealthCheck) annually with a hearing screening. The health provider’s hearing screening results shall be valid up to one year and meet the requirements of hearing screening, as indicated in W.Va. Code §18- 5-17 and West Virginia State Board of Education Policy.

Devised: 12/27/06

Revised: 08/2018

References

American National Standards Institute. (1996). Specifications for Audiometers (ANSIS.6-1996). New York: Acoustical Society of America.

American Speech-Language-Hearing Association. (1997). Guidelines for Audiologic Screening. Retrieved on May 2008 from http://resa7.k12.wv.us/.

Hendershot, L.B., Chair. WV Speech, Language, and Hearing Association Hearing Screening Task Force. (1999). Hearing Screening Guidelines. Fairmont, WV. Retrieved on May 2008 from http://resa7.k12.wv.us/

DISCLAIMER :

2018 RECOMMENDATION

THE USE OF PULSE OXIMETERS IN THE SCHOOL SETTING

The Basic and Specialized Procedure Manual for WV Public Schools currently has two procedures which have a pulse oximeter listed as equipment needed. Those are: Mechanical Ventilator and Phrenic Nerve Stimulator. These are student specific and ordered by a physician. The pulse oximeter is to be supplied by the parent / guardian. The student specific order should include interventions for abnormal readings.

Use of a pulse oximeter as an assessment tool for general school nurse practice should be determined by the comfort level of the individual school nurse. In this use, the pulse oximeter should be considered an assessment tool, not a procedure.

It is the West Virginia Council of School Nurses recommendation that if a school nurse chooses to utilize a pulse oximeter as an assessment tool to complement other forms of patient assessment, that school nurse must be familiar with how to use it, decide what its purpose will be and what actions will be taken if an abnormal reading is obtained.

Each nurse who utilizes this tool must be aware that several variables can cause an abnormal reading. Some of these variables include lighting, nail polish, cold temperatures (causing vasoconstriction) and certain disease processes.

Also, there is a “lag time” with a pulse oximeter. When using the oximeter to assist with assessment for anaphylactic reactions or asthma, it must be understood that by the time the pulse oximeter gives a low reading, the patient may already be in serious trouble and needing

intervention. When in doubt, the school nurse must rely upon clinical judgement / assessment skills, rather than the machine.

Devised: November 2009 Revised: 08/2018

References

West Virginia Council of School Nurses. (2006). Basic and Specialized Health Care Procedures Manual for West Virginia Public Schools.

Nettina,Sandra M. (2006). Lippincott Manual of Nursing Practice 8th Edition. pp. 213-214 Lippincott, Williams & Wilkins Publishers, Philidelphia, PA.:.

Lewis, Sharon M. (2004). Medical Surgical Nursing 6th Edition. pp. 547-548, 1772. Mosby, St. Louis, MO.:

DISCLAIMER :

recommendation based on consensus, evidence-based practice reviews and current research from the WVCOSN. The WVCOSN is set forth by W.Va. Code §18-5-22.

2018 RECOMMENDATION

REINSERTION OF GASTROSTOMY TUBE (G-TUBE)

It is the recommendation of the West Virginia Council of School Nurses that a gastrostomy tube (G-tube) should not be reinserted by the school nurse or other school personnel in the school setting. Accidental removal of a G-tube is not a life threatening situation, however timely reinsertion should be performed by the parent/guardian or student’s health care provider as arranged by the parent/guardian.

Devised: 2006

Revised: 08/2018

DISCLAIMER:

2018 RECOMMENDATIONS

VISION SCREENING

Vision screening for school children is intended to help identify children who have a vision problem that might affect physiological or perceptual processes of vision that could interfere with academic performance. Vision screenings are not diagnostic, but screening results may indicate a potential need for further assessment. The grade level in which students receive vision screenings vary from state to state. W.Va. Code §18-5-17 requires a vision screening on all children prior to entering a West Virginia public school for the first time.

The United States Preventive Services Task Force (USPSTF), a division of the Agency for Health Care Research and Quality (AHCRQ), estimates the occurrence of visual impairments in children five years of age and younger is between 5% to 10% (USPSTF, 2012). The National PTA has estimated that more than 10 million children from birth to age 10 have vision problems that cause them to fail in school (Press 2000). The incidence of visual problems increases among children with certain chronic, genetic, and congenital conditions; socioeconomic backgrounds; or parents or siblings with an identified vision problem (NASN, 2015). The highest incidence of newly acquired vision anomalies is between the ages of 9 and 13 (Proctor 2005).

The West Virginia Council of School Nurses (WVCOSN) recommends the following vision screening schedule:

• Visual acuity for all first time enterers and visual acuity between the ages of 11- 13 years

The following students should also be screened on a priority basis:

• Students referred by teacher, parent, or student him/herself

• Students at high risk: special education, repeating a grade or failed a previous vision screen without professional evaluation

• Additional screenings such as color vision or near vision may be performed if concerns are present.

• If time and resources permit, screening of additional grades is recommended vision acuity testing should be selected according to the child’s developmental level.

Developmental Level Recommended Tool Visual Function Pre-language LEA Symbols Chart Distance Vision (Students Ages 3-4)

Kindergartners LEA Symbols Chart Distance Vision

School Aged Snellen E Chart Distance Vision

Adolescents Other evidence-based tools Based on Tool

Other types of screening tools are available for use, however it is recommended that the school nurse follow evidence-based practice and utilize screening methods that research has shown to be effective. When performing vision screenings the school nurse should follow the appropriate procedure for the selected testing tool. Accurate screening is essential to identify vision problems and avoid false positives.

It is recommended that students who failed the initial vision screening should be rescreened before referral to reduce the incidence of inaccurate results. In children age 3 the recommended standard for referral of distance visual acuity is 20/50 or worse in each eye or if there is a two line or more difference between eyes. In children age 4 the recommended standard for referral of distance visual acuity is 20/40 or worse in each eye or if there is a two line or more difference between eyes. In children ages 5 and older, the recommended standard for referral of distance visual acuity is 20/30 or worse in each eye or if there is a two line or more difference between eyes. A referral letter communicating the results of the screening and a request for a report from an eye care professional with the results of examination or recommendations should be given to the parent or guardian as soon as possible. A method should be developed for tracking referrals

and for encourage follow-ups as needed. The West Virginia Information System (WVEIS) provides a method for recording and tracking vision screening results.

Age of Student Acuity Referral Criteria

Age 3 20/50

Age 4 20/40

Age 5+ 20/30

The responsibility of the school nurse is to help identify potential vision problems, and work as a liaison between student, family and vision professional to promote adequate follow-up treatment. School-based screening for vision, hearing, or other conditions require coordination between local physicians and the school nurse to prevent duplication of services while ensuring students are referred for additional evaluation and treatment and for communication with students, families, school administration, and the community. A total of 98% of West Virginia children have or qualify for medical insurance and should be receiving a comprehensive physical exam (i.e. Health Check) annually with a vision screening. The health provider’s vision screening results shall be valid up to one year and meet the requirements of vision screening, as indicate in W.Va. Code §18-5-17 and West Virginia State Board of Education policy. The school nurse also needs to be aware of community services available to assist students in obtaining follow-up treatment.

Devised: 2006

Revised: 08/18

References

Hartmann, E., Bradford, G., Chaplin, P.K., Johnson, T., Kemper, A., Kim, S., Tootle W. (2006). Universal Preschool Vision Screening: A Demonstration Project. Pediatrics, 117(2).

Mitchell M. Scheiman, O.D., M.S., Principal Author

Catherine S. Amos, O.D., et al. (2002). Pediatric Eye and Vision Examination. Journal of AAPOS (American Association for Pediatric Ophthalmology and Strabismus). Retrieved on March 2015 from http://www.aoa.org/documents/CPG-2.pdf.

National Association of School Nurses. (2015). Position Statements Resolutions and Consensus Statements. Retrieved on March 2015 from http://www.nasn.org/portals/0/binder_papers_reports.pdf

Press, L.J. (September, 2000). Students with Persistent Problems – The Visual Connection. School Nurse News.

Proctor, S.E. (2005). To See or Not To See: Screening the Vision of Children in School. Castle Rock, CO: National Association of School Nurses, Inc

U.S. Preventive Services Task Forces. (2012). Screening for Visual Impairment. Guide to Clinical Preventive Services 2nd Edition. Retrieved on March 2015 from

http://archive.ahrq.gov/professionals/clinicians-providers/guidelines- recommendations/guide2012/guide-clinical-preventive-services.pdf.

DISCLAIMER:

2018 POSITION STATEMENT

Immunizations for West Virginia Public Schools

The West Virginia Council of School Nurses (WVCOSN) supports West Virginia immunization laws and rules for required and recommended immunizations for all students attending public schools, whether voluntary or compulsory. The utilization of the yearly published age-appropriate, research-based “Recommended Immunization Schedule for Persons Aged 0-18” from the United States Department of Health and Human Services(USDHHS) and Centers for Disease Control(CDC) should be the gold standard for determining the yearly school entry requirements. The recommended immunizations schedules for persons 0-18 years are approved by the Advisory Committee on Immunizations Practices, the American Academy of Pediatrics and the American Academy of Family Physicians.

The West Virginia Bureau for Public Health should have the ability to establish recommendations for school immunization requirements based on the USDHHS and CDC yearly recommendations. The current minimum requirements are necessary to support an environment conducive to learning while practicing effective disease prevention especially for those already immunocompromised or chronically ill and attending schools. Since the creation of vaccinations, several communicable diseases have been eradicated. The safety and welfare of WV public school students is dependent upon immunization requirements.

The WVCOSN supports “medical exemptions only”. Medical exemptions should be based on a valid medical contraindication or precaution to a particular vaccine from a physician who has treated or examined the child. The local health officer in the county where the child attends school should be consulted for any questionable medical exemptions.

Devised: 01/10/08 Revised: 08/2018

References

Journal of Adolescent Health. (2006). Adolescent Immunizations: A Position Paper of the society for Adolescent Medicine. Retrieved on March 2006 from https://www.adolescenthealth.org/PositionPaper_Immunization.pdf.

Salmon, Daniel. (August 13, 2004). Factors Associated With Refusals of Childhood Vaccines Among Parents of School-Aged Children. Retrieved on May 2006 from www.archpediatrics.com.

Salmon, Daniel. (October 11, 2006). Nonmedical Exemptions to School Immunization Requirements. Retrieved on October 2006 from http://jama.ama-assn.org/cgi/content/abstract/296/14/1757.

United States Department of Health and Human Services and Center for Disease Control and Prevention. (2007). Recommended Immunization Schedule for Persons Aged 0-18. United States.

West Virginia Legislature. (1987). W.Va. Code §16-3-4. Retrieved December 10, 2007 from http://www.legis.state.wv.us/WVCODE/16/masterfrmFrm.htm.

West Virginia State Board of Education. (2007). Policy 2525 (126CSR28). Retrieved December 10, 2007 form http://wvde.state.wv.us/policies/.

DISCLAI MER:

2018 POSITION STATEMENT

Insulin Administration at School

Statement The West Virginia Council of School Nurses supports the need for safe administration of insulin at school for students with diabetes. Only a certified school nurse RN, registered nurse, licensed practical nurse, parent/guardian, or a trained parent designee (not employed by the board of education) and/or student may legally administer insulin the school setting. Students may self- administer insulin after demonstrating willingness, understanding and competency to perform the procedure to the school nurses with a licensed prescriber order and parent/guardian permission. Such independence is the ultimate goal and a part of all nursing patient goals.

An individualized student’s health care plan (IHCP) is developed by the certified school nurse RN for each student who requires insulin and other diabetes care during the school day. This plan includes information from the licensed prescriber managing the student’s diabetes, school nurse, school administrator, teacher or school personnel including bus drivers and aides who have direct educational interest with students, parent/guardian and of course the student. The plan describes training provided and staff designated to perform various functions in the care of the student with diabetes in that school setting. In addition, some, but not all, students diagnosed with diabetes may also require accommodations through either a 504 Plan or an Individualized Education Plan (IEP).

West Virginia state laws and rules currently provide a safety net to ensure insulin is administered in the school setting by a licensed nurse as indicated in the links below:

• West Virginia Legislative Code, Chapter 30, Article 7: Registered Professional Nurses at http://www.legis.state.wv.us/WVCODE/code.cfm?chap=30&art=7#1. • West Virginia Board of Examiners for Registered Professional Nurses Rule 19CSR10: Standards for Professional Nursing Practice at http://apps.sos.wv.gov/adlaw/csr/readfile.aspx?DocId=19119&Format=PDF. • West Virginia Board of Examiners for Registered Professional Nurses- Scope and Delegation Booklet called "Criteria for Determining the Scope of Practice for the Licensed Nurses and Guidelines for Determining Acts that May be Delegated or Assigned by Licensed Nurses" at

http://www.wvrnboard.com/images/Scope%20and%20Delegation%20Booklet%206.09. pdf. • West Virginia Legislative Code, Chapter 18, Article 2K: The Diabetes Care Plan Act at http://www.legis.state.wv.us/WVCODE/Code.cfm?chap=18&art=2K#02. West Virginia Board of Education Policy 2422.7-Standards for Basic and Specialized Health Care Procedures and accompanying Health Care Procedural Manual with specific insulin administration procedures at http://wvde.state.wv.us/policies/.

The West Virginia Council of School Nurses supports only the following individuals to administer insulin by injection, pump device, or any other methods in the school setting: 1.Certified school nurses 2.Registered nurses 3.Licensed practical nurse 4.Student, if determined by licensed prescriber, parent/guardian and school nurse to be competent to ensure the safety and welfare of the child. 5.Parent, guardian, or designee who is NOT a district employee

Summary

• Health care services must be provided in the school setting to students with chronic conditions, including diabetes, to meet requirements of federal laws and ensure the safety of students. These laws include the Individuals with Disabilities Education Act (IDEA), Section 504 of the Rehabilitation Act of 1973, and the Americans with Disabilities Act of 1990. Children with special health care needs have the right to be educated with their peers in the least restrictive environment.

• The Certified School Nurse RN is the only school staff member who has the skills, knowledge base, and statutory authority to fully meet the health care needs of students in the school setting. This includes coordinating, developing, and implementing the student’s individualized health care plan, case management, emergency care plan, 504 plan, or individualized education plan.

• In states like California that do not have an adequate ratio between school nurses and students, decisions are being made to meet the health care needs of students using unlicensed, assistive personnel. The scope of tasks which can be delegated varies from state to state. Some state boards of nursing do allow the delegation of insulin administration, with specific training and oversight by a registered school nurse. However, the California Nurse Practice Act does not allow nurses to delegate administration of insulin to unlicensed personnel.

• The most common medication which nurses error in dosage is insulin. Insulin errors can lead to brain damage and even death. The delegation of insulin administration to unlicensed, assistive school personnel like teachers, aides and secretaries places the life of our most valuable commodity, our children, at risk. Insulin is a

complicated drug with various onset, peak and trough times (action times), dosage based on carbohydrate counts and sliding scales, delivered in subcutaneous injectable doses, measured in syringe-marked in units or via a pre-programmed insulin pump. The individual must possess a complex understanding of nutrition, exercise and the interactions and dynamics of medication.

References

• Appellate Court Decision Number 07AS04631A (2010). Retrieved September 12, 2013 from California Law website: http://appellatecases.courtinfo.ca.gov/search/case/mainCaseScreen.cfm?dist=3&d oc_id=1387513&doc_no=C061150. • California Business and Professional Code: Chapter 6 Sections 2700-2838.4 (Nurse Practice Act). Retrieved September 12, 2013 from the California Law website: http://www.leginfo.ca.gov/. • California Department of Education: Program Advisory on Medication Administration (2005). Retrieved September 12, 2013 from California Department of Education website: http://www.cde.ca.gov/ls/he/hn/medication.asp. • California Education Code, Section 49423, 49414.5. Retrieved September 12, 2013 from the California Law website: http://www.leginfo.ca.gov/. • California School Nurse Organization Consensus Statement: Safe Administration of Insulin in California Schools (2006). Retrieved September 12, 2013 from the California School Nurses Organization website: http://www.csno.org. • National Association School Nurses Position Statement School Nurse Role in Care and Management of the Child with Diabetes in the School Setting (2006). Retrieved September 12, 2013 from the National Association of School Nurses website: http://www.nasn.org. • LVN Nursing Practice Act is Business and Professions Code, Chapter 6.5 sections 2859- 2895.5. Retrieved September 12, 2013 from the California Law website: http://www.leginfo.ca.gov/cgi-bin/displaycode?section=bpc&group=02001- 03000&file=2859-2873.6.

