Module 3School Nurse Practice

Medications, Emergencies, First Aid, Health Room, Immunizations

Introduction to School Nursing: 8/20/2018

MEDICATIONAdministration and delegation of

medications continues to be one of the most important, and legally one of the

most risky, tasks nurses perform.

Federal and state laws require schools to provide the necessary health services for students to safely and fully participate in their learning.

These accommodations may include administration of medication and treatments.

Medications and Treatments

Review and understand state laws, regulations and rules regarding medication administration, delegation, and supervision.

Review and learn your district’s medication-related policies, procedures and forms to assure compliance with current laws and district health service practice.

Medication and Treatment cont.

RCW 28A.210.260— Public and Private Schools—Administration of Medications—Conditions

RCW 28A.210.270 – Public and private schools—Administration of medications—Immunity from liability—Discontinuance, procedure

RCW 28A.210.275—Administration of medications by employees not licensed under chapter 18.79 RCW—Requirements—Immunity from liability

RCW 28A.210.278 –Topical sunscreen products—Sun safety guidelines

RCW 69.41.095 - Opioid Overdose Medication

Medication RCWs

OSPI Memorandum - Use of Naloxone

Components of Medication/Treatment Management:∗ Train∗ Delegate∗ Supervise∗ Document

Medication and Treatment Management

∗ When: Prior to the beginning of each school year.

∗ What: Identify at least 2-4 staff persons per building to administer medications for the coming school year that will receive training.

∗ Who: Usually school office secretaries, Special Education staff, Paraeducators, secretary substitutes.

Medication and Treatment Training

OSPI Guidelines for Medication Administration in Schools

Medication and Treatment Guidance

Prior to the beginning of a new school year, district administration or building principals, in consultation with the RN, identify in writing at least two staff persons per building to administer medications for the coming school year.

Medication and Treatment Training

Training includes:

∗ Review of school board policies and procedures governing the administration of medication and treatment

∗ Medication and treatment administration procedures, including description of when not to administer

∗ Procedures to follow in the event of a medication error, including missed or delayed doses

Medication and Treatment Training

Training includes:∗ Required charting

∗ When to contact the supervising nurse

∗ Confidentiality issues regarding student health information

Medication and Treatment Training

RNs delegating care must assess student prior to delegation and should determine the appropriate level of supervision based on the task and student specific circumstances.

Medication and Treatment Supervision

Lack of documentation equates with lack of care (if it wasn’t documented it wasn’t done)

Standards of nursing documentation need to be followed whether using paper or electronic documentation system.

Medication and Treatment Documentation

∗ Before anything is administered, a Medication Authorization form must be signed by LHP and Parent and reviewed by RN.

∗ Then Medication Administration form is started for each medication and the RN is responsible for the transcription from the LHP form to the Administration form.

∗ The Medication Administration record may also be used to make notes about any unusual circumstance related to the student receiving the medication/treatment, including contact with LHP and/or parent/guardian.

Medication and Treatment Documentation

∗ A medication/treatment request form and administration record or “log” must be kept for each student.

∗ The registered nurse is responsible for the transcription of medication and treatment administration information onto a medication/treatment record.

∗ The medication/treatment record may also be used to make notes about any unusual circumstance related to the student receiving the medication/treatment, including contact with LHP and/or parent/guardian.

Medication and Treatment Documentation

∗ When initialing on the medication administration record do not circle your initials unless there was an issue that needs to be further addressed such as a missed dose.

∗ When documenting the administration of PRN, record the time given and the dosage.

∗ Note unusual behaviors/occurrences that were observed after student received medication

Medication and Treatment Documentation

∗ If the medication is missed, cannot be given, falls to the floor, or the student refuses a medication, initial and circle in the appropriate box, provide an explanation on the back of the medication record.

∗ If medication is discontinued write “discontinued,” on the page as close to the date as possible and initial it. Ask parent/guardian to pick up any remaining medication.

Medication and Treatment Documentation

∗ At least two weeks prior to the end of the school year, or when a medication is discontinued, parent/guardian of students with leftover medication should be notified in writing and provided the opportunity to pick up any unused medication.

∗ If parent/guardian does not pick up the medication by the date specified, the medication should be counted by two school district staff and properly disposed. Document disposal.

