p - Lake Stevens School District

Health Services
August 19, 2013
8:30 am - 12:00 pm
@ Educational Service Center
Today's Agenda
Why are you here?
Then and Now...
Today’s plan
10 minute breaks
 After section 4
 After Section 8
Noon Lunch
Training Content
Health Service Staff Model
& Student Health Concerns
7 District Nurses
10 Schools + Homelink & ELC
8,200 students (1,171 average per Nurse)
281 Life Threatening Conditions
138 Anaphylaxis/Severe Allergies & 23 Diabetes Insulin D.
808 Asthma & 72 Seizure Conditions
Overall .... 4,925 students with Health Concerns
Only employees that have been delegated by the School RN are allowed to work in the Health Center. These
designated employees must also be:
- Certified in First Aid/CPR - Trained by the School RN - Receive documented annual reviews of health room policies
and procedures by the School RN
Health Room & School Nurse
School Nurse
Health Room Assistant
Office Professional
Paraeducator - General Clerical Support
Delegated Staffing: Job Description
Health Room Role
Office Professional
• Register new students and maintain student records including attendance,
discipline and health information.
• Oversee health room and provide basic services in the absence of a nurse.
• Know and follow health, safety and emergency procedures of the district
Paraeducator - General Clerical Support
• Assist students seeking care in the health room
• Provide general RN support, set appointments for parents to meet with
RN, make arrangements for School Bell
• Know and follow health, safety and emergency procedures of the district
Health Room Assistant
• Provide health room management and assists in the implementation of the
District health services programs.
• Assists students, staff and teachers with health-related issues.
Safe Schools
1. Participants will:
1. Understand their training assignments with safe schools
online and expectation for completion.
Safe Schools Online
1). Health Room Assistant Training by RN
Goal: To be completed by first day in position and then annually.
Safe Schools Online Cources: Blood borne Pathogen Exposure Prevention, Health
Emergencies Overview, HealthEmergencies: Asthma Awareness, Diabetes
Education, Hemophilia, Life Threatening Allergies, Seizures, Coking & the
Heimlich Maneuver, Medication Administration Basics, HIV Aids, AED Training,
Heat Illness Prevention, Concussion.
*First Aid Certified (every 2 years)
2). Health Room Para Educator and Secretary Annual August Training
Goal: To be completed annually at the beginning of each new school year.
Safe Schools Online Cources: Blood borne Pathogen Exposure Prevention, Health
Emergencies Overview, Health Emergencies: Asthma Awareness, Diabetes
Education, Hemophilia, Life Threatening Allergies, Seizures, Coking & the
Heimlich Maneuver, Medication Administration Basics, HIV Aids, AED Training,
Heat Illness Prevention, Concussion.
*First Aid Certified (every 2 years)
Safe Schools Online
3). General health related Training for All School Building Staff, New
Certificated Hires, New Classified Hires, New Subs
Certificated/Classified. Goal: To be completed by early September,
Safe Schools Online Courses: Blood borne Pathogen Exposure
Prevention, Health Emergencies Overview 25 mins (Asthma
Awareness, Diabetes Education, Life Threatening Allergies, Seizures)
Individualized staff specific training for individual student with
HCP/ECP Goal: As needed/promptly, ongoing
RN provides one-on-one or small group setting training.
Provides condition information and/or ECP
1. Participants will:
1. Understand their role and limitations with school nurse
2. Understand when to seek clarification and guidance.
Delegation Defined
Delegation is defined by the American Nurses’
Association as “the transfer of responsibility for
the performance of an activity from one
individual to another, while maintaining the
accountability for the outcome.”
The Nursing Care Quality Assurance
Commission (NCQAC) has the legal authority
(RCW 18.79 and RCW 18.130) to regulate
nursing practice in order to safeguard the health
and safety of citizens in Washington.
Nurse Delegation
A registered nurse may delegate tasks of nursing
to another individual where the registered
nurse determines that it is in the best interest
of the patient.
1) The delegating nurse shall:
a) Determine the competency of the
individual to perform the task;
b) Evaluate the competency of the
individual to perform the tasks;
c) Supervise the actions of the person
performing the tasks; and
d) Delegate only those tasks that are
within the registered nurse’s scope of practice.
Nurse Delegation
No person may coerce a nurse into
compromising patient safety by
requiring the nurse to delegate if the
nurse determines that it is
inappropriate to do so.