2018 INFORMATIONAL SHEET Chest Vests for Airway Clearance

Chest vests provide a method of airway clearance by producing high-frequency chest wall oscillation (HFCWO) which creates mini-coughs that dislodge and aid in the movement of mucus from the smaller airways to the larger airways. This facilitates the removal of secretions by coughing or suctioning. The chest vest is attached to an air-pulse generator by connecting tubes. The air-pulse generator rapidly inflates and deflates the vest, which compresses and releases the chest wall up to 25 times per second. The chest vest replaces chest percussion therapy (CPT) and an average therapy session will take 15-20 minutes. The chest vest promotes independence by allowing the student to remain upright during the treatment and to continue with normal activity. Individuals with endotracheal tubes or tracheostomies may use chest vests.

Chest vests require a physician’s order. Chest vests may be used for a variety of medical conditions to treat ineffective airway clearance (i.e., cystic fibrosis, cerebral palsy, muscular dystrophy, spinal cord injuries, etc.). The student may have orders to use the chest vest in conjunction with aerosol therapy or oxygen therapy. Orders for use in the school environment should include: time(s) of therapy, frequency (Hertz (Hz) cycles), pressure (cm H2o) and length of treatment. If adjunct therapies are indicated (i.e., aerosol, O2), physician orders should also be obtained. Suctioning equipment may be necessary for the student who is unable to effectively cough or expectorate.

Follow specific manufacturer’s instructions for using the individual chest vest. Document use of the chest vest in the school setting on the student’s individual treatment record.

The school environment should be assessed for safety concerns prior to use of the chest vest and air-pulse generator. The air-pulse generator should be placed on a stable, dry and level

surface. It should only be plugged into a grounded outlet and not used with extension cords or multiple-use electrical outlet adapters. The system should not be used in an area with combustible materials. To review more information on chest vest go to www.thevest.com.

Devised: 2006

Revised: 08/2018

2018 INFORMATIONAL SHEET

Intrathecal Baclofen Therapy

Intrathecal baclofen therapy is a treatment option that delivers an injectable form of baclofen, Lioresal Intrathecal, directly into the fluid surrounding the spinal cord using a programmable pump and catheter that have been surgically placed in the body, typically in the abdominal area. The medication is delivered continuously based on the prescription programmed by the doctor. The method delivers the medication in small, precisely controlled doses throughout the day. Baclofen relieves severe muscle spasticity with only tiny amounts of medicine delivered immediately to the area where it is most effective. Depending on the dosage the student is receiving, the medication may last up to 90 days. The student must return to the physician to have the pump refilled. The lithium battery will last three to five years in this pump. When the pump is inserted, the student is given a card with emergency medical information; this card needs to be with the student at all times.

The pump has different alarms that indicate potential problems. When an alarm is heard immediately contact the parent/guardian.

Students will need to be closely observed for signs of overdose and under -dose. Signs of an overdose include: drowsiness, dizziness, slow and shallow breathing, seizure, loss of consciousness, blurred or double vision and muscle weakness. Signs of an under-dose include: itching, blood pressure changes, spastic or rigid muscles, high fever, altered mental status, seizure, hallucinations, nausea or vomiting and headache. Redness, pain, and swelling of the skin at the incision site are signs of problems that need immediate attention. Although cellular phones and microwaves do not affect the functioning of the device, some electronic devices may affect these pumps.

Any student who has an intrathecal baclofen pump is potentially at risk for problems. When the physician inserts the pump, it is registered in a federal registry. The student must have an implanted device identification card and emergency medical information card with them at all times.

Devised: 2006

Revised: 08/2018

2018 INFORMATIONAL SHEET

Pacemaker and ICD

A permanent pacemaker is a small device that is implanted under the skin and sends an electrical signal to start or regulate a slow heartbeat. Its purpose is to stimulate the heartbeat if the heart’s natural pacemaker is not functioning properly, has developed an abnormal heart rate or rhythm, or if the electrical pathways are blocked. Pacemakers can remain in place for many years before being replaced.

Children’s pacemakers may be placed under the skin in one of several locations. Young children often have the pacemaker generator placed in the abdomen since the fatty tissue found there can help protect the generator from the normal everyday childhood activities such as playing. As a child gets older (nearing adult size) the generator is often placed in the shoulder area, just under the collarbone. Attached to the generator are one or two wires called leads. The opposite end of the lead(s) is in the atrium or ventricle of the heart to assist in generating the electrical impulse that results in a heartbeat. Typically, routine pacemaker checks are done at home using the telephone.

An implantable converter defibrillator (ICD) is a small device similar to a pacemaker. It is often implanted in the shoulder area just under the collarbone. An ICD senses the rate of the heartbeat and if the rate exceeds the programmed number of beats the ICD will deliver a small, electrical shock to the heart to slow the heart rate.

After receiving a pacemaker or ICD the individual will be given an ID card from the manufacturer that includes information about the child’s specific model of pacemaker

and the serial number. A copy of this should be on file with the child’s emergency card in case problems arise and emergency staff must contact them.

Individuals with pacemakers should avoid high-energy radar, industrial arc welders, electrocautery equipment, TENS, large motors, oversized magnets, and ultrasonic dental cleaning equipment. Microwaves and metal detectors will not affect pacemaker function. As a precaution cell phones should be held at least six inches from the devices.

Activity levels of those with pacemakers and/or ICD’s are usually very much like their peers. Blows to the body in areas where the generator is implanted should be avoided. If the student demonstrates shortness of breath, dizziness, fainting, prolonged hiccups, or describes palpitations or chest pain, this can be an indication of pacemaker failure and EMS should be notified.

Devised: 2006

Revised: 08/2018

2018 INFORMATIONAL SHEET

Pressure Garments for Burns

Pressure garments are specialized clothing items such as tight fitting gloves, masks, or sleeves that are worn to put pressure on the skin layers after a burn injury has healed. In a burn, the top layer of skin is gone so it is not able to put pressure on the skin below as it would in healthy skin. Without the skin pressure, very thick and stiff scarring called hypertrophic scarring can occur. This scarring can cause deformity and limits to movement. Pressure garments prevent and control the formation of hypertrophic scars by applying counter pressure to the wounded area.

There are different types of compression garments for scars including ace wraps, tubular elastic bandages, pre-fabricated and custom made garments. Precise instructions for pressure garment wear vary depending on the unique situation of the burn injury. Pressure garments are usually worn 23 hours a day, removing them for bathing and cleaning of the garments only. Pressure garments have to be worn until the scar matures which often takes about 12-18 months.

Pressure garments require a physician’s order. The pressure garment is ordered according to the student’s specific medical needs. A trained specialist will fit the garment. The school nurse should collaborate with the physician and physical therapist to develop a treatment plan for the student in the school setting. For more information on pressure garments, search www.pressuregarments.com/.

Devised: 03/2010

Revised: 08/2018

References

John Hopkins Medicine. (2010). Wound Healing and Post-Burn Care: Compression Garments. Baltimore, MD. Retrieved on January 2010 from http://www.hopkinsmedicine.org/burn/C.Cox/patients-old/healing/.

Pressure Garment. (2010). Retention garments for post operative treatment of cosmetic and reconstruction surgery. Online at http://pressuregarments.com/.

2018 INFORMATIONAL SHEET

REAL-time Continuous Glucose Monitoring System

Continuous glucose monitoring and standard blood glucose monitoring help people with diabetes make decisions regarding their diabetes care. Glucose meters have been the “gold standard” for measuring day to day glucose levels. Glucose meters do a great job of providing “snap shots” of glucose levels at a single moment; whereas the continuous glucose monitoring system is like a motion picture. The full story of continuous readings fills in the blanks between the snapshots that a glucometer gives.

It is important to understand the difference between glucose meter readings and the continuous monitor readings. Continuous glucose monitors do not replace glucose meter testing. It is important to do glucose meter readings to confirm continuous monitor readings and to calibrate and initiate the continuous monitor system. The Continuous Glucose Monitoring System uses a tiny sensor inserted under the skin to check glucose levels in tissue fluid. The glucose sensor is usually inserted in the abdomen or other fatty area with an insertion device. An introducing needle is used initially to insert the glucose sensor; the needle is removed, leaving the flexible sensor in place. The sensor stays in place for several days and then must be replaced. The transmitter sends glucose measurements to a wireless monitor. Glucose meter readings and continuous monitor readings may vary. The continuous system results may be a few minutes behind the actual glucose level taken by a glucometer. This lag time is the primary reason for the need to confirm all sensor glucose results with a finger stick before making treatment changes.

The system offers both real time and historical glucose monitoring information. The real time information helps discover how diet, physical activity, medication, and illness affect glucose

levels on a moment to moment basis. Real time values and high and low glucose alarms allow for quick intervention after confirmation with a finger stick. Real time is especially helpful to the person who is no longer able to recognize symptoms of a low glucose level.

The historical data can be used to discover how diet, physical activity, medication, and lifestyle changes affect glucose levels over a period of time. It can also be used to identify frequent patterns of highs and lows over periods of days, weeks or months. The system is expensive and few insurance plans will cover the cost of the system or the replacement sensors.

Devised: 2006

Revised: 08/2018

2018 INFORMATIONAL SHEET

Venous Access Devices

Central venous access devices are small, flexible tubes placed in large veins for people who require frequent access to their bloodstream. They are often referred to as venous access ports or catheters because they allow frequent access to the veins without deep needle sticks. They are usually placed in one of the large veins of the chest or neck, although they can be placed in the groin if necessary and they typically remain in place for long periods. Venous access devices can be implanted under the skin; they allow medications to be delivered directly into larger veins.

Central venous devices are usually inserted in one of three ways, which include: 1. Catheters are inserted by tunneling under the skin into either the subclavian vein (located beneath the collarbone) or into the internal jugular vein (located in the neck). The part of the catheter where medications are administered or blood drawn remains outside the skin. There is a central catheter or tunneled catheter; examples include Hickman, Broviac, and Groshong. 2. Unlike catheters, which exit from the skin, ports are placed completely below the skin. With a port, a raised disk about the size of a quarter or half-dollar is felt underneath the skin. Blood is drawn or medication delivered by placing a tiny needle through the overlying skin into the port or reservoir. Examples of central implanted devices are Port-A-Cath, Medi-Port, Infuse-A-Port and Groshong Port. 3. Peripherally inserted central catheter (PICC) lines, unlike central catheters and ports, are not inserted directly into the central vein. A PICC line is a hin flexible tube that

is inserted into an antecubital vein in the arm. It is threaded so that the tip lies in the superior vena cava (verified by x-ray).

Precautions Action

Blood in the tubing or bleeding from end of Check to see if clamp is open. If clamp is open, tubing. broken, or not functioning, clamp tubing, notify family, activate emergency plan. If student develops fever, redness at the CVC site, Notify family at once. These are signs of drainage, increased fatigue, irritability, or infection. headache. CVC is pulled out or falls out. Cover site immediately with sterile dressing, applying firm pressure. Notify family, activate emergency plan. Catheter is broken. Clamp catheter above the break, wrap broken end of catheter with sterile gauze. Notify family. Be prepared to activate emergency plan. Student complains of chest pain or difficulty Have student lie on left side, clamp tubing. Notify breathing. family. Be prepared to transport to ER.

Student should avoid contact sports. Contact healthcare provider for limitations of activities.

Devised: 2006

Revised: 08/2018

2018 INFORMATIONAL SHEET

Mitrofanoff

Continent Catheterizable Stomas

A Mitrofanoff or a continent urinary diversion involves using the appendix, or any piece of the bowel or genitourinary segment to channel between the bladder and the abdomen (usually at the umbilicus). The surgery allows for easier catheterization with less invasion of privacy. Children previously dependent on a caregiver for catheterization can often gain independence. With this type of stoma, many children are also able to achieve continence without the need of a collection bag or a catheter that has to stay in place at all times. The procedure and equipment is the same as catheterization through the urethra. Some of the most common problems encountered after the implantation of a catheterizable stoma includes, stomal stenosis, stomal incontinence and stone formation.

References:

New Innovations in Continent Catheterizable stomas by Albaha Barqawi, MB, Peter D. FurnessIII, MD, Aberlardo Erregon, MD, Martin A. Koyle, MD http://www.medscape.com/viewarticle/447774

Outcomes of Urinary Diversion in Children with Spinal Cord Injuries by Lisa A. Merenda, MSN, RN, CRRN; Theresa Duffy, MS, RN; Randal R. Betz, MD; Mary Jane Mulcahey, PhD, OTR/L; Gregory Dean, MD; Michel Pontari, MD J Spinal Cord Med. 2007; 30:S41-47 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2031994/

Mitrofanoffs, Maces and Bladder Augmentations (Oh MY!) Tips and Tricks to Manage the problems. Anne Boisclair-FAHEY, DNP, RN, CNP University of Minnesota http://punsonline.org/multimedia/files/2013/Bladder-Augmentations-Mitrofanoffs-and-Maces.pdf

Mitrofanoff Suppport http://www.mitrofanoffsupport.org.uk/mitrofanoff-procedure/

2018 INFORMATIONAL SHEET

Malone Antegrade Continence Enemas (MACE)

2018 INFORMATIONAL SHEET

Assessing Behavioral and Mental Health Needs of Students

Due to the increasing number of students with varying mental health needs, the West Virginia Council of School Nurses felt it would be helpful to formulate an informative guide explaining the role of the school nurse and how they can be a valuable resource as a member of the SAT (Student Assistance Team). The school nurse can act as an advocate and a facilitator with communication. In many situations, it is necessary to contact the student’s physician and the school nurse can provide this service. Many students with mental health needs are on medications and school nurses are knowledgeable regarding varying medical conditions and pharmaceuticals. Behavior modification is often the key with mental health conditions. School nurses can help with the identification of the different tools which help in assessing behavior. Common examples of typical problem behavior include, but are not limited to:

• Hitting

• Difficulty waiting or accepting “no”

• Kicking

• Noncompliance

• Biting

• Repetitive behaviors

• Scratching

• Difficulty with transitioning

Some copyright-free tools that can be used to assess behaviors as on the pages to follow.

Addressing Student Behavior Reproducible Forms

The forms in this file are model forms and tools that districts and schools may use at their discretion—they are not mandated by the state. They are also copyright free and no permission is needed to reproduce them for noncommercial purposes. If these forms are included in another non-profit publication, then the citation should read as follows:

Some information in this document was adapted from Addressing Student Behavior: A Guide for All Educators, which is a copyright-free technical assistance manual prepared by the New Mexico Public Education Department, Quality Assurance Bureau, Fall 2010. www.ped.state.nm.us

Functional Behavioral Assessment (FBA) Tools Scatterplot ...... 2 ABC Observation Form ...... 3 Sample Interview Script—Teacher/Parent ...... 4–5 Sample Interview Script—Student ...... 6 Data Triangle Chart ...... 7 FBA Hypotheses Template ...... 8 FBA Report Form ...... 9–11

Behavioral Intervention Plan (BIP) Tool BIP Form ...... 12–14

Scatterplot Student:______Grade: ______School: ______Date(s): ______Observer: ______Behavior of Concern: ______Additional relevant information: ______Code used (if any): ______

Setting or Times or Day/Date Day/Date Day/Date Day/Date Day/Date Total Times Class Intervals Observed

Observation Notes (e.g., specific circumstances under which the behavior occurred, particular antecedents that triggered the behavior, times/conditions during which the behavior does not occur, patterns observed, etc.) ______

ABC Observation Form Student:______Grade: ______School: Date(s): ______Observer: Behavior of Concern:

Sample Interview Script—Teacher/Parent

Concern has been expressed about ______’s behavior, specifically ______. We are gathering information for the purpose of identifying possible reasons for the behavior so that we are able to develop and recommend appropriate interventions.

Q. In what specific settings or under what conditions do you observe the behavior? A. Q. Are there settings, conditions, or situations in which the behavior does NOT occur? A. Q. Characterize your observation of the frequency, intensity, and duration of the behavior. A. Q. Who is present when the behavior occurs? A. Q. Which of these, if any, typically precede the behavior? directive or request from authority provocation from peers academic activity unstructured setting transition time certain time of day Describe the activity or interaction that takes place just prior to the behavior. A. Q. Which of these, if any, typically immediately follows the behavior? behavior is socially reinforced by peers receives attention gets corrective feedback is removed from the setting privileges are withheld negative consequence no consequences or behavior is ignored no obvious consistency other Describe the typical result of the behavior and consequence of it. A. Q. Are there other behaviors that usually occur along with the problem behavior? A. Q. What positive reinforcers have you used with this student and how effective were they? A. Q. What negative consequence have you used with this student and how effective were they? A. Q. For what reasons might the student be showing this behavior? (e.g., to get, control, or avoid something) A.

