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

2. 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

3. 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
7800 for immediate response
On-Call: , or #6005
Please do not call the Health Services main number when you need assistance

4. 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

5. 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)

6. 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

7. 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: 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

8. 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

9. 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

10. Bowel Management
Constipation and Diarrhea

12. 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

13. 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

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

15. 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

16. 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

17. 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

18. 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

19. Medication Administration Via G-tube
NqEPc
Medication Administration Via G-tube
Video

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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

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

28. Epi-Pens may only be administered by staff trained and cleared by Health Services
EpiPen video:
s:// FXlqSuzzrws

29. 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

30. 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.

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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

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

38. 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

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

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

41. 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

42. 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

43. 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

44. 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

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

46. 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

47. 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

48. 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

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

50. 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

51. 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

52. 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

54. Use of Rescue Inhalers and Nebulizers
Management of Asthma

55. 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

56. 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.

57. 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

58. 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

59. 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

60. 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

61. 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

62. Video How to Use a Nebulizer
v=svG5S2wn4xQ
How to Use a Nebulizer
Video

63. 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

65. 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.