Nurses shall not be subject to any
employer reprisal or disciplinary action
by the nursing care quality assurance
commission for refusing to delegate
tasks or refusing to provide required
training for delegation if the nurse
determines delegation may
compromise patient safety.
Nurse Delegation
Nurse delegation models the nursing process:
Assess – the student and the school
employee’s competency
Plan – documentation of the training and
nursing care
Implement – supervision requirements
Evaluate – changes in student needs,
changes in school personnel, activities,
change the plan or continue
Nurse Delegation
For school nurses, NCQAC (WAC 246-840-700) Standards of
Nursing Conduct or Practice discusses delegation of nursing
tasks to non-licensed personnel (WAC 246-840-010), and
provides direction on how tasks may be delegated to a nonlicensed individual by a licensed registered nurse. The
delegating school nurse will be responsible for ongoing training
and competency evaluations of the non-licensed personnel to
safeguard the health and welfare of the students in their care.
Even when unlicensed school personnel perform the task, the
nurse who delegates the task, will retain responsibility for the
outcome. Supervision of the unlicensed school personnel does
not require the delegating nurse to be present in the same
building, however the delegating school nurse should be
available by phone for consultation.
Medication Delegation
House Bill 2247 allows registered school
nurses to delegate the administration of
the following medications:
 Oral medications
 Eye drops
 Ear drops
 Topical ointments
Additionally, administration of an
epinephrine autoinjector (Epi Pen) may be
delegated by a licensed school nurse
Recent changes in legislation may expand
medications which may be delegated,
however, the school board will need to
review these legislative rulings and
respond with policies
Nurse Delegation
When accepting the delegation to perform medication
administration in a school setting, the unlicensed school
personnel performs this function under the supervision
of the delegating licensed professional nurse.
Unlicensed school personnel should only accept
delegation that he/she knows is within his/her skill set or
knowledge and should always contact the school nurse
if unclear about administration of medication.
Unlicensed staff have a responsibility to follow school
district policy and procedures and report to the nurse
immediately if they have any reason to believe they
have made a medication error.
Nurse Delegation
School district, school district employee, agent, or parentdesignated adult who, acting in good faith and in
substantial compliance with the student’s individual
health plan and the instructions of the student’s licensed
health care professional, provides assistance or services
under RCW 28A.210.330 shall not be liable in any
criminal action or for civil damages in his or her
individual or marital or governmental or corporate or
other capacities as a result of the services provided
under RCW 28A.210.330 to students with diabetes.
Nurse Delegation
The American Nurses Association (ANA) Code
of Ethics states, “The Nurse is responsible
and accountable for individual nursing
practice and determines the appropriate
delegation of tasks consistent with the
nurse’s obligation to provide optimum patient
care.” The National Council of State Boards
of Nursing (NCSBN) states the delegate must
be, “accountable for accepting the delegation
and for his/her own actions in carrying out the
1. Participants will:
2. 1. Gain a basic knowledge of the Washington State WAC
and of the LSSD policy on medication administration.
3. 2. Gain a basic knowledge of medication administration,
medication errors, classification, safety, and documentation.
Always refer to individual student care plan
Medication Administration
Schools will administer health services per
WAC392-172-A01155, including medication
administration, to students who require this
service during the school day. Therefore,
school districts should have in place, policies
and procedures that address how medications
and other health services should be delivered.
Lake Stevens School District policies for
medication administration are included in the
consent forms for Administration for Oral
Medication and on our HCP forms.
Medication Administration
Prescribed medication must be sent to school in the
original labeled container and the label should include:
o Name of student
o Expiration date of medication
o Name of medication, dosage and strength of
o Route of medication
o Name and address of pharmacy
o Name of the prescribing health care provider
o Date the prescription was dispensed.
Medication Administration
Student self medication is allowed under in certain
situations, with a written health care providers
authorization. Prescribing HCP shall include:
o The student demonstrated proper technique and is
capable of administering the prescribed med.
o The name and purpose of the medication
o The prescribed dosage of medication
o The times at which or circumstances under which
the medication may be given
o The time period for which the medication is
o The side effects and further instructions if order is for
more than 15 days.
Medication Safety
• Medication safety:
The first dose of a medication should be given at home
and not at school.
Prescribed medication should be brought to school by
parent or guardian and picked up by the same.
Prescribed medication should be counted and the
number of pills documented on the Medication
Administration form and signed by 2 adults.