Medication Disposal

The correct medications must be administered to the correct student at the correct time, in the correct dosage, by the correct route.

∗ A dose that is missed (omitted) for whatever reason may also be considered a medication error.

∗ A suspected error must be reported to the RN and School Administrator immediately.

∗ The RN, using clinical judgment, will determine if it is a medication error and the level of severity.

∗ RN, School Administrator, or designee should notify the parent/guardian and LHP (if appropriate).

∗ All actions taken as a result of the medication error are to be accurately documented.

Medication Error

For emergency medications for students with diabetes, asthma and allergies, districts must grant to any student in the school authorization for the self-administration of medication to treat that student's diabetes, asthma or anaphylaxis, if certain conditions are met.

For other, non-emergency medications, refer to school district policy and procedure.

Medication/TreatmentSelf-Administration

For emergency medications for students with diabetes, asthma and allergies, school districts must grant to any student in the school authorization for the self-administration of medication to treat that student's diabetes, asthma or anaphylaxis if certain conditions are met.

This practice must be addressed in district policy and procedure.

Refer to: RCW 28A.210.330 and RCW 28A.210.370

Medication and Treatment Self Administration

For medications other than for diabetes, asthma and allergies, school districts may want to consider an adaptation to district policy and procedure to address student self administration of additional medications.

Medication and Treatment Self Administration

Refer to specific medication training for unlicensed staff administering medications:

Medication Administration Training Manual for Non-Licensed School Personnel (2017)

Medication Training ofUnlicensed Staff

The correct medications must be administered to the correct student at the correct time, in the correct dosage, by the correct route.

∗ A dose that is missed (omitted) for whatever reason may be considered a medication error.

∗ A suspected error must be reported to the RN and School Administrator immediately.

∗ The RN, using clinical judgment, will determine if it is a medication error and the level of severity.

∗ RN, School Administrator, or designee should notify the parent/guardian and LHP (if appropriate).

∗ All actions taken as a result of the medication error are to be accurately documented.

Medication Errors

SPECIAL EVENTSFIELD TRIPS, SCHOOL

SPONSORED EVENTS, AND SUMMER SCHOOL, OH MY!

All students, including students with special healthcare needs, have the right to participate in field trips, school-sponsored events and summer school.

∗ Section 504 of the Rehabilitation Act of 1973 ∗ Individuals with Disabilities Education Improvement

Act (IDEIA)

SPECIAL EVENTS

School nurses plan and coordinate health services for all school-sponsored events to ensure all students with healthcare needs remain healthy and safe, including:

∗ Planning accommodations for health care needs∗ Determining required medications and treatments∗ Preparing for potential emergencies ∗ School personnel medication/treatment training

SPECIAL EVENTS

Standards for safe medication administration including delegation and supervision, do NOT change when students are on field trips, school sponsored events, and/or summer school programs.

SPECIAL EVENTS

Delegation of medication administration and treatments requires the delegating nurse to direct and supervise the delegate. The RN must remain reasonably available to the delegate through telecommunication or other means.

Plan ahead if students that require nursing care are attending special events, including summer school, to ensure School Nurse coverage is arranged.

SPECIAL EVENTS

∗ Review district Field Trip policy/procedure

∗ Set expectations with staff regarding prior notice and time needed to prepare field trip packet(s)

∗ Provide staff training

∗ Contingency Plan: What to do for last minute changes (e.g., trained staff member is unable to go)

∗ Nurse cannot train or give meds to volunteers

SPECIAL EVENTS

HEALTH ROOM

∗ School districts must provide health services that fulfill the emergent and ongoing needs of all students.

∗ Provision of health services should include health rooms with adequate staff, supplies, technology and privacy.

∗ Health rooms must have a desk area with lockable drawers and lockable file cabinets.

∗ If there is a rest area/cot, it must be in good condition (without rips/tears) and must be able to be sanitized.

Health Room

Some forms that may be helpful in any health room: ∗ Health Room Treatment Protocols∗ Health Room Pass ∗ Health Room Log∗ Illness/Injury Note∗ Head Injury Letter∗ Providing Health Care to Minors-Summary

Health Room Forms

EMERGENCIESFIRST AID

CONCUSSIONS

For injuries and illness in school, refer to DOH/OSPI How to Respond-Injury and Illness at School (10/2016), a reference guide designed to help school personnel respond quickly, safely and effectively when students or staff are injured or become ill at school.