Q. In your opinion, what would be an acceptable way for the student to achieve the same outcome? A. Q. Do you feel that this student does not “know how” to achieve his needs using appropriate behavior (can’t). Or, does the student know how to behave differently, but consistently chooses not to (won’t)? A. Q. What other insight can you offer about this student or the behavior that might assist us in developing appropriate, effective interventions? (Parents: any health, eating/sleeping habits, other patterns?) A.

Notes:

Sample Interview Script—Student

We are gathering information in order to better understand what goes on in and out of the classroom. We would like to know and consider the students’ point of view as well as the adults’. We need your help to get an accurate “picture.” Please answer these few questions as openly and honestly as possible. Q. Do you think that what goes on outside of school affects how a student works and behaves in class? How (give example)? A. Q. What about you? What is happening in your life outside of school that affects you in school? A. Q. Most students are bothered by someone or something that goes on at school. What bothers you? A. Q. Have you recently been punished or reprimanded for something you did in school? Why? A. Q. How about (identify the target behavior)? What was going on the last time or other times you behaved that way? What happened just before or what caused you to behave that way? A. Q. What usually happens right after you or another student behaves differently than expected to? A. Q. What do you think was expected of you? Was the judgment fair or not, and why? A. Q. How do you feel about (specific subject, teacher, students, situation)? A. Q. How do you think (specific teacher, students, other person/people) feels about you? A. Q. What happens when you DO do exactly as you are expected? What SHOULD happen? A. Q. What consequence has that behavior had for you? What SHOULD the consequence be? A. Q. Can you think of any times or situations in school that you would really avoid if you could? A. Q. Can you think of anything that you wish would happen that doesn’t happen often or at all? A. Q. Name one or two things you wish were different about school. A. Q. Name one or two things you wish were different outside of school. A. Q. Name one or two things you wish were different about yourself. A. ______

Data Triangle Chart

Student:______Grade: ______Dates: ______Behavior of Concern: ______

• Precipitating Events (conditions/circumstances under which target behavior occurs):

• Functions that Maintain the Behavior (what he/she gets, controls, or avoids as a consequence of the action):

Deficit(s) (skill or performance):

Interpretation Summary: ______

Functional Behavior Assessment (FBA) Hypothesis Template

The success of the developing behavioral interventions to be for a student depends on the accuracy of the efforts to define and evaluate the problem. Persons performing the FBA may want to use this template as a tool to synthesize their findings before including them on the last page of the FBA Report Form. See page 21 of Addressing Student Behavior for a sample.

______

When (X-target) behavior occurs, it is usually in the context of (X-where and/or when) and preceded by (X) trigger(s).

The student’s response is (X-describe in specific behavioral terms).

The result of the behavior is usually (X), which serves to (X-describe “pay-off” ).

The function and/or purpose of this response is likely to be a (X-to get/seek…or to escape and/or avoid…).

The behavior appears to be a (X-skill deficit or performance deficit) because (X).

Functional Behavioral Assessment Report Student Name: ______Date: School: ______Grade:___ Age: ____Gender: A Functional Behavioral Assessment (FBA) is done when a student’s behavior interferes with his or her learning or the learning of others. Its purpose is to identify why a behavior is happening so that the SAT, Section 504, or IEP team can develop appropriate interventions.

1. Sources of Information Check sources to be used; Circle E if reviewing existing data, Circle N if new data is needed* ______E N Anecdotal information provided by parents ______E N Parent interviews ______E N Diagnostic evaluation(s) done by ______E N Independent diagnostic evaluation(s) ______E N Tier 1 Interventions ______E N Classroom/school observation(s) ______E N Student interview ______E N Interview with other professionals ______E N Teacher interview(s) ______E N Behavior Rating Scales ______E N Discipline records ______E N IEP(s) and IEP progress reports ______E N Attendance records ______E N Assessment scores ______E N Grades/report cards ______E N Data collection tools: ______E N (other)

*Note: Written parent consent is necessary for an FBA that is part of a special education initial evaluation or reevaluation. For students without disabilities, written parental consent is highly recommended.

2. Identified Problem Behavior (what the student is doing or not doing) State setting, frequency, duration, intensity, and severity. A) Observed and/or reported by School staff Parents Other

B) Observed and/or reported by School staff Parents Other

C) Observed and/or reported by School staff Parents Other

3. Events that Typically Precede the Problem Behavior (school setting)

Check all that apply, then describe: directive or request from authority provocation from peers academic activity unstructured setting transition time certain time of day no obvious circumstance other ______

4. Events that Typically Follow the Problem Behavior (school setting) Check all that apply, then describe: behavior is socially reinforced by peers receives attention gets corrective feedback is removed from the setting privileges are withheld gets negative consequence no consequences or behavior is ignored no obvious consistency other ______

5. Effectiveness of Interventions on Behavior Describe what positive reinforcers have been tried and rate their level of effectiveness from 0- 5, with 5 being very effective and 0 being completely ineffective. Example: special activities (4); compliments (1) ______

Describe what consequences have been tried and rate their level of effectiveness from 0-5, with 5 being very effective and 0 being completely ineffective. Example: losing privileges (2); call to parents (4)

______

6. Analysis and Recommendation A) The presumed function or explanation of this behavior is to get to escape or to control

B) The problem behavior may be linked to a skill deficit in the following areas:

C) The problem behavior may be linked to a performance deficit in the following areas:

D) Next Steps: The student’s behavior patterns require instructional modifications or accommodations only. The student’s behavior patterns suggest that a Behavioral Intervention Plan is warranted. Existing data is insufficient for a complete functional assessment. Follow-up/additional data is needed as follows:

The following person(s) performed

this Functional Behavioral Assessment:

______Signature Title Date

Behavioral Intervention Plan

Student Name: ______Date: School: ______Age: ______Gender:

Date of Functional Behavioral Assessment (FBA) as a basis for this plan: ______

This Behavioral Intervention Plan (BIP) is being created for this student because persistent and/or severe behavior is being exhibited that interferes with the student’s learning or the learning of others and interventions are needed to positively redirect the targeted behavior. The approach identifies the type and cause of the behavior and then helps the student learn replacement behaviors through a combination of positive interventions and supports, as well as appropriate consequences. In addition to defining a how the student is to be taught the skills needed for behavior modification, the plan includes provisions for monitoring progress and crisis management.

All sections must be complete in order for this plan to be sufficient.

Problem Behavior and Target Goal: (in measurable observable terms)

Is this behavior a Skill Deficit or a Performance Deficit? Skill deficit: The student does not know how to perform the desired behavior. Performance deficit: The student knows how to perform the desired behavior, but does not consistently do so.

How do you know?

Presumed FUNCTION (cause) of the behavior: What desired thing(s) is the student trying to Get? What undesired thing(s) is the student trying to Avoid?

Intervention Strategies 1. Environment and/or Circumstances Can the environment or circumstances that trigger the behavior or the result of it be adjusted? If so, how?

2. Curriculum and/or Instruction Would changes in the curriculum or instructional strategies be helpful? If so, what and by whom?

3. Other Strategies or Positive Supports (including school personnel, peers, or family)

Desired Replacement Behavior What behavior will the student be taught to replace the targeted behavior? How and by whom?

Rewards and/or Motivators: How will the student be reinforced so that the replacement behaviors are more motivating than the problem behavior?

Consequences: What consequences will be implemented for repeated occurrences of the problem behavior? 1st occurrence?

2nd occurrence?

3rd occurrence?

Continuing?

Crisis Plan: How will an emergency situation or behavior crisis be handled? (Define possible scenarios, including the use of in-school or out-of-school suspension, or aversive techniques by trained personnel, as appropriate, and how parents will be notified)

Progress Monitoring of the Behavior and the Behavior Plan: How will behavior be assessed and evaluated? What data will be collected? How and by whom? When will the plan be first reviewed for its effectiveness? Thereafter?

Date plan will be reviewed for effectiveness______

Additional notes/information regarding this BIP: ______

______

Signatures

______Signature Title Date

INTERVENTION GUIDES AND EMERGENCY ACTION PLANS (EAP)

Return to School Nurse EMERGENCY ACTION PLAN

NEUROGENIC BLADDER

Student Name: ______DOB: ______Grade/Teacher: ______The student has the following restrictions/limitations: ______The following safety measures need to be taken during the school day: ______

EMERGENCY CONTACT INFORMATION

Parents/Guardians: Phone #1: Phone #2: Phone #3:

Alternate Contact: Phone #1: Phone #2: Phone #3:

*If School Nurse is in building please notify nurse immediately*

IF YOU SEE THIS: DO THIS: *Never send student anywhere alone!* Urinary Incontinence * Provide privacy * Allow student to use restroom * If applicable, allow student to self catheterize * Allow student to change clothes or pad * Encourage a set catheterization schedule

Report of Painful Urination * Notify Nurse and/or Parent/Guardian

Inability to Urinate * If applicable, allow student to self catheterize * Allow extra time in restroom * Encourage a set catheterization schedule

I understand and agree that information in this Emergency Action Plan will be shared with appropriate school staff.

______Parent/Guardian Signature Date

School Nurse Received and Reviewed: ______School Nurse Signature Date

March 2017- White

Return to School Nurse

EMERGENCY ACTION PLAN

CEREBRAL PALSY Student Name: ______DOB: ______Grade/Teacher: ______

The student has the following restrictions/limitations: ______The following safety measures need to be taken during the school day: ______

EMERGENCY CONTACT INFORMATION Parents/Guardians: Phone #1: Phone #2: Phone #3:

Parents/Guardians: Phone #1 Phone #2: Phone #3:

Alternate Contact: Phone #1 Phone #2: Phone #3:

*If School Nurse is in building please notify nurse immediately!*

IF YOU SEE THIS: DO THIS:

*Allow to rest in whichever position is most Shortness of Breath, Fatigue _comfortable.

*Contact parent with severe or frequent episodes.

*Adult stays with student and watches for any _worsening of symptoms.

*Clear area around student so that so that student _doesn’t injure self. Severe Muscle Spasms *If vomiting or choking, position student on side. *If loss of bowel/bladder control, please cover with _blanket to provide privacy. *Notify parent of episode.

Complaints of Pain *Administer pain medication if prescribed.

Choking *Initiate Heimlich Maneuver. *Call 911.

I understand and agree that information in this Emergency Action Plan will be shared with appropriate school staff.

______Parent/Guardian Signature Date

School Nurse Received and Reviewed: ______School Nurse Signature Date 67 Feb 2017- White

School Nurse Performance Evaluation Tool

The West Virginia Council of School Nurses (WVCOSN) recommends the use of the

“Evaluation of School Nurse Performance” tool to assist and explain the role of the West

Virginia Certified School Nurse. The recommended uses may include but not limited to the following:

• Evaluation of school health professional support personnel by non-health administrative personnel.

• Orientation/Mentorship of new school nurses and;

• School Nurse Certification course work.

Devised: 01/22/09

SAMPLE

Project ADAM™

Public Access Defibrillation Program POLICY AND PROCEDURE

POLICY:

1. An Automated External Defibrillator (AED) will be maintained on the premises of . 2. The AED shall be used in emergency situation warranting its use by individuals specifically trained in use of the device. This should include emergency response plan and protocols for use of the AED.

PROCEDURE:

Location, maintenance and testing of AED(s)

1. The AED shall be located

2. The type of device, intended use area, plan for maintenance and testing and location of the device on the premises shall be confirmed annually to: ♥ 911 for County ♥ ♥

3. Maintenance and testing is conducted as recommended by the manufacturer. a) Documentation of the maintenance and testing is maintained in a binder marked AED in the nurse’s office for a period of at least five years. b) Documentation shall record the date and type of maintenance/testing and the signature of the person performing the maintenance/testing.

SAMPLE

Training

1. Initial training in CPR and AED use is done according to the American Heart Association. 2. On going training in CPR and AED use is done ever two years with reviews twice during the school year (no longer than a 6(six) month period) 3. Records of training shall be kept in the AED binder in the nurse’s office.

Use of the AED

1. Determine unresponsiveness of victim and activate Emergency Response Plan. a) If a victim is unresponsive, call “9-1-1” and get AED. b) Assess the victim: airway, breathing circulation. c) Initiate CPR, if required, until the AED is brought to the victim’s side. d) The public address system will be used to activate responders and indicate location of victim e) Designate and individual to wait at school entrance to direct the EMS to victim’s location.

2. Upon arrival, place the AED near head of victim, close to AED operator.

3. Prepare to use the AED. a) Turn the poser ON b) Bare and prepare chest for AED use c) Place AED electrode pads on victim. d) Stop CPR while the AED analyzes the heart rhythm. e) Follow the AED prompts for further action. If shock is indicated, be sure all rescuers are ”clear” before shock is administered.

4. Upon arrival, EMS shall take charge of victim. a) Provide victim information: name, age, known medical problems, known allergies, time of incident. b) Provide information as to current condition and number of shocks administered.

5. Data card following AED use shall be delivered to Medical Director:

SAMPLE

After Use of AED

1. A Critical Incident Debriefing session will be held with in 48 hours for all initial responders Contact: The program Medical Director shall be notified of AED use. a) Complete follow-up report if deemed necessary by medical director. b) Arrange for quality improvement review.

2. The AED will be check and put back in readiness state. a) Remove data card and label with victim’s data. Deliver to appropriate personnel according to program protocol. Replace data card. b) Replace data card. c) Restock AED per AED inventory. d) Clean AED if needed according to manufacturer recommendations. e) Document readiness

Placing AED Back in Service After Use

1. Readiness status will be assured following any AED use. 2. Records of readiness verification shall be kept in AED binder in nurse’s office.

Routine Verification of AED Readiness Status

1. Readiness status will be assured weekly when school is in session. 2. Records of readiness verification shall be kept in the AED binder in the nurse’s office.

SAMPLE

Automated External Defibrillation Program

I. PURPOSE

The practices and procedures described in this document comprise the program through which will administer its Automated External Defibrillator (AED) Program. This program will conform to standards set forth by the American Heart Association® (AHA). It is the policy of to minimize the risk associated with Sudden Cardiac Arrest (SCA) among its employees, students, and visitors. This program is to be followed by all personnel that have volunteered for the CPR/AED Training. A copy of this program is to be made available to every employee upon hiring, and a copy will be supplied to any employee upon request. This program will be reviewed annually, and updated whenever new, or modified tasks, or procedures are implemented.

A copy of this Program has been provided to the local EMS agencies listed below:

Fire Department County 911 Center WV EMS TSN Field Office for Region

II. DEFINITIONS

Automated External Defibrillation (AED) – a device used to treat a patient with cardiac arrest whose heart is beating irregularly (fibrillating) by assessing the patient’s heart rhythm, judging whether defibrillation is needed, and then administering a shock to return the heart to normal.

AED Coordinator – the person designated by l who conducts the day- to-day duties associated with the AED program and serves as the Oversight Physician’s point of contact for the AED program.

AED Oversight Physician – a designated, licensed physician providing medial oversight to the AED program, who is responsible for medical control, development, implementation, and establishing response procedures and a quality improvement plan.

SAMPLE

Medical Response Team – the group of Trained Rescuers who provide basic life support (CPR & First Aid) and apply AED’s during medical emergencies.

Sudden Cardiac Arrest (SCA) – a condition where the heart stops beating suddenly and unexpectedly, due to a disturbance in the heart’s electrical system called ventricular fibrillation.

Trained Rescuer – a person or category of people designated to respond to medical emergencies, and possess proper training in CPR, First Aid, and AED use within the confines of the AED program including defibrillation of the victim.

III. RESPONSIBILITES

A. Oversight Physician

The Oversight Physician proving medical direction to this program is:

Medical direction will include: ♥ Development and review of policies and procedures defining the standards of patient care and utilization of all AED’s used within ♥ Review of response documentation and rescue data for all uses of AEDs ♥ Oversight of the initial and continuing training ♥ Provide advice regarding the medical care of those in need of such care

B. AED Coordinator

The AED Coordinator is

SAMPLE

The AED Coordinator is responsible for the following: ♥ Serves as liaison between the district’s AED program and the Oversight Physician ♥ Organizes all initial and refresher training programs ♥ Maintains all AED equipment and related supplies. ♥ Forwards incident data to the Oversight Physician ♥ Conducts post-incident debriefing sessions for any employees involved in AED use incidents.

