Medication Re-Clearance Review and Updates: Getting Back to the Basics Opening Week 2016

Areas of Review Contacting Program Nurses or Nurse on-Call Medication Administration: oral, g-tube, epi-pen, inhaler, nebulizer, diastat How to Prevent Medications Errors Bowel Management: constipation, diarrhea

Contacting Nursing Who Update: nursing assignments have changed Nurses are no longer assigned based on cottages When Emergency vs Urgent vs Minor or Routine How Desk phone Cell phone Email 7800 for immediate response On-Call: 339-221-2405, or #6005 Please do not call the Health Services main number when you need assistance

Pouring Medications Right Student Right Medication Right Time The 5 Rights of Medication Administration: Right Student Right Medication Right Time Right Dose Right Route And Don’t Forget the Right Documentation

Pouring Liquid Medications Pour At Eye Level Look for the Meniscus Shake all Liquids Do not pour over med sheets Cover the label with your hand to prevent dripping on it 5mL = 5cc = 1tsp (teaspoon) 15mL = 15cc = 1tbsp (tablespoon) 30mL =30cc = 2 tbsp = 1oz (ounce)

Read the Label and Check the 5 Rights 3 Times Before Giving Meds Wash your hands Read the Med Sheet Select and read the med label on the container Pick up the med and read the label (1st check) Compare the med label and med sheet information, they should be identical (2nd check) Prepare the med and then recheck 5 rights on the label and the med sheet and look at the med you poured in the cup or med syringe (3rd check) Document the med with your initials in the correct block on the med sheet, count and document any countable meds Replace the meds in the med cabinet Lock the cabinet Identify the student and administer the med

Health Services Staff Adria Hodas, Director of Health Services x7585 Susan Buckley, Administrative Assistant x 7273 Carol Anne O’Leary, Pediatric Nurse Practitioner x 7290 Erica Klag, Dietitian x 7467 _______________________________________________________ Health Services Emergency Line: x 7800 (M-F 8-4:30) Nurse On-Call: 339-221-2405 or #6005 (evenings/weekends) Program Nurses DeafBlind Program Darlene Stanton x 7564 Kami Guthrie x7470 ELC and Lower School Marissa Jenkins x 7274 Kelly Becker x 7276 Secondary Program Muriel Comick x 7277 Amy Milligan x 7351

Preventing Medication Errors Take your time, do not rush Check for changes before you begin Avoid distractions Check the 5 Rights 3 Times Do not give medications from memory If not sure, ask before your proceed Keep the med area neat and clean Double check your documentation

Birth Control Pills Read the instructions carefully on the med sheet, sometimes we need to skip the placebo or iron pills Placebo or iron pills are typically a different color than regular pills Always punch pills out in the proper order and on the correct day of the week, do no punch out randomly Check the day of the week 3 times, this is part of checking the right time when you check the 5 rights If the sequence is off, contact the program nurse or the nurse on-call before administering

Bowel Management Constipation and Diarrhea

Constipation Definition Constipation is an acute or chronic condition in which bowel movements occur less often than usual or consist of hard dry stools that are painful or difficult to pass. Bowel habits vary, but an adult who has not had a bowel movement in 3 days or a child who has not had a bowel movement in 4 days is considered constipated

What do you think? Which type on the Bristol Stool Form Scale is diarrhea? The answer is type 7 Which types on the Bristol Stool Form Scale are constipation? The answer is types 1 and 2

Common Causes of Constipation Inadequate fluid intake Inadequate fiber in diet Medication side-effects Limited mobility and physical activity Anatomical abnormalities

Constipation Management Monitor and Document daily bowel patterns; Report to Program Nurse Increase daily fluids and high fiber foods, offer prune juice Increase physical activity Consult with nursing staff to adjust bowel management medications and get additional interventions Common Examples of Bowel Management Medications Miralax (glycolax) Metamucil (psyllium) Colace (docusate sodium) Senna Milk of Magnesia Bisacodyl Enemas and Suppositories

