Introduction to School Nursing

1. Introduction to School Nursing MODULE III Health Services Management

2. Topics Medication Management Field Trip Management Concussions Emergencies/First Aid Health Room Management AED Immunizations

3. MEDICATIONS Administration and delegation of medications is one of the most important, and legally one of the most risky, tasks nurses perform.

4. Medications and Treatments 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 medications and treatments.

5. Nursing Responsibilities 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.

6. Medication RCWs 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

7. Special Considerations: Naloxone (Narcan)Marijuana (Prescription + Non-prescription)Floor Stock Medications

8. Medication and Treatment Guidance OSPI Guidelines for Medication Administration in Schools (2015) • Medication–related Form Templates • Training Guidelines

9. Medication and Treatment Management Components of Medication/Treatment Management: Train Delegate Supervise Document

10. Medication and Treatment Training Prior to the beginning of a new school year, district administration or building principal, in consultation with the RN, identify in writing 2 - 4 staff persons per building to administer medications or perform treatments for the coming school year. Principal may designate, but the RN must determine whether or not the staff is competent to be delegated to.

11. Training Components Review of school board policies and procedures governing the administration of medication/treatment. Medication/treatment administration procedures, including description of when not to administer. Procedures to follow in the event of any type of error. Required charting. When to contact the supervising nurse. Confidentiality issues regarding student health information.

12. Medication and Treatment Supervision RN delegating medication or treatment must first assess the student and determine the appropriate level of supervision based on the task and student specific circumstances.

13. Medication and Treatment Documentation Lack of documentation equates with lack of care (if it wasn’t documented it wasn’t done). The standards of nursing documentation must be followed whether using paper or electronic documentation system.

14. Medication and Treatment Documentation • A Medication Authorization Form must be signed by LHP and Parent and reviewed by RN prior to any administration. • A Medication Administration Form is started for each medication. The RN is responsible for the transcription from the LHP order form to the district’s Administration form. • A Medication Administration Form may also be used to document any related information, including unusual circumstance related to the student receiving the medication/treatment or contact with LHP and/or parent/guardian.

15. Medication and Treatment Documentation • Initial the Medication Administration Form when administering medications. • When administering a PRN medication, record the time given and dose. • Record any unusual behaviors/occurrences observed after student received medication.

16. Medication and Treatment Documentation • If a medication is missed, cannot be given, falls to the floor, or the student refuses it, initial and circle in the appropriate box. Document the explanation on the back of the medication form. • 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.

17. Medication Disposal At least two weeks prior to the end of the school year or when a medication is discontinued, notify the parent/guardian in writing to pick up the unused medication. Complete a medication receipt. If parent/guardian does not pick up the medication by the date specified, perform a verified medication count (by two school district staff) and dispose of properly. Document count and disposal. Sharps Disposal – Identify a sharps disposal site and acceptable packaging.

18. Medication Errors A dose that is missed (omitted) for whatever reason maybe considered a medication error. Suspected medication errors 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.

19. Medication and Treatment Self 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

20. 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.

21. Medication Training of UAPs Specific medication training tools for unlicensed staff administering medications is available in the OSPI Medication Administration Manual (See Non-Licensed School Personnel) (2015)

22. Addressing Medication Errors 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 maybe 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 must notify the parent/guardian and LHP (if appropriate). All actions taken as a result of the medication error must be accurately documented.

23. SPECIAL EVENTSFIELD TRIPS, SCHOOL SPONSORED EVENTS, AND SUMMER SCHOOL, OH MY!

24. SPECIAL EVENTS 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)

25. 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

26. 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.

27. 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.

28. 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

29. HEALTH ROOM

30. 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 require a desk area with drawers and file cabinets that lock for security. If there is a rest cot, it must be in good condition and must be able to be sanitized.

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

32. Emergencies First AidConcussions

33. Emergencies / First Aid Refer to DOH/OSPI How to Respond - Injury and Illness at School (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.

34. Common Wounds and Injuries Abrasions Punctures Lacerations (simple and complex) Avulsions Head/Neck Injuries Eye Injuries Sprains Fractures

35. Basic First Aid & CPR Wound Care – Clean, Apply Pressure, Dress RICE – Rest, Intermittent Ice, Compression, Elevation Immobilize / Splint Bleeding Management Tourniquet Application Cardiopulmonary Resuscitation AED Use and Management

36. Concussions • Concussion rates increase around sports schedules • Symptoms: • One pupil larger than the other • Drowsiness / Can’t wake up • Numbness • Restlessness • Confusion • Seizures

37. Evidence-based Concussion Guidelines School districts are required to 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

38. 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 communityso 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 Allianceand NESCAC Medical Aspects In Sport Committee (MASC) Return to Function Process for Concussed Students

39. AED Guidance for Washington State Public Schools https://c.ymcdn.com/sites/www.wasbo.org/resource/resmgr/risk_mgmt/AED_Manual_2016.pdf

40. Immunizations

41. Immunization RCWs and WACs 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 Manualfor Schools, Preschools and Child Care Centers (2019)

42. Immunization Resources WA State DOH Individual Vaccine Requirements Summary (updated annually) Immunity Community: Immunization Toolkit for Schools and Childcares McKinney-Vento Immunization guidance

43. Immunization CIS and COE Certificate of Immunization Status (CIS) & Certificate of Exemption (COE)

44. Form Screenshots

46. DOH Immunization Information System 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.

47. School Access to WA IIS 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).

48. Immunization Exclusion From School Attendance "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.

49. DOH Immunization Status Report All WA State schools, preschools and child care facilities 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 DOH. • Reports may be completed by school office staff. School nurse must verify data. Request a copy of submitted report. Refer to: WAC 246-100-166

50. Immunization Reporting Revisions