Medication shall only be administered according to the
health care provider’s instructions on the Medication
Authorization form and should match the information on
the prescription label
No change in prescription can be made without
authorization from prescribing HCP.
Storage and Disposal of Medication
Storage and Disposal of medication:
Except for emergency medications (EpiPens and
inhalers and antihistamines) all medications should
be kept in a secure, locked container or cabinet
accessible only to responsible authorized school
o Medications requiring refrigeration shall be kept in
separate refrigerator in a supervised area.
Temperature of that refrigerator will be checked on a
regular basis
o Disposal of medications may be made at the Lake
Stevens Police department office. Document
disposal date.
Medication Errors
Medication Errors:
A medication error occurs when on the “6 rights of
medication administration” has been violated, ie:
o Administering the wrong medication
o Administering the wrong dosage of medication
o Administering the medication at the wrong time
o Administering medication in the wrong way
o Administering medication to the wrong student
o Failing to document that medication was given or
inaccurate documentation of medication given.
Medication errors may result in adverse reactions to the
student. These reactions could range from a rash to life
Medication Errors (con’t)
When a medication error occurs, follow
these guidelines:
o Keep the student in the health room or office
o If the student has returned to class, have them escorted
by an adult back to health room
o Observe the student’s status and document what you see
o Identify the incorrect dose or type of medication taken
o Notify the supervising school nurse or principal if
medication was given by non-licensed personnel.
o Complete a Medication Administration Incident Report
o Call Parent/Guardian to inform of the incident.
The 6 Rights of Medication
1. Right student
2. Right medication
3. Right dose
4. Right time
5. Right documentation
6. Right route (eye drops, oral med, ear drops)
Classification of Medications
Classification of Medications:
Prescription medications: have been ordered for
treatment by a health care provider
o Controlled/scheduled meds: are medications that
are potentially addictive and are regulated under the
Controlled/scheduled Substance Act of 1970
o Non-controlled/scheduled medication:require an
order from a HCP.
o Over-the-counter (OTC) medications: OTC
medications are administered to students according
to district policy. OTC meds require a completed
authorization form by parent/guardian and the
student’s HCP.
Field Trip Procedures-Medication
Notification and preparation for administering
medications during a field trip should begin
well in advance of the day of the field trip(at
least 2 weeks). The medication should not be
repackaged for field trips by school personnel
and student medication bottle should have a
pharmacy prescription label attached.
Medication Handouts
Administration of Medication Policy Letter
Medication Dosage Log
Medication Error Report Form
Common Medication Abbreviations
Glossary of Medical Terms
Brand & Generic Names for Common
Common Medications
Medication Administration Checlist
(i.e. Oral, Liquid, Eye Drops, Oinment, Ear Drops, Topical Ointment, Inhalers, EpiPen)
•• 1. Gain a basic understanding of diabetes.
Participants will:
2. Identify signs and symptoms of low and high blood sugar.
3. Understand their role in treatment and emergency
Always refer to individual student care plan
Diabetes Management
Training For School Personnel Is Essential
• For the immediate safety of
students with diabetes
• For the long-term health of
students with diabetes
• To ensure that students with
diabetes are ready to learn
and participate fully in school
• To minimize the possibility
that diabetes-related
emergencies will disrupt
classroom activities
Diabetes results from the failure of the
pancreas to make insulin. Insulin is a
hormone that is necessary for the
body to convert sugar or glucose into
energy. Without insulin, sugar
accumulates in the blood causing
Type 1 Diabetes
• Most children with
diabetes have Type 1
Pancreas makes too
little or no insulin.
Treatment consists of
administering multiple
doses of insulin,
monitoring blood sugar
levels throughout the
day, eating nutritious
meals and snacks, and
following a regular
exercise program.
Symptoms of Type 1 Diabetes
• Increased thirst
and urination
• Weight loss
• Blurred vision
• Feeling tired all
the time
Risk Factors:
• Genetics
• Environment
The symptoms of type 1
diabetes are due to an increase
in the level of glucose in the
blood. These symptoms may be
mistaken for the flu. If left
undiagnosed, the child with type
1 diabetes can lapse into a lifethreatening condition known as
diabetic ketoacidosis (DKA).
Signs of DKA include vomiting,
sleepiness, fruity breath, difficulty
breathing, and if untreated, coma
and death.