C. MEDICAL RESPONSE TEAM and TRAINED RESCUERS

The Medical Response Team and Trained Rescuers are responsible for the following: ♥ Activating the internal emergency response system during medical emergencies ♥ Providing emergency First Aid, CPR, and application of AEDs to victims of SCA ♥ Understanding and complying with the requirements of this policy The Trained Rescuers for are

AED Operator Training (Class and Date)

SAMPLE

I. AED LOCATION

A. Location The AED is to be located in an unrestricted, public area within the school building at all times. This location will allow quick access for first responders in the event of a cardiac arrest. The AED is located:

B. Locator placard The following placard indicates the location of the AED:

Place your AED logo here

D. Equipment Each AED will be equipped with ♥ two sets of electrodes ♥ two pair of latex gloves ♥ one facemask barrier device

IV. TRAINING REQUIREMENTS (Trained Rescuers)

Any employee (Trained Rescuer) who is expected to provide emergency care to a patient of SCA, or other medical emergency, will be trained in basic first aid, CPR and AED use. This training will conform to the American Heart Association® (AHA) standards or another nationally recognized training organization. Training will also include information on observing “Universal Precautions” against blood borne pathogens when treating SCA and/or accident victims. The AED Coordinator will maintain all training records.

Trained Rescuers are required to renew First Aid, CPR, and AED training every two (2) years. In addition, refresher training will be required every year to review proper procedures.

SAMPLE

V. INDICATIONS FOR AED USE

The AED should be used only on a patient who: ♥ is unconscious ♥ is not breathing ♥ has no pulse

The AED should be used with caution if the victim has; ♥ nitroglycerin patch on chest (remove nitroglycerin patch carefully, the apply AED electrodes ♥ implanted pacemaker (pacemaker may interfere with the rhythm analysis; do not place electrodes directly over pacemaker

VI. RESPONDING TO EMERGENCIES

A. Access Scene Safety During emergency situations, Trained Rescuers must assess the scene for safety hazards. Some examples are; ♥ Electrical dangers (downed power lines, electrical cords, etc,) ♥ Chemical (hazardous gases, liquids or solids, smoke, etc.) ♥ Harmful people (anyone that could potentially harm you) ♥ Traffic (make sure you are not in the path of traffic) ♥ Fire or flammable gases (medical oxygen, cooking gas, etc.)

B. Assess Unresponsiveness Verify that the victim is actually unconscious. Tap the victim on the shoulder and shout, “Are you OK?”

C. Activate the EMS system – Dial 911 or call . Have a designated person wait outside for EMS to arrive to lead emergency response personnel to the victim. You must dial “9” first to get an outside line, then 911.

D. Use the pre-selected code over the PA system to have the AED brought to the scene or send someone to get the AED.

E. Perform CPR until the AED arrives at the scene. Check for signs of circulation such as pulse, coughing, or movement. Remember, verify that the victim

♥ is unconscious ♥ is not breathing

SAMPLE

♥ has no pulse

If all the above are true, apply the AED.

F. Turn on the AED and follow all voice prompts ♥ Place electrodes (for patients with large amounts of body hair, it may be necessary to shave areas prior to placement of electrodes. Boyd hair may interfere with the AED. The First Aid Kit includes disposable razor.) ♥ Stand clear of the victim and allow the AED to analyze. ♥ If prompted by the AED, verify that the victim is clear and deliver shock.

The Trained Rescuer will state “clear” and make a visual head-to-toe check of the victim making certain that he/she and other rescuers are “clear” of contact with the victim. Once this is accomplished, the Trained Rescuer will press the button to deliver a defibrillation pulse.

If no shock is advised, the AED will prompt the Trained Rescuer to check pulse, and if absent, perform CPR for one minute. If pulse or signs of circulation such as breathing and movement are present, check for normal breathing. If the victim is not breathing, give rescue breaths and the AED will re-analyze after one minute.

G. When EMS arrives provide the following information if known:

♥ Victim’s name ♥ Any known medical problems, allergies or medical history ♥ Time victim was found ♥ Initial and current condition of the victim ♥ Information from the AED screen (number of shocks delivered, length of time the defibrillator has been use)

VII. POST EVENT REVIEW

The AED Program Coordinator must complete an AED Response Documentation Form after each use of the AED. This form must be provided to the Oversight Physician for review along with all rescue data recorded by the AED.

SAMPLE

The Medical Response Team shall conduct an incident debriefing to determine any deficient practices and opportunities for improvement. All depleted AED supplies must be restocked, and the AED checked for damage. The AED battery must be checked prior to returning to service.

SAMPLE

VIII. BACIS MAINTENANCE

Refer to User Manual for complete maintenance schedule.

SAMPLE

Early Defibrillation Program Operator Roster

DATE ENTITY PROGRAM OFFICAL

AED Operator Training (Class and Date)

Skills Performance Checklist

Table of Contents

Handling of Body Fluids ...... 1

Gloves ...... 2

Hand Washing ...... 3

Cane ...... 4

Crutches ...... 5

Walker ...... 7

Wheelchair ...... 8

Assisting with Clothing ...... 9

Body Mechanics ...... 11

Oral Feeding of Student ...... 12

Oral Hygiene ...... 15

Pediculosis Detection ...... 17

Safety While Using Assistive Devices ...... 18

Skin Care and Positioning For Prevention of Pressure Areas ...... 19

Bedpan ...... 20

Urinal ...... 22

Use of Disposable Diapers/Briefs ...... 24

Feminine Hygiene ...... 26

Table of Contents (continued)

Mechanical Lift ...... 28

Orthopedic Device ...... 29

Passive Range of Motion Exercise ...... 30

Enteral Feeding Via Gastrostomy Tube or Bolus Method ...... 31

Enteral Feeding Via Gastrostomy Tube Slow Drip ...... 34 and/or Continuous Method

Enteral Feeding Via Gastrostomy Button Bolus Method ...... 37

Enteral Feeding Via Gastrostomy Button Slow Drip...... 40 and/or Continuous Method

Enteral Feeding Via Nasogastric Tube Bolus Method ...... 43

Enteral Feeding Via Nasogastric Tube Slow Drip ...... 45 and/or Continuous Feeding

Inserting a Nasogastric Tube ...... 48

Ostomy Care Emptying/Changing of Ostomy Pouch ...... 51

General Guidelines for Diabetic Management ...... 52

Measurement of Blood Sugar with Glucometer ...... 53

Insulin Administration by Injection ...... 55

Administration of Insulin by Pump ...... 56

Glucagon Administration ...... 57

Long-Term Medication Administration ...... 59

Table of Contents (continued)

Emergency Medication Administration ...... 60

Administration Medication Via G-Tube ...... 62

Administration of Rectal Diazepam ...... 64

Phrenic Nerve Stimulator ...... 66

Seizure Management ...... 67

Vagus Nerve Stimulator with Magnet ...... 69

Anaphylactic Reaction ...... 70

Epinephrine Auto-Injector ...... 71

Epinephrine Twinject……………………………………………………………… 73

Inhalation Therapy by Machine ...... 75

Manual Resuscitator ...... 77

Mechanical Ventilator ...... 79

Metered Dose Inhaler Therapy (MDI) ...... 81

Oral Suctioning ...... 82

Oxygen Administration ...... 83

Peak Flow Meter ...... 85

Percussion and/or Postural Drainage ...... 87

Emergency Care and Cleaning of Tracheostomy...... 89 Tube and Stoma

Table of Contents (continued)

Emergency Replacement of Tracheostomy Tube ...... 92

Tracheostomy Suctioning Sterile Technique ...... 94

Clean Catheterization ...... 97

Self-Catheterization ...... 99

Sterile Catheterization ...... 101

Crede’s Method ...... 103

Skills Performance Checklist

Handling of Body Fluids

School Employee______Position______County______Certified School Nurse Instructor______

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

A. Wash hands.

B. Put on gloves when touching or handling body fluids.

C. Verbalize/demonstrate proper disposal of contaminated items.

D. Verbalize/demonstrate prompt clean up of spills.

E. Verbalize/demonstrate proper cleaning utensils, disinfecting agents and cleaning methods.

F. Remove and discard gloves.

G. Wash hands.

Skills Performance Checklist

Gloves

School Employee______Position______County______Certified School Nurse Instructor______

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

A. Wash hands

B. Apply gloves to both hands.

C. Verbalize when gloves should be worn.

D. When cleanup is finished remove first glove by turning “inside out” and then pull second glove to envelope the first glove.

E. Drop gloves into plastic- lined trash container.

F. Repeat hand washing.

Skills Performance Checklist

Hand Washing

School Employee______Position______County______Certified School Nurse Instructor______

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

A. Wet hands using warm, running water.

B. Apply liquid soap and lather well.

C. Rub hands together in a circular motion for 20 seconds.

D. Rinse hands well under running water.

E. Dry hands with paper towels. Turn off water with paper towel and discard towel. –OR-

F. Apply alcohol-based hand rub to the palm of one hand then rub hands together.

G. Continue to rub hands together covering all surfaces of hands and fingers until dry.

Skills Performance Checklist

Cane

School Employee______Position______County______Certified School Nurse Instructor______

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

A. Obtain instructions from school nurse.

B. Tell the student what you will be doing and how he/she can help.

C. Verify whether the student will use one or two canes.

D. Confirm the type of cane and the type of handle the student should be using.

E. Check the fit of the cane for the student’s height.

F. Verbalize/demonstrate how to assist the student walking with a cane.

G. Verbalize/demonstrate how to assist the student to go upstairs.

H. Verbalize/demonstrate how to assist student to go downstairs.

I. Verbalize/demonstrate proper care of cane for safety of student.

Skills Performance Checklist

Crutches

School Employee______Position______County______Certified School Nurse Instructor______

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

A. Obtain instructions from school nurse.

B. Demonstrate how to assist student with strengthening exercises.

C. Check the crutches for appropriate length when student is standing erect.

D. Assist the student with the tripod stance to stand with balance and stability.

E. Check the hand piece so that the student’s elbows have 20 to 30 degrees of flexion when the arm piece is 2 finger widths below the axilla.

F. Use the axillary arm pad only if ordered by the physician.

G. Check to see that the crutches are labeled with the student’s name.

H. Verbalize/demonstrate that student is using the crutch gait prescribed by the physician.

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

I. Assist the student with stair climbing: 1. To go up stairs 2. To go down stairs

J. Arrange for the student to use the school elevator, if elevator is available.

K. Verbalize safety points for using crutches.

Skills Performance Checklist

Walker

School Employee______Position______County______Certified School Nurse Instructor______

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

A. Obtain instructions from school nurse.

B. Tell the student what you will be doing and how he/she is to assist.

C. Demonstrate checking the walker for appropriate height.

D. Demonstrate assisting the student to walk using the walker.

E. Do not allow the student to use the walker on stairs.

F. Arrange for the student to use the school elevator, if elevator is available.

G. Verbalize key safety points when using a walker.

Skills Performance Checklist

Wheelchair

School Employee______Position______County______Certified School Nurse Instructor______

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

A. Obtain instructions from school nurse.

B. Tell the student what you will be doing and how he/she can assist.

C Verbalize/demonstrate how to assist student into wheelchair.

D. Verbalize/demonstrate how to ambulate student from bed/resting table to wheelchair.

E. Verbalize/demonstrate how to sit the student on the edge of the bed/resting table.

F. Verbalize/demonstrate how to assist the student to stand.

G. Demonstrate how to assist student with transfer board.

H. Verbalize key safety points when using a wheelchair.

Skills Performance Checklist

Assisting with Clothing

School Employee______Position______County______Certified School Nurse Instructor______

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

A. Obtain instructions from school nurse.

B. Dress the weak or most involved extremity first.

C. Undress the weak or involved extremity last.

D. Put clothing within reach and in the order it will be used.

E. Position the student in front of mirror to help monitor own progress.

F. Put suggested/prescribed assistive devices near clothing.

G. Allow enough time for student to complete task.

H. Follow the same routine each time the student dresses and undresses.

I. Determine student’s developmental readiness to assist in dressing. Verbalize what skills to look for in student.

Skills Performance Checklist

Body Mechanics

School Employee______Position______County______Certified School Nurse Instructor______

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

A. Verbalize/demonstrate stooping positions.

B. Verbalize/demonstrate reaching positions.

C. Verbalize/demonstrate pivoting positions.

D. Verbalize/demonstrate lifting and carrying positions.

E. Verbalize/demonstrate pushing and pulling positions.

Skills Performance Checklist

Oral Feeding of Student

School Employee______Position______County______Certified School Nurse Instructor______

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

A. Obtain instructions from school nurse.

B. Determine if suctioning and/or postural drainage are necessary before feeding.

C. Explain the procedure to the student.

D. Wash hands and put on gloves, if appropriate.

E. Choose an area of the classroom or lunchroom that has the most suitable atmosphere for this task.

F. Place the student in a sitting position if this is allowed.

G. Wash the student’s hands and face, if necessary.

H. Place towel on the student’s chest.

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

I. Provide oral hygiene as needed.

J. Measure food, if required, and bring it to the student’s table.

K. Demonstrate how to feed student.

L. Check to see if the student needs assistance with opening mouth, chewing, swallowing or tongue thrust.

M. Offer the student liquids throughout the meal.

N. Praise and encourage the student’s efforts.

O. Remove uneaten food from the student’s table. Measure it if required. Return it to kitchen or discard it.

P. Provide oral hygiene and brush the student’s teeth.

Q. Wash the student’s face and hands. Remove the protective covering from clothing.

R. Remove gloves, wash hands.

S. Have the student resume scheduled classroom activity.

T. Document feeding on the student’s individual treatment record.

U. Summarize the student’s need for and apparent benefit (or lack) from being fed at school.

Skills Performance Checklist

Oral Hygiene

School Employee______Position______County______Certified School Nurse Instructor______

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

A. Obtain instructions from school nurse.

B. Tell the student what you will be doing and how student can help.

C. Arrange for privacy.

D. Gather the equipment and supplies.

E. Demonstrate how to position the student appropriately.

F. Wash your hands; wash student’s hands. Put on gloves.

G. Drape the towel across the student’s chest.

H. Place a mirror in front of the student.

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

I. Offer the student water to rinse mouth. Have student swish and expectorate.

J. Prepare the toothbrush.

K. Assist the student to systematically brush all surfaces of teeth.

L. Discard used supplies in waste container. Clean and store reusable equipment.

M. Wash hands.

N. Document procedure on student’s individual treatment record.

Skills Performance Checklist

Pediculosis Detection

School Employee______Position______County______Certified School Nurse Instructor______

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

A. Screen in natural light (near window) or with magnification lamp.

B. Use disposable screening tools as needed.

C. Begin by separating hairs over ears, near the crown and back of neck. If no louse or nits are found, continue to examine all areas of the head.

D. Differentiate nits from psuedonits.

E. If pediculosis is detected, follow the recommended guidelines of County Health Department and/or County Board of Education for management, treatment, and education.

Skills Performance Checklist

Safety While Using Assistive Devices

School Employee______Position______County______Certified School Nurse Instructor______

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

A. Verbalize essential personnel to student’s needs.

B. Verbalize environmental concerns.

C. Verbalize transportation concerns.

D. Verbalize field trip concerns.

E. Identify key school personnel responsible for dissemination of health information to the school nurse.

F. Verbalize what to look for in student behavior.

G. Documentation of health care plan.

Skills Performance Checklist

Skin Care and Positioning For Prevention of Pressure Areas

School Employee______Position______County______Certified School Nurse Instructor______

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

A. Obtain instructions from school nurse.

B. Verbalize/demonstrate how to inspect skin daily for signs of pressure.

C. Verbalize /demonstrate how to relieve pressure points.

D. Verbalize /demonstrate how to maintain good skin hygiene.

E. Document on student’s individual treatment record.

Skills Performance Checklist

Bedpan

School Employee______Position______County______Certified School Nurse Instructor______

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

A. Obtain instructions from school nurse.

B. Provide privacy for the student.

C. Verbalize what equipment is needed and how the student is to help.

D. Wash hands and put on gloves.

E. Place student on changing table or mat in supine position.

F. Assist student or place student onto bedpan.

G. Assist student with hygiene after toileting.

H. Assist or remove student from bedpan.

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

I. Assist student to redress as needed.

J. Assist student to wash hands.

K. Dispose of contents of bedpan and clean bedpan with approved germicidal solution and store appropriately.

L. Remove gloves and wash hands.

M. Document procedure on student’s individual treatment record.

Skills Performance Checklist

Urinal

School Employee______Position______County______Certified School Nurse Instructor______

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

A. Obtain instructions from school nurse.

B. Provide privacy for the student.

C. Assemble the necessary equipment and wash student hands. Undress, as needed maintaining privacy.

D. Wash hands and put on gloves.

E. Place disposable pad under penis and thighs. Place urinal in position.

F. If not sitting, place in sitting position with support of back. Drape student.

G. Leave the area to give the student privacy, unless he should not be left alone.

H. Remove the urinal, cover and place on a protected surface.

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

I. Note condition of student’s skin and genitalia. Cleanse area.

J. Remove disposable underpad and redress student.

K. Allow the student to wash hands and help him to get into a comfortable position.

L. Empty contents of urinal in toilet. Note appearance.

M. Clean the urinal with germicidal solution and store in appropriate area.

N. Remove gloves and wash hands.

O. Document on student’s individual treatment record.

Skills Performance Checklist

Use of Disposable Diapers/Briefs

School Employee______Position______County______Certified School Nurse Instructor______

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

A. Place student on changing table with protective covering, maintain privacy.

B. Wash hands and put on gloves.

C. Remove soiled diaper and place in plastic bag.

D. Cleanse perineum and buttocks with wipes. Use powders and ointments only when prescribed and apply clean diaper or brief.