Diarrhea Definition Diarrhea describes loose, watery stools that occur more frequently than usual. Diarrhea is something everyone experiences. Diarrhea often means more-frequent trips to the toilet and a greater volume of stool. In most cases, diarrhea signs and symptoms may last a couple of days. But sometimes diarrhea can last for weeks. Signs and symptoms associated with diarrhea may include: Frequent, loose, watery stools Abdominal cramps Abdominal pain Fever Blood in the stool Bloating

Diarrhea Causes Diarrhea may be due to food sensitivities and intolerances such as to gluten, fructose, or lactose Viral infections Medication adverse reactions such as to antibiotics Food or water contaminated with bacteria or parasites Digestive disorders such as irritable bowel syndrome, inflammatory bowel disease, celiac disease Constipation causing a bowel obstruction

Diarrhea Management Maintain good fluid intake; offer water, broth, tea, Gatorade and other clear liquids, Pedialyte (consult nursing first) Avoid some foods such as dairy, high fiber foods, fatty/greasy foods Foods to offer: crackers, toast, eggs, rice, or chicken Monitor for fever, blood in stool, and other symptoms of illness Use good infection control (handwashing, gloves, disinfectant wipes, etc…) Consult nursing to: adjust diet and bowel medications get instructions on infection control measures if needed and get additional interventions

Medication Administration Via G-tube https://www.youtube.com/watch?v=QQt1a- NqEPc Medication Administration Via G-tube Video

Epi-Pen Training for Non-Licensed Staff Green is Epi-Pen Jr. (33 to 66 lbs) Yellow is Epi-Pen (over 66 lbs)

What is an Epi-Pen A disposable, pre-filled automatic injection device (auto-injector) Used for allergic emergencies (anaphylaxis) Contains a single dose of epinephrine

Epi-Pen Dispensing Epi-Pens may be dispensed by the pharmacy as a one or two per package. Some Epi-Pen packages come with a trainer which does not contain medication; it is intended for practice use only Epi-Pen trainers need to be removed from the package and given to Health Services All new Epi-Pens must be checked in by Health Services

What is Anaphylaxis Anaphylaxis is a serious allergic reaction that is potentially and rapidly life threatening if not treated immediately Can be caused by allergies to food, medication, latex, chemicals, insects bites or stings Involves 2 or more systems of the body

Signs and Symptoms of Anaphylaxis Hives (rash) Swelling of the throat, lips, tongue, or around the eyes Difficulty breathing or swallowing Other common symptoms of anaphylaxis may include: Metallic taste or itching in the mouth Generalized flushing, itching, or redness of the skin Abdominal cramps, nausea, vomiting, or diarrhea Increased heart rate Sudden decrease in blood pressure (and accompanying paleness) Sudden feeling of weakness Anxiety or an overwhelming sense of doom Collapse Loss of consciousness

Your Responsibilities Know which students have allergies and what they are allergic to (allergens) Know which students carry Epi-Pens and where to find them Epi-Pens must be checked daily Monitor the environment for things your students may be allergic to Be prepared to respond rapidly if a student is exposed to an allergen

When to Use the Epi-Pen Immediately if the student begins to experience any of the signs of anaphylaxis after exposure to something he/she may be allergic to

The Epi-pen must be kept with the student at all times

Epi-Pens may only be administered by staff trained and cleared by Health Services EpiPen video: https://youtu.be/FXlqSuzzrwshttp s://www.youtube.com/watch?v= FXlqSuzzrws

Caution Check directions for use Never put thumb, fingers or hand over black Do not remove from carrier and do not remove blue safety release until you are ready to use Do not use if solution is discolored appears in clear window Do not place patient information sheets or any other foreign objects in carrier with auto-injector, as this may prevent you from removing the Epi-Pen from the carrier

To Remove Auto-Injector From Carrier Tube 1. Flip open the yellow cap of the Epi-Pen or the green cap of the Epi-Pen Jr. Auto-Injector Carrier Tube.