Type 2 Diabetes
• Cells are insulin
resistant and do not
use insulin well.
• Children with Type 2
Diabetes often do not
take insulin but may
take a diabetes pill
such as Metformin.
• Blood sugar monitoring,
careful attention to a
healthy diet, and daily
exercise are important
to controlling Type 2
Type 2 diabetes is the most common form of the disease. It can
develop at any age, even during childhood. Type 2 diabetes is a
progressive disease and usually begins with insulin resistance
where muscle, liver, and fat cells do not use insulin effectively.
The pancreas produces more insulin but eventually loses its
ability to produce enough insulin to control the glucose levels.
More children and adolescents in the United States have become
overweight and sedentary in their activity level resulting in an
increase of Type 2 diabetes occurring in this younger population.
Risk Factors:
Being overweight
Having a family member who
has type 2 diabetes
Being African American,
Hispanic/Latino, American
Indian, Alaska Native, Asian
American, or Pacific Islander
including Native Hawaiian
• Feeling tired all the time
• Increased thirst and
Weight loss
Blurred vision
Frequent infections
Slow-healing wounds
Prevalence of Diabetes in
Children is Increasing
200,000 or 1 in every 400 children and adolescents
in the United States has Diabetes. According to
recent estimates, about 19,000 youths are
diagnosed with type 1 and type 2 diabetes each
Goals of Diabetic Management in
To promote normal childhood and
adolescent growth and development.
To promote healthy, emotional wellbeing.
To maintain a balance between
insulin, food and exercise.
Diabetes Research
Research has shown that maintaining good control of
blood sugar levels can prevent long-term
complications of diabetes.
Good Blood Glucose Control is a Balancing Act 24/7
The goal of effective
management is to
keep the blood
glucose levels in the
“target range” which
is determined by the
student’s health care
Diabetes management involves checking blood glucose
levels throughout the day, following an individualized
meal plan, getting regular physical activity, and
administering insulin to try to maintain blood glucose
levels in the target range and to prevent hypoglycemia
or hyperglycemia.
Checking Blood Glucose Levels
Regular glucose
monitoring is essential in
good diabetic
management. Blood
glucose levels are most
often done by poking the
end of the finger with a
lancet via a poking
device and placing a
drop of blood on a test
strip which is inserted
into a glucose meter
where the meter displays
the blood glucose level.
Helpful information:
Students usually check
their blood glucose:
As outlined in their
Individual Health Plan
Before and after eating
snacks and meals
Before and after physical
When they have
symptoms of low or high
blood glucose levels
Students should be allowed access to their
diabetic testing equipment and supplies at
all times
Students experiencing hypoglycemia (low
blood sugar) may need assistance in
testing their blood glucose levels
If low blood sugar is suspected, testing
should be done in the tip of the finger
Hands should be thoroughly washed and
dried before testing
Sharps and contaminated supplies must
be disposed of according to district policy
and students IHP
• Hypoglycemia, which is not always
Hypoglycemia means
LOW blood sugar and
is defined as a blood
sugar less than 60
preventable, is the greatest
immediate danger to students with
• Low blood sugar can develop
within minutes and requires
immediate attention
• Hypoglycemia usually can be
treated easily and effectively. If it is
not treated promptly, however,
hypoglycemia can lead to loss of
consciousness and seizures and
can be life threatening
Causes of Hypoglycemia
• Too much insulin
• Missing or delaying meals or snacks
• Not eating enough food (carbohydrates)
• Getting extra, intense, or unplanned physical
• Being ill, particularly with gastrointestinal
• Hypoglycemia is most likely to occur before
lunch, end of the school day or after
Hypoglycemia Symptoms
Hypoglycemia can
impair a student’s
cognitive abilities and
adversely affect
Sometimes, its
symptoms are
mistaken for
“I’m the Blood Sugar Fairy.
If you can see me, yours is too low.”
Mild to Moderate Hypoglycemia
Shaky or jittery
Blurry vision
Irritable or nervous
Changed personality
Changed behavior
Inability to concentrate
• When hypoglycemia is suspected,
always treat immediately as
outlined in student’s Emergency
Care Plan (ECP)
• Never leave a student unattended
who is suspected of having
• Never allow another student to
escort a student suspected of
having hypoglycemia
• Do not delay treatment, when in
doubt always treat for hypoglycemia
as symptoms may progress rapidly
Treatment for Mild to Moderate
Hypoglycemia: Requires immediate action
Give the student a quick-acting
glucose (sugar) equivalent to 15 gm
of carbohydrate:
3-4 glucose tabs
4 oz fruit juice
6 oz regular soda (1/2 can)
1 tube glucose gel
Wait 10-15 minutes and recheck blood
glucose (BG)
Repeat treatment if BG is below target
range as indicated on student’s ECP
Follow with snack of complex
carbohydrate and protein if longer than 30
minutes until next meal.