E. Clean changing table or mat with germicidal solution.

F. Remove gloves and wash hands.

G. Note and report any abnormal conditions to school nurse and parent/guardian.

H. Document procedure on student’s individual treatment record.

Skills Performance Checklist

Feminine Hygiene

School Employee______Position______County______Certified School Nurse Instructor______

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

A. Assure privacy.

B. Wash hands and put on gloves.

C. Undress student as needed and remove sanitary pad.

D. Clean perineum after bowel/bladder elimination with disposable wipes.

E. Wipe from the vulva toward the anal area.

F. Discard the used wipe after each cleansing stroke in waste container.

G. Apply clean sanitary napkin to clean undergarment and assist with redressing.

H. Remove undergarments if soiled, and rinse with cold water and place in plastic bag to be sent home.

I. Remove gloves and wash hands.

J. Document procedure on student’s individual treatment record.

Skills Performance Checklist

Mechanical Lift

School Employee______Position______County______Certified School Nurse Instructor______

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

A. Assemble all necessary lift equipment and any supplies needed to perform task.

B. Inspect lift before each use. Verbalize/demonstrate what needs to be inspected.

C. Follow manufacturer’s instruction manual for transfer.

D. Follow manufacturer’s instruction manual for maintenance.

E. Verbalize emergency plan for emergency use.

Skills Performance Checklist

Orthopedic Device

School Employee______Position______County______Certified School Nurse Instructor______

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

A. Removing the device: 1. Loosen all the straps and attachments of the device. 2. Lift the limb carefully out of the device. 3. Inspect skin observe for signs of pressure areas.

B. Report any changes to school nurse and parent/guardian.

C. Reapply device 1. Make sure skin is clean and dry. 2. Use stockinette or thin material between skin and device. 3. Check that device is put on properly. 4. Fasten straps securely.

D. Document procedure on student’s individual treatment record.

E. Major concerns: 1. Observe for proper fit and report abnormal findings to school nurse and parent/guardian. 2. Encourage good hygiene.

Skills Performance Checklist

Passive Range of Motion Exercise

School Employee______Position______County______Certified School Nurse Instructor______

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

A. Obtain instructions from school nurse.

B. Explain procedure to student.

C. Place student into proper position.

D. Support the extremity at the joint with one hand while moving the extremity smoothly, slowly, and gently through its range of motion.

E. Document procedure on student’s individual treatment record.

Skills Performance Checklist

Enteral Feeding Via Gastrostomy Tube or Bolus Method

School Employee______Position______County______Certified School Nurse Instructor______

Date Date Date Date Date Completed Completed Completed Explanation/Demonstration Completed Completed

A. Obtain instructions from school nurse.

B. Demonstrate correct positioning of student for feeding.

C. Verbalize what feeding is supposed to look like and correct temperature of feeding.

D. Wash hands and put on gloves.

E. Check student for abdominal distensions belching, loose stools, flatus or pain.

F. Remove cap or plug from G- tube and insert a catheter-tipped syringe into the end of feeding tube.

G. Check placement of feeding tube prior to initiating each feeding by unclamping the tubing and injecting 10cc of air into the G-tube while listening for a whooshing sound over the epigastric area of the abdomen with a stethoscope.

H. Aspirate and measure Date Date Date Date Date residual feedings after Completed Completed Completed Completed Completed confirming G-tube placement. Adjust the feeding volume according to orders if residual is present.

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

I. Re-instill the gastric contents into the stomach. Clamp or pinch tube.

J. Disconnect the syringe.

Remove bulb or plunger from syringe and reconnect the syringe to a pinched or clamped

G—tube.

K. Unclamp tube and allow bubbles to escape. Add feeding to syringe barrel, allowing feeding to flow slowly. Continue to add feeding and keep solution in syringe at all times until feeding is completed. Pinch off tubing if student experiences discomfort. Clamp tube and discontinue feeding if student should vomit during the feeding.

L. Instill prescribed amount of water after feeding is administered.

M. Vent G-tube by opening G- tube to air if ordered.

N. Clamp tube, remove barrel of syringe and reinsert cap or plug into end of tubing.

O. Verbalize/demonstrate care of student after feeding is completed.

P. Wash all reusable equipment with warm soapy water after each feeding, rinse thoroughly and dry. Store in a clean area.

Q. Remove gloves and wash hands.

R. Document procedure on student’s individual treatment record.

Skills Performance Checklist

Enteral Feeding Via Gastrostomy Tube Slow Drip and/or Continuous Method

School Employee______Position______County______Certified School Nurse Instructor______

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

A. Obtain instructions from school nurse.

B. Demonstrate correct positioning of student for feeding.

C. Verbalize what feeding needs to look like and correct temperature.

D. Wash hands and put on gloves.

E. Check student for abdominal distention, belching, loose stools, flatus or pain.

F. Remove cap or plug from G- tube and insert a catheter-tipped syringe into the end of feeding tube.

G. Check placement of feeding tube prior to feeding.

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

H. Aspirate and measure residual feedings after confirming placement.

I. Reinstill the gastric contents into the stomach. Clamp or pinch tube

J. Clamp the G-tube and disconnect the syringe.

K. Demonstrate administration of feeding steps. 1. Remove hanger from hook or standard. 2. Place bottle/bag with prescribed formula in hanger and attach administration set, making sure tubing is clamped. 3. Hang bottle/bag on hook or standard. 4. Open clamp on administration set tube and prime tube by allowing fluid to fill tubing before attaching to G-tube. Prime tubing according to manufacturer’s instructions if using pump. 5. Attach tubing to G-tube and tape securely. Unclamp G-tube. Open clamp of feeding container tubing and regulate fluid drip to approximately 60 drops per minute, unless otherwise ordered or set pump according to manufacturer’s instructions. 6. Check student frequently, pinch off tubing to stop the flow if the student experiences discomfort. Clamp tube and discontinue feeding if student should vomit during the feeding.

L. Clamp G-tube and feeding container tubing and disconnect.

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

M. Insert syringe into G-tube and instill prescribed amount of water.

N. Vent G-tube if ordered.

O. Verbalize care of the student after feeding.

P. Wash all reusable equipment and store in clean area.

Q. Remove gloves and wash hands.

R. Document on student’s individual treatment record

Skills Performance Checklist

Enteral Feeding Via Gastrostomy Button Bolus Method

School Employee______Position______County______Certified School Nurse Instructor______

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

A. Obtain instructions from school nurse.

B. Demonstrate correct positioning of student for feeding.

C. Verbalize what feeding is supposed to look like and correct temperature of feeding.

D. Wash hands and put on gloves.

E. Check student for abdominal distention, belching, loose stools, flatus or pain.

F. Observe for leakage around button.

G. Attach adapter with tubing to syringe, keeping tube clamped.

H. Open safety plug and insert adapter into the button, keeping the tube clamped. Unclamp and aspirate immediately, if ordered. If aspiration is not required, move to step J.

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

I. Reinstill the gastric contents into the stomach. Clamp or pinch tube.

J. Remove bulb or plunger from syringe and fill syringe with feeding solution, keeping tubing clamped.

K. Unclamp tubing, allowing feeding to flow slowly. Continue adding feeding to syringe, keeping syringe partially filled at all times until feeding is complete. Pinch off tubing to stop the flow if the student experiences discomfort and clamp tubing if student begins to vomit.

L. Flush with prescribed amount of water after feeding is administered.

M. Lower syringe below stomach level to facilitate burping.

N. Remove adapter and feeding catheter. Snap safety plug into place.

O. Verbalize care of the student after feeding.

P. Wash all equipment with warm soapy water after each feeding, rinse thoroughly and store in clean area.

Q. Remove gloves and wash hands.

R. Document procedure on student’s individual treatment record.

Skills Performance Checklist

Enteral Feeding Via Gastrostomy Button Slow Drip and/or Continuous Method

School Employee______Position______County______Certified School Nurse Instructor______

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

A. Obtain instructions from school nurse.

B. Demonstrate correct positioning of student for feeding.

C. Verbalize what feeding is supposed to look like and correct temperature of feeding.

D. Wash hands and put on gloves.

E. Check student for abdominal distention, belching, loose stools, flatus or pain.

F. Observe for leakage around button.

G. Attach adapter with tubing to syringe, keeping tubing clamped

H. Open safety plug and insert adapter into the button, keeping the tube clamped. Unclamp and aspirate immediately, if ordered. If aspiration is not required move to step J.

I Re-instill the gastric contents into the stomach. Clamp or pinch tube.

Explanation/Demonstration Date Date Date Date Date Completed Completed Completed Completed Completed

J. Attach adapter and tubing to administration set, keeping tube clamped.

K. Demonstrate administration of feeding. 1. Remove hanger from hook or standard. 2. Place bottle/bag in hanger and attach administration set, making sure tubing is clamped. 3. Hang bottle/bag on hook or standard at height to achieve prescribed flow. Open clamp on administration set and fill tubing then reclamp. If pump is used, place tubing into pump mechanism and set proper flow rate. Prime according to manufacturer’s instructions. 4. Open the safety plug and insert adapter into the button. Unclamp tubing and administer at prescribed rate. Stop feeding if student experience discomfort or should vomit during procedure.

L. Flush with prescribed amount of water after feeding is administered.

M. Lower feeding bottle or bag below the stomach level to facilitate burping.

N. Remove adapter from button. Snap in plug.

O. Verbalize care of student after feeding.

P. Wash all equipment with warm soapy water after each feeding rinse thoroughly and dry. Store in a clean area.

Q. Remove gloves and wash hands.

R. Document procedure on student’s individual treatment record.

Skills Performance Checklist

Enteral Feeding Via Nasogastric Tube Bolus Method

School Employee: ______Position: ______County: ______Certified School Nurse Instructor: ______

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

A. Obtain instructions from school nurse.

B. Demonstrate correct positioning of student for feeding.

C. Verbalize what feeding is supposed to look like and correct temperature of feeding.

D. Wash hands and put on gloves.

E. Check student for abdominal distention, belching, loose stools, flatus or pain.

F. Check tube placement.

G. Aspirate and measure residual feedings after confirming tube placement. Adjust the feeding volume according to orders if a residual is present.

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

H. Reinstill the gastric contents into the stomach. Clamp or pinch the tube.

I. Remove bulb or plunger from syringe.

J. Add feeding to syringe barrel and unclamp tube, allowing feeding to flow slowly. Pinch off tubing if student experiences discomfort.

K. Instill prescribed amount of water after feeding is administered.

L. Clamp tube and remove syringe.

M. Verbalize post feeding and daily care of the student.

N. Remove gloves and wash hands.

O. Wash all equipment with warm soapy water after each feeding, rinse thoroughly and dry. Store in a clean area.

P. Document procedure on student’s individual treatment record.

Skills Performance Checklist

Enteral Feeding Via Nasogastric Tube Slow Drip and/or Continuous Feeding

School Employee: ______Position: ______County: ______Certified School Nurse Instructor: ______

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

A. Obtain instructions from school nurse.

B. Demonstrate correct position of student for feeding.

C. Verbalize what feeding is supposed to look like and correct temperature of feeding.

D. Wash hands and put on gloves.

E. Check student for abdominal distension, belching, loose stools, flatus or pain.

F. Check for tube placement.

G. Aspirate and measure residual feedings after confirming tube placement.

H. Re-instill the gastric contents into the stomach. Clamp or pinch tube.

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

I. Demonstrate administration of feeding steps 1-6. 1. Remove hanger from hook or standard. 2. Place bottle/bag with prescribed formula in hanger and attach administration set, making sure tubing is clamped. 3. Hang bottle/bag on hook or standard. 4. Open clamp on formula tube and prime tube by allowing fluids to fill tubing before attaching to NG tube. Prime tubing according to manufacturer’s instructions if using a pump. 5. Attach formula tube to NG tube, open clamp and regulate fluid drip to approximately 60 drops per minute, unless otherwise ordered or set pump according to manufacturer’s instructions. 6. Check student frequently. Pinch off tubing to stop the flow if the student experiences discomfort. Clamp tube and discontinue feeding if student should vomit during feeding.

J. Insert syringe into NG tube and instill prescribed amount of water after feeding is administered.

K. Allow some of the water to remain within NG tube and clamp or plug tubing.

L. Verbalize post feeding and daily care of student after feeding.

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

M. Clean all equipment and store in clean, dry place.

N. Remove gloves and wash hands.

O. Document procedure on student’s individual treatment record.

Skills Performance Checklist

Inserting a Nasogastric Tube

School Employee______Position______County______Certified School Nurse Instructor______

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

A. Obtain instructions from school nurse.

B. Explain procedure to student.

C. Assemble equipment.

D. Wash hands and put on gloves.

E. Position student into fowler’s position and place towel across chest.

F. Insert nostrils to determine which nostril is most patent.

G. Measure distance to insert tube and mark with tape.

H. Coil the first 3-4 inches of tube around fingers.

I. Lubricate about 6-8 inches (15- 20 cm) of tube with water- soluble jelly.

J. Tilt head back and insert tube through the posterior nasopharynx.

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

K. Allow student to rest for a few moments. When tube reaches the pharynx, student may gag.

L. Tilt head slightly forward and offer several sips of water through straw while advancing tube as student swallows.

M. Continue advancing tube gently each time student swallows.

N. Stop advancing tube when obstruction appears to prevent tube from passing.

O. Advance tube until tape mark reaches nostrils.

P. Verbalize when to remove tube due to signs of distress.

Q. Check placement of nasogastric tube. Clamp tube after correct placement confirmed.

R. Secure NG tube with tape on bridge of student’s nose.

S. Secure NG tube to clothing with rubber band or tape and safety pin.

T. Discard disposable equipment.

U. Remove gloves and wash hands.

V. Document procedure on student’s individual treatment record.

Skills Performance Checklist

Ostomy Care Emptying/Changing of Ostomy Pouch

School Employee______Position______County______Certified School Nurse Instructor______

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

A. Obtain instructions from school nurse.

B. Assemble equipment in appropriate private location.

C. Position student in relaxed position.

D. Wash hands and put on gloves.

E. Verbalize/demonstrate steps to empty ostomy pouch.

F. Verbalize/demonstrate steps to change ostomy pouch.

G. Secure lower opening of pouch with clamp or be sure adapter is closed.

H. Remove gloves and wash hands.

I. Document on student’s individual treatment record.

Skills Performance Checklist

General Guidelines for Diabetic Management

School Employee______Position______County______Certified School Nurse Instructor______

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

A. Obtain instructions from school nurse.

B. Verbalize characteristics of hypoglycemia and hyperglycemia.

C. Assess school day activities.

D. Prepare school staff for prescribed procedures during the school day.

E. Document procedure on student’s individual treatment record.

Skills Performance Checklist

Measurement of Blood Sugar with Glucometer

School Employee______Position______County______Certified School Nurse Instructor______

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

A. Obtain instructions from school nurse.

B. Prepare work area; assemble equipment and prepare the meter for use.

C. Have student cleanse hands or use alcohol wipes on chosen puncture site, if needed.

D. Wash hands and put on gloves.

E. Perform puncture and place drop of blood on test strip or proper port.

F. Cover lanced area with gauze or adhesive bandage.

G. Verbalize appropriate actions to take with regard to blood glucose reading.

H. Dispose of chemstrip, lancet, and any material potentially contaminated with blood in appropriate manner.

I. Remove gloves and wash hands.

J. Document on student’s individual treatment record.

Skills Performance Checklist

Insulin Administration by Pen

School Employee______Position______County______Certified School Nurse Instructor______

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

A. Obtain written orders from licensed prescriber and parent or guardian written consent to perform procedure.

B. Read the licensed prescriber’s order and document the newest glucose measurement. Review the prescribed sliding scale and/or algorithm and calculate the dosage needed, if necessary.