2. Remove the Epi-Pen or Epi-Pen Jr 2. Remove the Epi-Pen or Epi-Pen Jr. Auto-injector by tipping and sliding it our of the carrier tube

To Use the Auto-Injector Grasp unit with the orange tip pointing downward. Form fist around the unit (orange tip down). 3. With the other hand pull off the blue safety release

Stop and Check Check the expiration date Check the window to be sure the solution is not discolored If there is a problem or question: Contact the nurse on-call Use a different Epi-pen

4. Hold orange tip near outer thigh Do not inject into buttock Check pockets to be sure you are not injecting into something in a pocket

5. Swing and firmly push against outer thigh until it clicks so that unit is perpendicular (at 900 angle) to the thigh Auto injector is designed to work through clothing

6. Hold firmly against the thigh for 3 seconds to deliver medication 6. Hold firmly against the thigh for 3 seconds to deliver medication. (The injection is now complete. The window on the auto-injector will be obscured). ( note the change from 10 to 3 seconds) 7. Remove unit from thigh (the orange needle cover will extend to cover needle) 8. Massage the injection area for 10 seconds

Call 911 Call Health Services Call your Supervisor Mon-Fri 8-4:30 call #7800 Evenings/Weekends call 339 221-2405 #6-005 -------------------------------------------------------------------------------------------- Call your Supervisor Call the student’s parents Call the AEC during evenings/weekends

While Waiting for the Ambulance Have the person lie down and remain calm If difficult breathing, the student may be more comfortable sitting up Continue to monitor the student Do not leave the student alone Sometimes the person may need a second dose if he/she continues to have difficulty breathing, speak with a nurse if this may be necessary Contact the student’s parent/guardian

To Destroy used Epi-Pen Take the used auto-injector with you to the hospital emergency room or give to Health Services to destroy

Diastat Training for Non-Licensed Staff (Supervisors and Program Nurses will determine which staff are student specific cleared FOR DIASTAT)

What is Diastat? Diastat is: A medication used to stop seizure activity A form of diazepam in a gel preparation Administered rectally from a pre-measured syringe

When Do We Use Diastat Seizures that last more than a few minutes have the potential to be harmful Students with Diastat orders have a specific protocol for when to administer it written by their neurologist Protocols are student specific and vary; generally Diastat is administered if the seizure has lasted between 5-10 minutes or there has been a cluster of several seizures

Your Responsibilities Know which students have seizures Know what they look like, what is typical, what is not typical Know what types of care each student needs for his/her seizures Know what medications each student takes for prolonged seizures Know where to find each student’s seizure protocol and medications such as Diastat Check the Diastat daily Contact Health Services immediately if the student is close to the criteria for Diastat

A Student Needs Diastat: Call 7800 (during Health Services regular hours) Tell the nurse who answers: The student’s name The exact location When the seizure began When the protocol indicates to administer the Diastat Anything unusual including injuries Remember that the nurse may not be your program nurse so the more information you give the better, including directions to your location If possible send someone to find and direct the nurse to the location

Diastat and the Diastat Protocol must be kept with the student at all times

Who Administers Diastat Diastat is administered as much as possible by a nurse during hours when Health Services staff are present on campus Diastat may only be administered by staff trained and cleared by Health Services Diastat Training Video

Diastat Accudial has a green ready band set by the pharmacy, make sure you see this green band before giving Wear gloves Ensure the student’s privacy with a blanket, screen, closed door, or removing others from the area

Have the student lying on his/her side Remove cap, apply lubricating gel to tip Insert into rectum Push plunger in slowly while counting to 3 Hold in rectum while counting to 3 Remove and hold buttocks together Continue to observe the student

Common Diastat Adverse Effects Drowsiness Dizziness Changes in Breathing, especially slowed breathing

What Do We Do After Diastat is Administered When Health Services is Open: Nursing staff will determine whether the student must be sent to the hospital for further monitoring and evaluation Allow the student to rest comfortably and privately Monitor the student closely for 4 hours Monitor for drowsiness, unsteadiness, changes in facial color, slowing of breathing, further seizure activity Contact #7800 if there are concerns about the student’s condition, or if seizures recur

When Health Services is Not Open or You are Off Campus: Contact Nurse on Call, Residential Supervisor and AEC Call 911 for further evaluation and transportation to emergency room Contact parent When Off Campus: Contact Health Services and appropriate supervisor