Treatment should follow
guidelines outlined in
student’s Emergency
Care Plan (ECP)
Notify school nurse at
first sign of
Check blood sugar to
determine low blood
Student safety is priority,
when in doubt treat for
hypoglycemia then
continue procedures
outlined in student’s
Severe Hypoglycemia: Urgent Response
necessary to treat life-threatening symptoms
Contact school nurse or
initiate 911 if nurse if not
immediately available
Position student on side
School RN to administer
Glucagon per HCP orders
Do not attempt to put
anything in student’s
Notify parent
Inability to eat or
Seizure activity or
Glucagon is hormone that raises
blood sugar levels and is administered
as an injection for the treatment of
severe hypoglycemia
Glucagon can only be administered by
the school nurse or qualified Parent
Designated Adult (PDA), glucagon
cannot be delegated to non-licensed
Glucagon may cause nausea or
vomiting once the student regains
consciousness, student should be
placed in a side-lying position to
prevent choking
•Call 911 when
Glucagon is
•Call 911 immediately if
Glucagon is not
prescribed or included in
student’s ECP or if
school nurse is not
immediately available
Hyperglycemia •
means HIGH
blood sugar and
is defined as a
blood sugar
greater than 250 •
Elevation in blood sugars in children
are usually minimally above the target
range and are short in duration,
whereas older children may
experience frequent spikes throughout
the day in blood sugars that are high
(above 250 mg/dl) and last longer in
Short-term effects of hyperglycemia
impact student’s cognition and
academic performance
Long-term effects of hyperglycemia
result in serious health complications
such as heart disease, kidney failure,
stroke, blindness, and amputation
Causes of Hyperglycemia
• Too little insulin or other glucose-lowering
• Too little food intake that has not been covered
by insulin
• Decreased physical activity
• Illness, infection, injury, or severe physical or
emotional stress
The onset of hyperglycemia may occur over
several hours or days
Hyperglycemia Symptoms
• Increased thirst
and/or dry mouth
• Frequent or
increased urination
• Change in appetite
• Nausea
• Blurry vision
• Fatigue
Treatment for Hyperglycemia
Contact school nurse at first sign of
Check blood glucose levels to
determine if blood sugar is above
target range
Encourage student to drink water or
non-sugar beverage
Allow for free and unrestricted
access to water and restroom
Modify physical activity in presence
of ketones and according to
student’s ECP
Authorized staff to verify pump is
connected and working properly if
student wearing insulin pump
Treatment should follow
student’s Emergency Care
Plan and may include:
Insulin administration as
Urine ketone testing
Additional blood sugar
Pump troubleshooting
Personnel are
limited to tasks
delegated by the
licensed school
nurse in accordance
to state nursing laws
Diabetic Ketoacidosis (DKA)
Diabetic ketoacidosis develops over
hours to days and is associated with
hyperglycemia, a buildup of ketones
(ketosis) in the blood, and dehydration
• Caused by prolonged inefficient
delivery of insulin, pump malfunction in
delivery of insulin, illness, or prolonged
physical or emotional stress
• Signs include severe abdominal pain
with vomiting, dry mouth and extreme
thirst, fruity breath, heavy breathing
and shortness of breath, chest pain,
increasing sleepiness or lethargy, and
decreased level of consciousness
Contact school
nurse or 911 if
nurse is not
Insulin is
classified in four
types by how it
Insulin has three characteristics
• Onset of effect – the length of time insulin
reaches the bloodstream and starts lower
blood glucose levels
• Peak time of effect – time insulin is at its
maximum effect in lower blood glucose
• Duration of effect - number of hours
insulin actively lowers blood glucose levels
Improvements in the types of insulin and delivery systems help
keep blood glucose levels within the target range, however,
this means more frequent blood glucose monitoring and
greater need for student assistance in diabetic management
Insulin Administration
Schedule for blood sugar testing,
insulin administration, and level
of student independence is
detailed in the student’s
Individual Health Plan (IHP)
according to physician orders.