C. Wash hands and put on gloves.

D. Check the drug label to be sure it is what is prescribed.

E. Check the expiration date on the pen.

F. Remove pen cap.

G. Look at insulin.

H. Intermediate or mixed insulins should be gently mixed before use.

Explanation/Demonstration Date Date Date Date Date Completed Completed Completed Completed Completed

I. Remove the protective pull tab from the needle and screw it onto the pen until snug.

J. Remove both the plastic and inner needle cap.

K. Look at the dose window and turn the dosage knob to “2” units. Holding the pen with the needle pointing upwards, press the button until at least a drop of insulin appears.

L. Dial the number of units your need to administer.

M. Decide where in the body you will give the injection. Be sure to give the injection in a different place each time. You may stay in the same general area but at least 1 inch from the las injection, scars, and naval.

N. Inject insulin at a 45 – 90 degree angle.

O. Press the button all the way returning to zero, and keep pressing for six to ten seconds before withdrawing from skin.

P. Remove needle from pen.

Q. Document procedure on student’s individual treatment record.

R. Additional Considerations 1. Date insulin cartridge when opened and start using. 2. Label insulin pen with student’s name. 3. Store opened pens at room temperature. Unopened pens should be stored in the refrigerator at about 40 F. Avoid exposure to temperature extremes.

Skills Performance Checklist

Insulin Administration by Injection

School Employee______Position______County______Certified School Nurse Instructor______

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

A. Obtain instructions from school nurse.

B. Review the prescribed sliding scale and/or algorithm and latest glucose measurement and calculate dosage needed, if applicable.

C. Wash hands and put on gloves.

D. Wipe bottle cap with alcohol and draw up insulin or set pen to required dosage.

E. Select a correct site for injection.

F. Inject insulin.

G. Withdraw and dispose of needle and syringe in appropriate container.

H. Remove gloves and wash hands.

I. Document procedure on student’s individual treatment record.

Skills Performance Checklist

Administration of Insulin by Pump

School Employee______Position______County______Certified School Nurse Instructor______

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

A. Obtain instructions from school nurse.

B. Assemble equipment.

C. Wash hands and put on gloves.

D. Obtain blood glucose measurement and review licensed prescriber’s orders.

E. Assess pump insertion site.

F. Administer bolus dose as ordered by licensed prescriber.

G. Remove gloves and wash hands.

H. Document procedure on student’s individual treatment record.

I. Verbalize special considerations for hypoglycemia and hyperglycemia.

Skills Performance Checklist

Glucagon Administration

School Employee______Position______County______Certified School Nurse Instructor______

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

A. Obtain instructions from school nurse.

B. Obtain Glucagon and ensure proper storage.

C. Verbalize emergency plan for delegated personnel to follow.

D. Verbalize when glucagon should be administered.

E. Verbalize care of unresponsive student.

F. Verbalize/demonstrate preparation of glucagon.

G. Put on gloves.

H. Demonstrate correct selection of site for injection on upper arm or thigh.

I. Cleanse injection site with alcohol if needed.

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

J. Insert the needle and inject glucagon.

K. Withdraw and dispose of needle and syringe in appropriate container.

L. Remove gloves and wash hands.

M. Document on student’s individual treatment record.

N. Verbalize monitoring of student until emergency personnel arrives.

Skills Performance Checklist

Continuous Glucose Monitoring

School Employee______Position______County______Certified School Nurse Instructor______

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

A. Obtain licensed prescriber’s order and parent/guardian written. B. Obtain CGM reading from monitor or insulin pump to interstitial view fluid glucose levels.

C. If CGM alarms a finger stick blood glucose monitor (BGM) is required follow measurement of blood glucose (BG) with meter procedure.

D. Document procedure on student’s individual treatment record.

Skills Performance Checklist

Long-Term Medication Administration

School Employee______Position______County______Certified School Nurse Instructor______

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

A. Obtain instructions from school nurse.

B. Obtain medication and store appropriately.

C. Remove medication from storage area and verify student’s name, medication, dosage, time and route of administration according to the written medication order and the pharmacy-labeled container.

D. Wash hands: Put on gloves, if needed.

E. Ensure positive identification of student.

F. Verbalizes/demonstrates correct way to administer prescribed medication.

G. Verbalize when to let student self-administer and what to do when the student is unable to self-administer.

H. Document procedure on the student’s individual treatment record. Use a separate record for each medication.

Skills Performance Checklist

Emergency Medication Administration

School Employee______Position______County______Certified School Nurse Instructor______

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

A. Obtain instructions from school nurse.

B. Verbalize the need for emergency medication in the school setting.

C. Obtain medication and store appropriately.

D. Verbalize/demonstrate emergency care for student.

E. Ensure positive identification of student.

F. Verbalize/demonstrate administration of correct emergency medication, dosage, time and route of administration according to written medication order and pharmacy-labeled container.

G. Verbalize/demonstrate proper disposal of used needle/syringe, if needed.

H. Document procedure on student’s individual treatment record.

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

I. Observe student’s response to medication and document.

J. Monitor until emergency personnel arrive.

Skills Performance Checklist

Administering Medications through Gastrostomy/N-G Tube

School Employee______Position______County______Certified School Nurse Instructor______

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

A. Obtain instructions from school nurse.

B. Verify medication order before administering via gastric tube.

C. Wash hands and put on gloves.

D. Prepare medication for administration.

E. Elevate student’s head to a 30-45 degrees or assist in sitting position.

F. Check placement of feeding tube prior to administering the medication.

G. Aspirate and measure residual feedings confirming gastric tube placement.

H. Put the correct amount of medication into the syringe and allow to flow by gravity.

I. Pour 30 cc of water into gastric tube after medication is instilled.

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

J. Clamp tube, remove barrel of syringe and reinsert cap into end of tubing.

K. Verbalize/demonstrate proper care of the student.

L. Wash all reusable equipment after each use. Store in a clean area.

M. Remove gloves and wash hands.

N. Document procedure on student’s individual treatment record.

Skills Performance Checklist

Administration of Rectal Diazepam

School Employee______Position______County______Certified School Nurse Instructor______

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

A. Obtain instructions from school nurse.

B. Verbalize student history of seizures and their response to diazepam.

C. Verbalize where procedure can be performed in school setting.

D. Verbalize emergency plan for individual student.

E. Obtain rectal diazepam and ensure proper storage.

F. Check student and provide safety measures for student during seizure.

G. Verbalize/demonstrate administration of rectal diazepam for established criteria.

H. Monitor student until EMS arrive.

I. Document activity on student’s individual treatment record.

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

J. Verbalize additional considerations for using rectal diazepam.

Skills Performance Checklist

Administration of Intranasal Midazolam

School Employee______Position______County______Certified School Nurse Instructor______

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

A. Obtain instructions from school nurse.

B. Verbalize student history of seizures and their response to intranasal midazolam.

C. Verbalize where procedure can be performed in school setting for student privacy.

D. Verbalize emergency plan for individual student.

E. Verbalized procedure for administration and monitoring student’s response.

F. Obtain pre-dosed needless intranasal or auto- injectable/carpuject intranasal midazolam and ensure proper storage.

G. Check student and provide safety measures for student during seizure.

H. Verbalize/demonstrate administration of intranasal midazolam for established criteria.

I. Monitor student’s pulse and respirations until EMS arrive.

J. Document activity on student’s individual treatment record. K. Verbalize additional considerations for using intranasal midazolam.

Skills Performance Checklist

Phrenic Nerve Stimulator

School Employee______Position______County______Certified School Nurse Instructor______

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

A. Obtain instructions from school nurse.

B. Monitor pacer operation, carbon dioxide and oxygen levels upon student’s arrival at school. Make adjustments to settings as indicated by physician’s orders throughout the day.

C. Refer to manufacturer’s instructions when making adjustments to PNS.

D. Verbalize signs of PNS malfunction.

E. Document information on student’s individual treatment record.

F. Verbalize other considerations when using PNS.

Skills Performance Checklist

Seizure Management

School Employee______Position______County______Certified School Nurse Instructor______

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

A. Obtain instructions from school nurse.

B. Verbalize types and characteristics of seizures.

C. Verbalize seizure history from parent/guardian and student.

D. Verbalize needs of student’s environment and class schedule with nurse.

E. Review with school nurse written emergency plan for student.

F. Verbalize/demonstrate care of student during seizure.

G. Verbalize/demonstrate administering medications and/or other treatments for seizures.

H. Verbalize trigger factors for seizures in school setting.

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

I. Document procedure on student’s individual treatment record.

Skills Performance Checklist

Vagus Nerve Stimulator with Magnet

School Employee______Position______County______Certified School Nurse Instructor______

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

A. Obtain instructions from school nurse.

B. Observe or assist student or verbalize/demonstrate use of the magnet according to physician’s orders.

C. Observe student response and monitor seizure activity response to magnet use.

D. Document procedure on student’s individual treatment record.

E. Verbalize magnet care and precautions.

F. Verbalize/Observe for side effects of Vagus Nerve Stimulator.

Skills Performance Checklist

Anaphylactic Reaction

School Employee______Position______County______Certified School Nurse Instructor______

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

A. Verbalize emergency plan for student with a documented history of anaphylactic reaction or potential for anaphylaxis.

B. Verbalize how to determine if the student is having an anaphylactic reaction and verbalize symptoms.

C. Verbalize/demonstrate medication to be administered for anaphylactic reaction.

D. Establish vital functions.

E. Call Emergency Medical Services and notify parent/guardian and school nurse.

F. Document procedure on student’s individual treatment record.

Skills Performance Checklist

Epinephrine Auto-Injector

School Employee______Position______County______Certified School Nurse Instructor______

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

A. Obtain instructions from school nurse.

B. Store epinephrine auto- injector at room temperature in a dark place. Keep in light- protective covering.

C. Check epinephrine auto- injector routinely to make sure solution in auto-injector is not discolored, contains a precipitate or expired.

D. Review intervention guide and emergency plan for each student.

E. Remain with student while sending someone to obtain the medication, call EMS and notify the parent/guardian, and the school nurse.

F. Provide for student safety before administering the epinephrine.

G. Remove the gray safety cap from the epinephrine auto- injector.

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

H. Place black tip on the outer thigh at a right angle to the leg. Do not attempt to inject medication into a vein or into the buttocks.

I. Press hard into thigh until auto-injector mechanism functions and hold in place 10 seconds. J. Remove the auto-injector. Message the area for 10 seconds. Bend needle of auto-injector back against a hard surface. Place the unit back into its carrying tube and send the used Epi-Pen with the EMS transporting the student to the emergency room.

K. Remove and discard auto- injector into sharps container.

L. Massage injection site for 10 seconds.

M. Document on student’s individual treatment record.

Skills Performance Checklist

Epinephrine Twinject

School Employee______Position______County______Certified School Nurse Instructor______

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

A. Obtain instructions from school nurse.

B. Determine student’s history of an allergic reaction and obtain order from licensed prescriber and instructions for use of epinephrine Twinject. Obtain parent/guardian’s written consent to perform procedure.

C. Store epinephrine Twinjet at room temperature in a dark place. Keep in light-protective covering.

D. Check epinephrine Twinjet routinely to make sure solution in Twinjet is not discolored, contains a precipitate or expired.

E. Verbalize/demonstrate the understanding of the written intervention guide and emergency plan for the student.

F. Remain with the student while sending someone to obtain medication, call EMS, notify the parent/guardian and notify the school nurse

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

G. Provide for student safety before administering the epinephrine.

H. Pull off the green cap labeled “1” to expose the red tip. Then remove the end cap labeled “2” to engage the auto-injector to administer the first dose of epinephrine.

I. Place the red tip on the middle of the outer thigh at a right angle to the leg.

J. Press auto-injector hard into the thigh until mechanism functions and hold in place for 10 seconds.

K. Remove the device from the thigh and check the red tip to see if the needle is exposed. If the needle is not visible repeat step K.

L. Unscrew and remove the red tip from the auto-injector.

M. Grab the blue hub at the needle base and pull the syringe from the barrel. Slide the yellow or orange collar of the plunger.

N. Push the needle into the middle of the outer thigh at a right angle to the leg. Push the plunger down all the way. Remove the syringe from the thigh.

O. Place the used syringe into the carrying case. Store second dose if not used.

P. Document procedure on student’s individual treatment record.

104

Skills Performance Checklist

Inhalation Therapy by Machine

School Employee______Position______County______Certified School Nurse Instructor______

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

A. Obtain instructions from school nurse.

B. Assemble equipment in an appropriate location for administration of treatment.

C. Wash hands and put on gloves.

D. Student should be in a sitting or semi-fowlers position.

E. Connect tubing and add prescribed medication to clean chamber.

F. Demonstrate the ordered delivery method. 1. Ensure face mask is positioned properly. 2. Instruct student to take in a deep breath from the mouthpiece, seal lips around it and breathe through mouth only.

G. Disassemble and clean machine. Dispose of contaminated tissues and materials.

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

I. Remove gloves and wash hands.

J. Document on student’s individual treatment record.

Skills Performance Checklist

Manual Resuscitator

School Employee______Position______County______Certified School Nurse Instructor______

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

A. Obtain instructions from school nurse.

B. Verbalize location of equipment.

C. Wash hands and put on gloves.

D. Demonstrate checking for proper functioning of manual resuscitator.

E. Explain procedure to student.

F. Verbalize/demonstrate proper delivery by mask.

G. Verbalize/demonstrate proper delivery with tracheostomy.

H. Verbalize/demonstrate checking effectiveness of ventilation.

I. Verbalize how long to continue bagging.

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

J. Clean equipment and reassemble for use.

K. Remove gloves and wash hands.

L. Document procedure on student’s individual treatment record.

Skills Performance Checklist

Mechanical Ventilator

School Employee______Position______County______Certified School Nurse Instructor______

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

A. Obtain instructions from school nurse.

B. Verbalize/demonstrate manufacturer’s instructions for specific ventilator.

C. Verbalize/demonstrate daily ventilator checks.

D. Demonstrate checking tubing to tracheostomy for patency.

E. Demonstrate how to check respiratory rate, lung sounds, skin color and mental alertness.

F. Demonstrate how to monitor student’s oxygen and carbon dioxide levels.

G. Demonstrate suctioning tracheostomy as needed or ordered.

H. Document information on student’s individual treatment record.

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

I. Verbalize/demonstrate how to establish vital functions in case of ventilator failure.

J. Verbalize where to find emergency power source if power goes out or battery fails.

Skills Performance Checklist

Metered Dose Inhaler Therapy (MDI)

School Employee______Position______County______Certified School Nurse Instructor______

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

A. Obtain instructions from school nurse.

B. Wash hands if assisting with Metered Dose Inhaler.

C. Verbalize/demonstrate how to assist student to use MDI, according to order.

D. Verbalize/demonstrate how to obtain and document Peak Flow, if ordered.

E. Verbalize/demonstrate correct procedure for using MDI.

F. Monitor student for administration technique.

G. Document procedure on student’s individual treatment record.

Skills Performance Checklist

Oral Suctioning

School Employee______Position______County______Certified School Nurse Instructor______

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

A. Obtain instructions from school nurse.

B. Assemble equipment.

C. Wash hands and put on gloves and goggles.

D. Position child.

E. Verbalize/demonstrate suctioning with bulb syringe.

F. Verbalize/demonstrate suctioning by machine.

G. Remove gloves and wash hands.

H. Document on student’s individual treatment record.

Skills Performance Checklist

Oxygen Administration

School Employee______Position______County______Certified School Nurse Instructor______

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

A. Obtain instructions from school nurse.

B. Verbalize assessment of environment for safety.

C. Review student’s daily schedule. Identify school personnel responsible for student safety.

D. Wash hands.

E. Assemble equipment.

F. Connect tubing to oxygen source. Attach humidifier, if ordered, to oxygen tubing.

G. Flush line by turning oxygen on and adjusting flow rate to ordered level. Feel for oxygen flow through tubing.

H. Place nasal cannula or face mask on the student’s face or attach the tracheostomy adaptor.

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

I. Verbalize how to monitor student for any change in condition while receiving oxygen.

J. Document on student‘s individual treatment record.

Skills Performance Checklist

Peak Flow Meter

School Employee______Position______County______Certified School Nurse Instructor______

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

A. Obtain instructions from school nurse.

B. Have student stand or sit upright. Instruct the student to place the mouthpiece on the peak flow meter.

C. Ensure that the red indicator is at the bottom of the scale.

D. Hold the peak flow meter according to manufacturer’s instructions, being careful that the student’s fingers do not block the opening.