Emergencies / First Aid

∗ Abrasions∗ Punctures∗ Lacerations (simple and complex)∗ Avulsions∗ Head/Neck Injuries∗ Eye Injuries∗ Sprains∗ Fractures ∗ Poisoning

Common Wounds and Injuries

∗ Wound Care – Clean, Apply Pressure, Dress ∗ RICE – Rest, Intermittent Ice, Compression, Elevation∗ Immobilize / Splint ∗ Bleeding Management ∗ Poison Control

Basic First Aid

∗ Rates increase around sports schedules∗ Symptoms: ∗ One pupil larger than the other∗ Drowsiness / Can’t wake up∗ Numbness∗ Restlessness ∗ Confusion∗ Seizures

Concussions

Concussion and head injury guidelines require school districts adopt policies for the management of concussion and head injury in youth sports.

For concussion and head injury guidance, see WIAA Concussion Management Guidelines.

Refer to: RCW 28A.600.190

Concussion Guidelines

Concussion Reminders

∗ Work with Athletic Director to assure a concussion prevention plan is in place and that communication is clear with Health Providers in the community so that providers know why the student is being referred and the school knows what the provider’s plan is.

∗ Coaches have clear guidelines and training for utilizing a Concussion/504 Plan with appropriate accommodations and a clear plan for gradual “return to play”.

∗ Teachers need to be clear on plan for “return to academics”.

*See Brain Injury Alliance and NESCAC Medical Aspects In Sport Committee (MASC) Return to Function Process for Concussed Students

AED Guidance for Washington State Public Schools

https://c.ymcdn.com/sites/www.wasbo.org/resource/resmgr/risk_mgmt/AED_Manual_2016.pdf

Immunizations

Immunizations are addressed in RCW 28A.210.060 through RCW 28A.210.170.

State law requires the immunization status of all children to be screened and assessed by the first day of school. Thescreening and documentation process is established by WAC 246-105

For specific school guidance see:Immunization Manual for Schools, Preschools and Child Care Centers (8/2017)

Immunization RCWs and WACs

∗ WA State DOH Individual Vaccine Requirements Summary (updated annually)

∗ Immunity Community: Immunization Toolkit for Schools and Childcares

∗ McKinney-Vento Immunization guidance

Immunization Resources

Certificate of Immunization Status (CIS)&

Certificate of Exemption (COE)

Immunization CIS and COE

∗ Form Screenshots

WA State Immunization Information System (WA IIS)

A secure database that permits access to a student’s healthcare provider to access immunization information. Data base components include: ∗ Immunization histories∗ Recommendations and forecasts of immunizations needed∗ Recall/reminder lists∗ Vaccine usage reports∗ Data for practice-specific immunization assessment reports.

If a student changes providers, the new provider can access the system to review the student's record.

DOH Immunization Information System

∗ Access to view immunization records is available to all school districts in Washington State.

∗ The RN must register with WA IIS and will serve as the district’s point person, deciding who else gets access.

∗ The required CIS form is printable pre-filled from the WA IIS website. A parent signature is required.

∗ Update WA IIS on current staff access needs (delete access for staff who have left).

School Access to WA IIS

"Exclusion" shall mean the case or instance when the student is denied initial or continued school attendance because he/she failed to submit a schedule of immunization or a certificate of exemption.

Refer to: RCW 28A.210.120.

Immunization Exclusion From School Attendance

DOH Immunization Status Report

All school, preschool, and child care facility in WA State must:

∗ Submit an immunization status report to the Washington State Department of Health every year by November 1, either electronically or on a form provided by the department.

∗ Reports are usually completed by school office staff. School nurse to verify and request a copy of submitted report.

Refer to: WAC 246-100-166

Staff Immunizations

∗ Local health jurisdictions (LHJ)s have the authority to exclude from work all staff not considered immune during an outbreak of vaccine preventable disease.

∗ It is recommended that district HR staff request completed Immunization History Form to show proof of immunity (a titer/ blood test, physician verification of disease, or vaccination) for vaccine preventable diseases and to be kept on file in the district office.

∗ The Nurses role is to assure policy and forms are up to date and to encourage compliance.

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