This may include a plan to take
insulin to cover meals and/or
snacks, the need for additional
or corrective dosages of insulin
to treat hyperglycemia, and a
plan to cover a rise in blood
glucose levels
Insulin Delivery
Three most common ways to
administer insulin:
• Insulin syringe – syringe is used to
draw up prescribed amount of insulin
out of vial
• Insulin pen – pen holds a cartridge
of insulin, needle tip is screwed onto
tip of pen, desired insulin dosage is
dialed up
• Insulin pump – small computerized
device which delivers a set amount of
insulin 24 hours a day directly into
the student’s skin
Insulin-to-carb ratio for meals
• Carbohydrate (carb) counting is the most popular meal
planning approach for children and youth - the number of
grams of carbohydrate, or choices of carbohydrate, the
student eats is calculated (one carb choice equals 15
grams of carbohydrate)
• Insulin-to-carb ratio - determines the number of units of
insulin needed to cover the number of grams of carbs to be
•The blood glucose correction factor (insulin sensitivity
factor)—determines the amount of insulin needed to lower
blood glucose to target level. This additional insulin may
be needed if blood sugar is elevated above target level
prior to meal or snack
Example of HCP order
Insulin-tocarb ratio 1:10
ratio 1:50
Sensitivity –
50 mg/dl
Target BS 120 mg/dl
Parent Designated Adult (PDA)
A Parent
Designated Adult
(PDA) is a
volunteer, who may
be a school district
employee who
receives additional
training from a
professional or
expert in diabetic
care selected by the
parent and who
provides care for
the child consistent
with the individual
health plan.
• Written documentation of intent to
be a PDA along with ongoing
training documentation required to
be submitted to district
• Must attend district training for
direct care (IHP)
• Additional training requirements if
PDA is a school employee
• School nurse is not responsible for
the training, supervision, or actions
of a PDA
Personnel Guidelines for Care of
Students with Diabetes in School
• Verify number on insulin pen for student
independent in management of selfDelegation of
responsibilities to
unlicensed staff by
• Verify number on glucose meter for
the licensed staff R.N.
student independent in the management
is in accordance with
of his/her self-monitoring
statute, regulation,
• Ketone urine testing per physician order
Nursing Care Quality
• Treatment of mild and moderate
hypoglycemia, initiation of 911 for
guidelines, nurse
severe hypoglycemia
practice act , and best
• Administration of snacks as needed
All other responsibilities and tasks require nursing
judgment and cannot be delegated.
Diabetes affects the entire family
Night Visits
The minutes tick by
I watch the clock,
can't sleep
It strikes midnight
and into your room I creep.
Not for a tuck in or even a drink,
but to test your blood sugar
while you sleep.
Your sweet little face,
your "Barrie" held tight,
these awful visits in the night.
I hate this diabetes
it won't go away!
Please God let her numbers
be good today.
One test down,
thousands to go,
I need to be strong for her
I love her so.
Written by Pam Bushway in 2005 for her 6 year-old child
Diabetes is considered a disability under federal law. Under
Section 504 of the Rehabilitation Act of 1973, it is illegal
to discriminate against a person with a disability.
Children with diabetes must have full access to all
activities, services, or benefits provided by public
schools. Any school receiving federal funds must
accommodate the special healthcare needs of students
with disabilities in order to provide them with “free
appropriate public education.” These accommodations
are developed with parent consent and may be reflected
in the student’s Individual Health Plan (IHP)/504 Plan or
as part of the student’s individualized education program
(IEP) if student qualifies for special education services.
Common accommodations for
students with Diabetes
Eligibility and
accommodations are
determined through
district process, either
by the Guidance
Team or team of
members coordinating
504 plans or by
coordinated efforts of
the school nurse
through the
Education Group for
students qualifying for
specialized education.
The parent is involved
in the team process in
Free access to testing equipment and supplies with ability to test
and treat as needed without restriction according to DMMP and
Free and liberal access to food
Free and liberal access to water or non-sugar drinks, as well as
access to restroom
Meals must never be withheld for nonpayment of fees or
disciplinary action
Access to fully participate in physical education and team sports
in accordance to DMMP and ECP
Participation in school-sponsored field trips and extracurricular
activities without restriction, including supervision by school
personnel at outlined in DMMP and IHP
Extra time to complete tests or work without penalty when
related to high or low blood glucose levels
Extra time to complete missed work without penalty when due to
absences related to diabetic care
Washington State Law, SHB 2834, now requires that the necessary
order, medications, equipment, and nursing plan must be in place
before a student with a life-threatening condition may attend school.