E. Instruct the student to inhale as deeply as possible and place mouth firmly around the mouthpiece, making sure lips form a tight seal.

F. Instruct the student to exhale as hard and as fast as possible. This will cause the red indicator to move up the scale. The final position of the red indicator is the student’s peak expiratory flow.

G. Document the reading on the student’s individual treatment record and repeat two times to confirm results.

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

H. Refer to student’s intervention guide or emergency plan for instructions related to peak flow value.

I. Document on student’s individual treatment record.

J. Verbalize/demonstrate use of electronic peak flow meter according to manufacturer’s instructions.

Skills Performance Checklist

Percussion and/or Postural Drainage

School Employee______Position______County______Certified School Nurse Instructor______

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

A. Obtain instructions from school nurse.

B. Wash hands.

C. Assemble equipment in appropriate location.

D. Verbalize/demonstrate sequence for percussing each lobe of the lungs.

E. Verbalize/demonstrate the 8 positions for percussing student 40 pounds or more.

F. Verbalize/demonstrate techniques for student under 40 pounds.

G. Verbalize/demonstrate 5 breathing techniques after percussing.

H. Discard contaminated articles.

I. Wash hands.

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

J. Document on student’s individual treatment record.

Skills Performance Checklist

Emergency Care and Cleaning of Tracheostomy Tube and Stoma

School Employee______Position______County______Certified School Nurse Instructor______

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

A. Obtain instructions from school nurse.

B. Explain procedure to student.

C. Determine if student can be taken off ventilator during procedure.

D. Position student with tracheostomy area exposed.

E. Assess condition of stoma and examine neck for subcutaneous emphysema.

F. Wash hands and put on gloves.

G. Suction trachea and pharynx thoroughly before tracheostomy care.

H. Remove gloves and wash hands.

I. Assemble equipment needed for cleaning tube and stoma.

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

J. Wash hands and put on non- sterile gloves.

K. Remove soiled dressing and discard.

L. Remove gloves and wash hands.

M. Put on face shield and sterile gloves.

N. Verbalize/demonstrate steps to clean stoma.

O. Verbalize/demonstrate steps to clean tracheostomy tube.

P. Verbalize/demonstrate steps to replace soiled tie tapes.

Q. Verbalize/demonstrate how to clean inner cannula.

R. Verbalize/demonstrate how to determine student ventilating adequately.

S. Place gauze dressing, if ordered, between the stoma site and the tracheostomy tube to absorb secretions and prevent irritation of the stoma

T. Dispose of all supplies in appropriate container.

U. Remove gloves and wash hands.

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

V. Document on student’s individual treatment record.

Skills Performance Checklist

Emergency Replacement of Tracheostomy Tube

School Employee______Position______County______Certified School Nurse Instructor______

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

A. Obtain instructions from school nurse.

B. Verbalize/demonstrate equipment needed and where stored.

C. Puts on gloves immediately.

D. Reassure student.

E. Tilt student’s head back as far as possible.

F. Open tracheostomy tube package.

G. Moisten tube and obturator with sterile normal saline.

H. Insert tracheostomy tube with obturator into trach opening in neck from which previous trach has just been removed.

I. Hold tracheostomy tube, pull out the obturator and insert cannula.

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

J. Hold on to the newly placed tube carefully at its insertion sight. Minimize movement as much as possible.

K. Assess respiratory status. Suction or use manual resuscitator as indicated.

L. Verbalize/demonstrate replacement of trach ties or securing with appropriate device.

M. Verbalize/demonstrate replacement of soiled tie tapes.

N. Determine by bilateral auscultation that student is ventilating adequately. Attach ventilator if removed prior to cleaning.

O. Demonstrate replacement of gauze, if ordered, between the stoma site and tracheostomy tube to absorb secretions.

P. Remove gloves and wash hands.

Q. Document procedure on student’s individual treatment record.

Skills Performance Checklist

Tracheostomy Suctioning Sterile Technique

School Employee______Position______County______Certified School Nurse Instructor______

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

A. Obtain instructions from school nurse.

B. Position student for suctioning.

C. Wash hands and put on goggles or face shield.

D. Turn on suction machine and check for function. Adjust machine to ordered vacuum settings.

E. Encourage student to cough and deep breathe to expel secretions. Manually ventilate with resuscitation bag, if indicated.

F. Open sterile suction catheter or kit. Open saline dosette, if ordered.

G. Fill sterile container with sterile saline or sterile water.

H. Put on sterile gloves.

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

I. Hold end of sterile suction catheter in dominant sterile hand and attach it to the suction machine tubing held in non-dominant hand.

J. Disconnect tubing from tracheostomy if student is on a mechanical ventilator, CPAP device or oxygen. Attach manual resuscitator bag to tracheostomy tube. Ventilate and oxygenate with bag 4-5 times to approximate student tidal volume. In spontaneously breathing student, coordinate manual ventilations with student’s own respiratory effort.

K. Remove sterile suction catheter from package. Hold suction catheter 2-3 inches from tip with sterile hand and insert into saline or water. Cover vent into hole with thumb to suction a small amount of solution through catheter.

L. Demonstrate inserting sterile suction catheter as far as possible into artificial airway without applying suction.

M. Withdraw sterile catheter 2-3 cm and cover vent hole. Quickly rotate sterile catheter with sterile hand while it is being withdrawn. Withdraw within 5-10 seconds.

N. Suction sufficient amount of sterile water or saline from sterile container to clear tubing of secretions.

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

O. Allow student to deep breathe or give 4-5 breaths with resuscitator bag between suctioning attempts.

P. Open sterile normal saline dosette and instill 3-5 ml into tracheostomy with non-sterile hand, if ordered. Manually ventilate with resuscitation bag to disperse saline.

Q. Repeat suctioning procedure if needed to clear airway.

R. Give student 4-5 ‘sigh’ breaths with manual resuscitator when suctioning is complete.

S. Reconnect student to mechanical ventilator, CPAP device or oxygen when suctioning is complete.

T. Disconnect catheter from suction tubing. Holding catheter in gloved hand, pull gloves off, encasing catheter in glove and discard. Discard all disposable equipment.

U. Turn off suction machine. Clean adapter of manual resuscitator with alcohol. Empty suction bottle and wash with warm soapy water at end of day.

V. Wash hands and remove goggles or face shield.

W. Document on student’s individual treatment record.

Skills Performance Checklist

Clean Catheterization

School Employee______Position______County______Certified School Nurse Instructor______

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

A. Obtain instructions from school nurse.

B. Assemble equipment in appropriate private location for performance of procedure.

C. Wash hands.

D. Have student lie on back with knees flexed and separated or position according to student’s need.

E. Undress student as needed, maintaining privacy.

F. Place disposable underpad beneath student’s buttocks.

G. Put on gloves.

H. Open disposable wipes.

I. Open or obtain catheter from storage.

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

J. Use lubricant if ordered and squeeze it onto a clean surface.

K. Verbalize/demonstrate steps for females.

L. Verbalize/demonstrate steps for males.

M. Verbalize/demonstrate procedure for Suprapubic Catheters.

N. Advance catheter approximately one inch further after urine begins to flow.

O. Withdraw catheter slowly when flow of urine has stopped.

P. Remove all equipment and waste materials and discard appropriately.

Q. Redress student, making certain the student is dry and comfortable.

R. Remove gloves and wash hands.

S. Document on student‘s individual treatment record.

Skills Performance Checklist

Condom Catheterization

School Employee______Position______County______Certified School Nurse Instructor______

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

A. Obtain orders from licensed prescriber and written parent/guardian written consent.

B. Wash hands and put on gloves.

C. Assemble equipment including basin with lukewarm water in appropriate private location for performance of procedure.

D. If circumcised, wash with soap and water and dry. If not circumcised, gently retract foreskin and clean beneath it. Rinse well, but don’t dry, and replace foreskin to avoid penile constriction. If necessary, clip hair from the base of the shaft of the penis to prevent adhesive strip or skin bond cement from pulling the pubic hair.

Explanation/Demonstration Date Date Date Date Date Completed Completed Completed Completed Completed

E. If you are using a precut commercial adhesive strip, insert the glans penis through its opening and position the strip 1 inch from the scrotal area. If using uncut adhesive, cut the strip to fit around the shaft of the penis, Remove the protective covering from one side of the adhesive strip and press this side firmly to the side of the penis to enhance adhesion. Remove the covering from the other side of the strip. If commercial adhesive strip isn’t available, apply skin bond cement and let it dry for a few minutes.

F. Position the rolled condom at the tip of the penis and leaving one half inch between the tip of the condom and the penis with its drainage opening at the urinary meatus

G. After the condom catheter is in place, secure it with a hypoallergenic tape or an incontinence sheath holder.

H. Using extension tubing, connect the condom catheter to the leg bag or drainage bag. Remove and discard gloves.

F. Position the rolled condom at the tip of the penis and leaving one half inch between the tip of the condom and the penis with its drainage opening at the urinary meatus.

G. After the condom catheter is in place, secure it with a hypoallergenic tape or an incontinence sheath holder.

H. Using extension tubing, connect the condom

catheter to the leg bag or drainage bag. Remove and discard gloves.

REMOVING THE DEVICE:

F. Wash hands and put on gloves. Simultaneously unroll the condom catheter and the adhesive strip off the penis and discard them. If using skin bond cement instead of adhesive strip, use a solvent. Also remove and discard the incontinence sheath holder.

G. Clean the penis with disposable wipe.

H. Check for swelling or signs of skin breakdown.

I. Remove the leg bag by closing the drain clamp, unlatching the leg straps and disconnecting the extension tubing at the top of the bag.

J. Discard your gloves.

Skills Performance Checklist

Self-Catheterization

School Employee______Position______County______Certified School Nurse Instructor______

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

A. Obtain instructions from school nurse.

B. Assemble equipment in an appropriate private location.

C. Have student wash hands thoroughly. Staff should also if intervention is necessary.

D. Position student appropriately for condition. Assist with undressing as needed, maintaining privacy.

E. Open disposable wipes for the student to self cleanse.

F. Open packet of water- soluble lubricating jelly, if ordered.

G. Verbalize/demonstrate steps for females.

H. Verbalize/demonstrate steps for males.

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

I. Verbalize/demonstrate procedure for Suprapubic Catheters.

J. Remove catheter after flow of urine stopped.

K. Cleanse, dry and redress, assist as necessary.

L. Discard disposable equipment and waste materials.

M. Remove gloves and wash hands.

N. Document on student‘s individual treatment record.

Skills Performance Checklist

Sterile Catheterization

School Employee______Position______County______Certified School Nurse Instructor______

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

A. Obtain instructions from school nurse.

B. Assemble equipment in appropriate private location.

C. Wash hands.

D. Position student and assist with undressing as needed, maintaining privacy.

E. Place sterile catheter set between female’s thighs.

F. Open sterile catheter tray by folding top layer away from your body and bottom layer towards body.

G. Open and place sterile catheter on sterile field in sterile manner, if packaged separately.

H. Put on sterile gloves.

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

I. Open sterile antiseptic and pour over cotton balls or open antiseptic swabs.

J. Open sterile lubricant and lubricate catheter generously, if ordered.

K. Verbalize/demonstrate steps for cleansing females.

L. Verbalize/demonstrate steps for cleansing males.

M. Insert sterile lubricated catheter into the urethra with sterile gloved hand making sure the other end of the catheter is placed in the sterile collection container.

N. Insert sterile catheter until there is urine flow. Allow urine to drain into sterile collection container.

O. Withdraw catheter slowly when flow has stopped.

P. Remove all equipment And discard appropriately.

Q. Redress, making sure student is dry and comfortable.

R. Remove gloves and wash hands.

S. Document on student’s individual treatment record.

Skills Performance Checklist

Crede’s Method

School Employee______Position______County______Certified School Nurse Instructor______

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

A. Obtain instructions from school nurse.

B. Provide privacy for student.

C. Position student according to needs.

D. Apply repeated inward and downward pressure gently with one or both hands over lower abdomen, beginning in the umbilical area and progressing down toward the symphysis pubis.

E. Continue the procedure as long as urine can be manually expressed.

F. Document procedure on student’s individual treatment record.

Comments: ______

______School Employee______Date______Certified School Nurse______Date______

Comments: ______

______School Employee______Date______Certified School Nurse______Date______

Comments: ______

______School Employee______Date______Certified School Nurse______Date______

Comments: ______

______School Employee______Date______Certified School Nurse______Date______

Comments: ______

______School Employee______Date______Certified School Nurse______Date______

Skills Performance Checklist

Nasopharyngeal Suctioning

School Employee______Position______County______Certified School Nurse Instructor______

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

A. Obtain a written order from a licensed prescriber for nasopharyngeal suctioning and written consent from parent/guardian.

B. Obtain student history of airway obstruction and previous response to nasopharyngeal suctioning.

C. Evaluate school setting and student’s schedule to determine where procedure may be performed.

D. Develop written emergency plan for personnel to follow.

E. Train designated RNs and LPNs to administer nasopharyngeal suctioning and to monitor student’s response.

F. Assess equipment and provide safety measures for student during suctioning.

G. Position the student for optimal suctioning.

H. Provide an ongoing assessment of student’s respiratory status.

Explanation/Demonstration Date Date Date Date Date Completed Completed Completed Completed Completed

I. Wash hands

J. Use appropriate personal protective equipment.

K. Aseptic technique using a sterile catheter is the standard for this procedure.

L. Approximate the insertion length of the catheter by measuring the catheter from the nose to the ear, and use the thumb and forefinger of your nondominant hand to mark the catheter at that point of maximal insertion.

M. Dip the catheter tip in sterile water- soluble lubricant to minimize trauma to the nasal mucosa.

N. Without applying suction gently introduce the catheter into the nostril and slowly proceed along the floor of the nasal cavity.

O. Duration of suction should not exceed 15 seconds.

P. Monitor student carefully to ensure oxygenation, stabilized airway and heart rate.

Q. Discard disposable equipment

R. Remove gloves and wash hands.

S. Documents activity on student’s individual treatment record.

T. Additional Considerations:

Skills Performance Checklist

Administration of Intranasal Midazolam

School Employee______Position______County______Certified School Nurse Instructor______

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

A. Obtain physician’s order for intranasal midazolam and parent/guardian written consent for administration.

B. Obtain student history of seizure activity and previous response to intranasal midazolam.

C. Evaluate school setting and student’s schedule to determine where procedure may be performed.

D. Develop written emergency plan for personnel to follow. No delegation of intranasal midazolam medication to unlicensed personnel.

E. Train designated RNs and LPNs to administer versed to monitor student’s response. Intranasal midazolam CANNOT be delegated in the WV Public School setting.

F. Obtain midazolam and ensure proper storage.

G Assess student and provide safety measures for student during seizure.

Explanation/Demonstration Date Date Date Date Date Completed Completed Completed Completed Completed

H. Administer intranasal midazolam if student’s seizure activity meets criteria established by physician’s order. 1.Check student’s pulse and respiration rate before administering midazolam. Keypoint: Baseline rates should be established. 2.Place student in supine position. 3.Assure privacy. Keypoint: Follow plan for evacuation. 4.Obtain intranasal midazolam and notify Emergency Medical Services (EMS). Keypoint: Do not leave student alone. Plan for another staff member to obtain medication and notify EMS. Use of “walkie-talkies”, cell phones, etc. should be considered in planning for care of the student. 5.Put on gloves. Keypoint: Refer to Gloves-Use and Removal procedure. 6.With student in supine position use one hand and hold crown of head stable, place tip of atomizer snugly against the nostril and aim slightly up and outward (towards the top of the ear on the same side). 7.Briskly compress the syringe plunger to deliver half of the medication into the nostril. 8.Move the device to the opposite nostril and administer the remaining medication into that nostril.

I. Monitor student carefully after administering midazolam and wait for EMS to arrive on scene.

J. Documents activity on student’s individual treatment record.

Explanation/Demonstration Date Date Date Date Date Completed Completed Completed Completed Completed

K. Additional Considerations: 1. Assess mucous membranes for open sores or areas of irritation. 2. Assess for patterns of seizure activity in school setting. 3. Plan for care of student during transport on school bus. 4. Plan for field trips or other co- curricular activities in which student may participate.

Skills Performance Checklist

Administration of Sublingual or Buccal Klonipin

School Employee______Position______County______Certified School Nurse Instructor______

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

A. Obtain physician’s order for sublingual or buccal Klonopin Wafer and parent/guardian written consent for administration.