Additional Information Check the student’s bag daily to be sure the Diastat is present Check the Diastat to be sure the expiration date on the label is not expired Have Health Services check in the Diastat and label it Diastat must be counted daily and extras kept in the locked cabinet in the med room Immediately notify Health Services is the student did not arrive with his/her Diastat or if it is expired

Use of Rescue Inhalers and Nebulizers Management of Asthma

What are Inhalers Used for Inhalers are used to administer medications into the lungs Most commonly used to treat asthma and other respiratory illnesses. An inhaler is a device that helps deliver a specific amount of medication to the lungs

What is Asthma Asthma is a chronic, or long-term, disease. If you have asthma, at times your airways (the air passages of your lungs) become inflamed. When this happens, your airways get red and swollen. They become narrow, making it harder for you to breathe. You may also wheeze or cough. This is called an asthma flare-up (or "attack"). Even when you feel good, your airways can be inflamed. Certain things, such as smoke, dust, pollen or other allergens, colds can start or trigger an asthma attack.

Asthma Attacks Act fast if an asthma attack starts. Know the signs that an asthma attack is starting: Coughing Wheezing Tight chest Waking up at night Nasal flaring

What To Do Move student to a quiet setting If you can ask the student “do you think you may need your inhaler” Assist the student to use the inhaler Contact program nurse or nurse on call If the student uses a nebulizer instead of an inhaler, immediately contact a nurse or med cleared staff Inhaler with Spacer Training Video

Your Responsibilities Know which students have physicians orders for inhalers and nebulizers Know who has regularly schedule treatments and who has PRN (rescue) treatments Know where to quickly locate these students inhalers and nebulizers Know the signs of asthma and respiratory distress and what to do for each student Take immediate action if a student is having an asthma attack

How to Use an Inhaler Without a spacer When you first use an inhaler, or if you haven’t used it in awhile, you need to “prime” the pump to ensure that you’re getting the accurate dose of medication. Priming entails spraying a dose or doses into the air, and priming requirements are different for each inhaler. Without a spacer Take off the cap. Shake the inhaler. Breathe out. Put the inhaler in your mouth or put it just in front of your mouth. As you start to breathe in, push down on the top of the inhaler and keep breathing in slowly. Hold your breath for 10 seconds. Breathe out. If you need a second puff, wait one minute between puffs

Using a Spacer/Holding Chamber A spacer, or a holding chamber attached to the inhaler which makes it easier to use a spray inhaler. Put the open end of the spacer in your mouth, or cover mouth with mask. Spray the asthma medicine into the spacer one time. Take a deep breath and hold it for 10 seconds. Breathe out into the spacer. Breathe in again, but do not spray the inhaler again If unable to hold breath allow student to breath normally into spacer If orders to repeat, wait one minute before repeating Some inhalers require students to rinse mouth after use

Video How to Use a Nebulizer https://www.youtube.com/watch? v=svG5S2wn4xQ How to Use a Nebulizer Video

How to Use a Nebulizer Place the compressor where it can safely reach its power source and where you can reach the ON/OFF switch. Wash your hands prior to preparing each treatment. Measure the correct dose of medication and other solutions prescribed by your physician. Add these to the nebulizer. Connect the air tubing from the compressor to the nebulizer base. Make sure all connections are snug. Attach a mask to the nebulizer. Turn the compressor on and check the nebulizer for misting. Hold the mask to the face so both the nose and mouth are covered. The mask may be secured to the head with an elastic band. Turn the compressor on to start the mist. The head should be held upright. This correctly positions the nebulizer and opens the airway. Do deep breathing throughout the treatment. Occasionally tapping the side of the nebulizer helps the solution to drop to where it can be misted. Continue the treatment until the onset of inconsistent nebulization, i.e. sputtering

What To Do If the Asthma Medication Doesn’t Help Any time a student requires a PRN treatment for breathing by inhaler or nebulizer you must contact Health Services or the Nurse-on Call If the medication has not adequately helped immediately contact Health Services or the Nurse-on-Call Call 911 if The medicine does not help for very long or it does not help at all. Breathing is still fast and hard. It is hard to walk or talk. Lips or fingernails turn gray or blue. The nose opens wide when breathing. Skin is pulled in around the ribs and neck with breaths. Heartbeat or pulse is very fast.