B. Obtain student history of seizure activity and previous response to Klonopin Wafer.

C. . Evaluate school setting and student’s schedule to determine where procedure may be performed.

D Develop written emergency plan for delegated personnel to follow. Look at seizure emergency treatment plan form.

E. Train designated unlicensed school personnel to administer Klonopin Wafer and to monitor student’s response.

F. Obtain Klonopin Wafer and ensure proper storage.

G. Assess student and prove safety measures for student during seizure.

Explanation/Demonstration Date Date Date Date Date Completed Completed Completed Completed Completed

H. Administer sublingual/buccal Klonopin Wafer if student’s seizure activity meets criteria established by physician’s order. 1. Check Student’s pulse and respiratory rate before administering Klonopin Wafer. 2. Place student in a sitting position to prevent accidental aspiration of the medication. 3. Assure Privacy 4. Obtain Klonopin Wafer and notify Emergency Medical Services (EMS) 5. Put on Gloves. 6. Remove Klonopin Wafer from package. 7. For SUBLINGUAL: Have the student open his or her mouth and raise the tongue. The tablet should then be placed under the tongue. For BUCCAL: Have student open his or her mouth. Tablet should be placed between the gum and the wall of the cheek. 8. With mouth closed, the tablet should be held in this position for 5-10 minutes, or until it have dissolved. SWALLOWING THE MEDICATION SHOULD BE PREVENTED. Buccal or sublingual medication should not be used when a student is uncooperative or unconscious. Student should not eat or drink, chew or swallow until the medication has been absorbed. NOTE: Sublingual/buccal Klonopin Wafers should not be administered if the gums or mucous membranes have open sores or irritations.

I. Monitor student carefully after administering sublingual/buccal Klonopin Wafer and wait for EMS to arrive on the scene.

Explanation/Demonstration Date Date Date Date Date Completed Completed Completed Completed Completed

J. Document activity on student’s individual treatment record.

K. Additional Considerations: 1. Klonopin Wafer should not be administered if gums or mucous membranes have open sores or areas of irritation. 2. Assess for patterns of seizure activity in school setting. 3. Plan of care of student during transport on school bus. 4. Plan for field trips or other co-curricular activities in which student may participate.

Skills Performance Checklist

Administration of Sublingual or Buccal Ativan

School Employee______Position______County______Certified School Nurse Instructor______

Date Date Date Date Date Explanation/Demonstration Completed Completed Completed Completed Completed

A. A. Obtain physician’s order for Sublingual or buccal Ativan and parent/guardian written consent for administration. The physician’s order must specify if Sublingual/buccal Ativan may be administered by unlicensed personnel.

B. Obtain student history of seizure activity and previous response to Ativan.

C. . Evaluate school setting and student’s schedule to determine where procedure may be performed.

D Develop written emergency plan for delegated personnel to follow. Look at seizure emergency treatment plan form.

E. Train designated unlicensed school personnel to administer Ativan and to monitor student’s response.

F. Obtain Ativan and ensure proper storage.

Explanation/Demonstration Date Date Date Date Date Completed Completed Completed Completed Completed

G. Assess student and prove safety measures for student during seizure.

H. Administer blingual/buccal Ativan if student’s seizure activity meets criteria established by physician’s order. 1. Check Student’s pulse and respiratory rate before administering sublingual/buccal Ativan. 2. Place student in a sitting position to prevent accidental aspiration of the medication. 3. Assure Privacy 4. Obtain Ativan and notify Emergency Medical Services (EMS) 5. Put on Gloves. 6. Remove Ativan from package. 7. For SUBLINGUAL: Have the student open his or her mouth and raise the tongue. The tablet should then be placed under the tongue. For BUCCAL: Have student open his or her mouth. Tablet should be placed between the gum and the wall of the cheek. 8. With mouth closed, the tablet should be held in this position for 5-10 minutes, or until it have dissolved. SWALLOWING THE MEDICATION SHOULD BE PREVENTED. Buccal or sublingual medication should not be used when a student is uncooperative or unconscious.

I. Monitor student carefully after administering sublingual/buccal Ativan and wait for EMS to arrive on the scene.

Explanation/Demonstration Date Date Date Date Date Completed Completed Completed Completed Completed

J. Document activity on student’s individual treatment record.

K. Additional Considerations: 1. Ativan should not be administered if gums or mucous membranes have open sores or areas of irritation. 2. Assess for patterns of seizure activity in school setting. 3. Plan of care of student during transport on school bus. 4. Plan for field trips or other co-curricular activities in which student may participate.

APPENDIX

AUTOMATED EXTERNAL DEFIBRILLATOR (AED)

Early Defibrillation Program Registration Guidelines

West Virginia Department of Health and Human Resources Bureau for Public Health Office of Emergency Medical Services

Table of Contents Introduction...... -1- Program Requirements ...... -2- How To Meet Program Requirements ...... -3- How Does Being Compliant Help? ...... -4- What Can’t You Do? ...... -5- Approved Training Courses ...... -6- Training Contacts ...... -6- Early Defibrillation Program Registration Application ...... -7- Early Defibrillation Program Operator Roster ...... -8- Early Defibrillation EMS Integration Sample Plan ...... -9- Early Defibrillation Patient Contact Form ...... -10- TSN Regional EMS Field Offices ...... -11- House Bill 2269 ...... -12-

Introduction During the 1999 Legislative Session, House Bill 2269 was passed, amending Chapter 16 Article 4C of the West Virginia State Code, authorizing the West Virginia Office of Emergency Medical Services to “register early defibrillation programs”. Working in partnership with the American Heart Association, American Red Cross, EMS, fire fighting, and law enforcement communities, the Legislation established definitions and criteria for entities providing early defibrillation programs including training, medical direction, protocols, and notification of local EMS systems.

Purpose The 1999 Legislature agreed with the scientific findings of the American Heart Association and others that as many as 250,000 Americans each year suffer from out-of-hospital sudden cardiac arrest. The medical/scientific community believes that 95% of these incidents result in death, and many of these deaths can be prevented if properly trained individuals could provide early automatic external defibrillation. The Legislature felt very strongly that communities have invested significantly in enhanced 911 and emergency medical services systems. They indicated that early defibrillation programs had to meet certain standards and be coordinated with local 911and EMS systems.

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Program Requirements

The Legislation requires that “an entity providing an early defibrillation program shall”: 1. Register the program with the Office of Emergency Medical Services, pursuant to article four-c of this chapter, identifying the placement of AEDs, training of AED operators, preplanned EMS system coordination, designation of a medical director, maintenance of AED equipment and reports of AED utilization;

2. Require the operator of an AED to receive appropriate training in cardiopulmonary resuscitation, referred to as “CPR”, in the operation of an AED and in the determination of advance directives from the American Heart Association, American Red Cross, any other nationally recognized course in CPR and AED, or an AED and CPR training program approved by the Office of Emergency Medical Services;

3. Maintain and test the AED in accordance with the manufacturer’s guidelines, and keep written records of this maintenance and testing;

4. Designate a medical director for the coordination of the program, which shall include, but not be limited to, training, coordinating with EMS, creating AED deployment strategies and reviewing each operation of an AED;

5. Notify the local EMS system and public safety answering point or other appropriate emergency dispatch center of the existence of an entity’s early defibrillation program, the location of the program and the program’s plan for coordination with the EMS system;

6. Provide that an operator of an AED who renders emergency care or treatment on a person experiencing cardiac arrest shall activate the EMS system as soon as possible and shall report the use of an AED to the program medical director; and

7. Comply with the guidelines of the West Virginia Office of Emergency Medical Services regarding data collection and reporting.

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How To Meet Program Requirements

1. The Program’s Official Representative completes the enclosed application (page 7) and returns it to the Regional EMS Field Office (see map of field office locations).

2. The Program’s Official Representative obtains an American Red Cross (ARC) or American Heart Association (AHA) course of instruction for each program provider/AED operator (see list of courses and contacts for ARC and AHA).

3. The Program’s Official Representative prepares and administers the entity’s AED maintenance program (see manufacturer’s guidelines).

4. The Program’s Official Representative retains the services of a licensed physician to be the Early Defibrillation Program Medical Director. This individual signs the entity’s registration application and agrees to coordinate training, EMS integration, AED deployment strategies, and reviews each AED patient contact.

5. The Program’s Official Representative confers with the local EMS agency and 911 center to establish a brief written plan for notification of the EMS system in case of an AED patient contact. This plan is to be submitted to the Regional EMS Field Office with the registration application (a sample plan can be found on page 9).

6. The Program’s Official Representative prepares the list of AED operators affiliated with the entity including the operators’ training. This list is part of the entity registration application submitted to the Regional EMS Field Office.

7. The Program’s Official Representative completes and submits an AED Patient Contact Form whenever an AED operator uses the AED on a patient (submit the form as specified).

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How Does Being Compliant Help?

e.Being compliant with the provisions for an early defibrillation program:

f.Means you are lawfully performing a vital function for your community;

b. According to the Automated External Defibrillator section of Chapter 16 Article 4D, you as an AED provider are “not liable for civil damages as a result of any act or omission in rendering emergency medical care or treatment involving the use of an AED if the care or treatment does not amount to gross negligence, and the following conditions are met:

g.The person, entity, certified trainer or medical director of the early defibrillation program is in compliance with the provisions of section three of this article, and;

h.The person is an operator of an AED who gratuitously and in good faith rendered emergency medical care, pursuant to the requirements of section three of this article, other than in the ordinary course of the person’s employment or profession.”

Note: “Section three of this article” refers to the actual legislation in code.

c. Means you are supporting your local 911 center and EMS system by involving them in your planning and operations.

d. Means you are giving your program medical accountability and credibility by obtaining a physician medical director.

e. Means you are guiding the future of AED use in the state by filling out and mailing the Patient Contact Forms when you operate an AED with a patient. This data will allow researchers to determine trends on deployment strategies, program viability, patient response, etc.

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What Can’t You Do?

1. You can’t respond with an AED off-site to provide this service unless you are a licensed EMS agency or have an Affiliation Agreement with a licensed EMS agency. Early defibrillation programs are established for use on-site and should be placed in a central location. Vehicles used on-site, i.e., a coal mine or industrial facility may be used to transport the AED for use elsewhere on the site.

Site examples are:

a. Sports Complexes b. Churches c. Industrial Sites/Coal Mines d. Schools e. Community Swimming Pools f. Retail Stores g. Others as agreed upon

2. An individual responder cannot provide medical assistance above the level of his/her training, certification or professional license, and the regulations associated with such training, certification or professional license.

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Approved Training Courses The Office of EMS has approved several courses of instruction from two current sources - the American Red Cross and the American Heart Association. Others will be reviewed as necessary. The approved American Red Cross course is: ! Adult CPR/AED Training Course The approved American Heart Association courses are: ! Heartsaver AED (with skills-station and exam) ! Heartsaver FACTS ! Healthcare Provider (with AED module and exam) ! ACLS Provider Course ! ACLS Instructor Course

Training Contacts:

American Red Cross: Karen Shuster, Director, Health and Safety Services or American Red Cross, North Central WV Chapter 718 West Pike Street Clarksburg, WV 26301 Phone: Main Office Number: 304-624-7689 Cell Number: 304-476-2812

American Heart Association: Megan Bibler, ECC Regional Associate American Heart Association 5455 North High Street PO Box 163549 Columbus OH, 43216-3549 Phone: 1-800-282-0291 Extension 360 or further information or assistance - contact your Regional EMS Field Office (see the attached map).

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ENROLLED

COMMITTEE SUBSTITUTE

FOR

H. B. 2269

(By Delegates Staton, Facemyer and Martin)

[Passed March 11, 1999; in effect ninety days from passage.]

AN ACT to amend chapter sixteen of the code of West Virginia, one thousand nine hundred thirty-one, as amended, by adding thereto a new article, designated article four-d, relating to automated external defibrillators; setting forth legislative purposes and findings; defining terms; establishing certain criteria for entities providing an early defibrillation program, including training for designated operators within a defibrillation program; involving a physician medical director in the medical protocols of a defibrillation program; notifying emergency medical services system when an entity establishes an early defibrillation program; activating the emergency medical services system when an automated external defibrillator is used by an operator; authorizing the development of guidelines for coordination of early defibrillator programs by the office of emergency medical services; and providing limitation of liability for compliance with the statutory provisions except in instances of gross misconduct.

Be it enacted by the Legislature of West Virginia:

That chapter sixteen of the code of West Virginia, one thousand nine hundred thirty-one, as amended, be amended by adding thereto a new article, designated article four-d, to read as follows:

ARTICLE 4D. AUTOMATED EXTERNAL DEFIBRILLATORS.

§16-4D-1. Purpose and findings.

(a) The West Virginia Legislature hereby finds and declares that each year more than two hundred fifty thousand Americans die from out-of-hospital incidents of sudden cardiac arrest. More than ninety five percent of these incidents result in death and, in many cases, death occurs because properly trained persons with life- saving automated external defibrillators arrive at the scene too late.

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(b) The American Heart Association estimates that more than twenty thousand deaths could be prevented each year if early defibrillation were more widely available.

(c) Many communities around the country have invested in 911 emergency notification systems and emergency medical services, including well-trained emergency personnel and ambulance vehicles. However, in many communities, there are not enough strategically placed automated external defibrillators and persons trained to properly operate them.

(d) It is, therefore, the intent of this Legislature to improve access to early defibrillation by encouraging the establishment of automated external defibrillator programs in careful coordination with the emergency medical services system.

§16-4D-2. Definitions.

(a) "Automated external defibrillator”, hereinafter referred to as AED, means a medical device heart monitor and defibrillator that: (1) Has undergone the premarket approval process pursuant to the Federal Food, Drug and Cosmetic Act, 21 U.S.C. § 360, as amended; (2) is capable of recognizing the presence or absence of ventricular fibrillation; (3) is capable of determining, without intervention by the operator, whether defibrillation should be performed; and (4) upon determining that defibrillation should be performed, automatically charges and requests delivery of an electrical impulse to an individual’s heart.

(b) "Early defibrillation program" means a coordinated program that meets the requirements of section three of this article and one that provides early public access to defibrillation for individuals experiencing sudden cardiac arrest through the use of an automated external defibrillator.

(c) "Emergency medical services (EMS)" means all services established by the Emergency Medical Services Act of 1973 in article four-c of this chapter including, but not limited to, the emergency medical services plan of the department of health and human resources providing a response to the medical needs of an individual to prevent the loss of life or aggravation of illness or injury.

(d) "Entity" means a public or private group, organization, business, association or agency that meets the requirements of section three of this article. “Entity” does not include emergency medical services operational programs or licensed commercial ambulance services.

(e) "Medical director" means a duly licensed physician who serves as the designated medical coordinator for an entity’s early defibrillation program.

§16-4D-3. Early defibrillation programs.

(a)An entity providing an early defibrillation program shall: (b)

(1) Register the program with the office of emergency medical services, pursuant to article four-c of this chapter, identifying the placement of AEDs, training of AED operators, preplanned EMS system coordination, designation of a medical director, maintenance of AED equipment and reports of AED utilization;

(2) Require the operator of an AED to receive appropriate training in cardiopulmonary resuscitation, referred to as “CPR”, in the operation of an AED and in the determination of advance directives from the American Heart Association, American Red Cross, any other nationally recognized course in CPR and AED, or an AED and CPR training program approved by the office of emergency medical services;

(3) Maintain and test the AED in accordance with the manufacturer’s guidelines, and keep written records of this maintenance and testing;

(4) Designate a medical director for the coordination of the program, which shall include, but not limited to, training, coordinating with EMS, creating AED deployment strategies and reviewing each operation of an AED;

(5) Notify the local EMS system and public safety answering point or other appropriate emergency dispatch center of the existence of an entity’s early defibrillation program, the location of the program and the program’s plan for coordination with the EMS system;

(6) Provide that an operator of an AED who renders emergency care or treatment on a person experiencing cardiac arrest shall activate the EMS system as soon as possible and shall report the use of an AED to the program medical director; and

(7) Comply with the guidelines of the West Virginia office of emergency medical services regarding data collection and reporting.

§16-4D-4. Limitation on liability.

A person is not liable for civil damages as a result of any act or omission in rendering emergency medical care or treatment involving the use of an AED if the care or treatment does not amount to gross negligence and the following conditions are met:

(1)The person, entity, certified trainer or medical director of the early defibrillation program is in compliance with the provisions of section three of this article; and

(2) The person is an operator of an AED who gratuitously and in good faith rendered emergency medical care, pursuant to the requirements of section three of this article, other than in the ordinary course of the person’s employment or profession.