Registrars, Head
Secretaries and Office
Staff play a key role in
identifying students
with life-threatening
health conditions
before they begin their
first day of school.
Any student indicating
a life-threatening
health condition on the
enrollment health
history form must
meet with the school
nurse to coordinate a
treatment plan before
the student may
attend school.
The statue adds the requirement that every
student with diabetes has an Individualized
Health Plan
School district, school district
employee, agent, or parentdesignated adult who, acting in
good faith and in substantial
compliance with the student’s
individual health plan and the
instructions of the student’s
licensed health care
professional, provides
assistance or services under
RCW 28A.210.330 shall not be
liable in any criminal action or
for civil damages in his or her
individual or marital or
governmental or corporate or
other capacities as a result of
the services provided under
RCW 28A.210.330 to students
with diabetes.
Diabetic Medical Management Plan
(DMMP) includes the health care provider
orders for all aspects of student’s routine
and care
The school nurse uses the DMMP for
developing the student’s Individual Health
Plan (IHP) which details the specific care
for the student as outlined by the
physician. In many cases, the IHP and
504 are the same document
The Emergency Care Plan (ECP) is
created by the school nurse from the IHP
and describes emergency treatment for
the treatment of hypoglycemia and
hyperglycemia for the student
Example of required medical documentation required for
school attendance (Seattle Children’s DMMP with HCP orders)
Seattle Children’s DMMP – Parent form
• Information from the
DMMP, along with
parent and student input
is essential for the
school nurse in
developing student’s
• Students who fail to
provide the required
physician orders and
emergency medication
are subject to exclusion
from school (SHB 2834)
IHP in Skyward
Emergency Care Plan (ECP)
Useful Tips
• Become familiar with students in your building who have life•
threatening conditions – look up their pictures on Skyward
Never leave a student with diabetes unattended in the health room
Become familiar with the IHP and ECP of students in your building
who have life-threatening health conditions, know where emergency
medication is stored according to
Perform only those duties which you have been delegated
Consult the school nurse in your building for concerns or questions,
contact a district nurse if the nurse assigned to your building is
Diabetes Q/A
1. Participants will:
1. Identify signs and symptoms of types of seizures.
2. Understand how to respond to a student having a seizure
and the appropriate emergency procedures.
Always refer to individual student care plan
Seizure Medication
Seizure: Scenario 1
Called to classroom for a student who
appears to be having a grand mal (tonicclonic) seizure.
Student does not have a known seizure
How do you respond?
Seizure: Scenario 1
1. Call 911 - this is a first time seizure for a
student without a seizure disorder diagnosis.
2. Ensure student's safety.
3. Protect student's head. Assist student to side
lying position.
4. Time the seizure.
Seizure: Scenario 2
Called to a classroom for student with a
known seizure disorder who is having grand
mal (tonic- clonic) seizure.
How do you respond?
Seizure: Scenario 2
1. Ensure student's safety.
2. Protect student's head. Assist student to side lying
3. Time the seizure. If the seizure lasts longer then 5
minutes call 911.
4. Stay with the student until they regain consciousness.
Provide emotional support.
5. Allow student to rest. Notify parents.
6. Document seizure.
Participants will understand that:
1. 1. Cardiac arrest can happen to anyone (e.g., student,
parent, co-worker, visitor, etc.).
2. 2. Cardiac arrest is not always associated with sports.
3. Sometimes the person doesn't know they have symptoms
or won’t admit them if they do.
4. Cardiac arrest can happen at anytime without warning.
Always refer to individual student care plan
Project ADAM...
Sudden Cardiac
The mission of Project ADAM is to serve children and
adolescents through education and deployment of lifesaving programs that help prevent sudden cardiac
arrest. Project ADAM helps schools across the nation
implement public access defibrillation programs through
support and education.
Project ADAM...
Sudden Cardiac
1. Participants will:
2. 1. Recognize the symptoms of cardiac arrest.
3. 2. Know how to check the person’s airway, breathing, and
3. Know when to start CPR and call 911.
It is your responsibility to keep your
CPR/AED & First Aid certification up to date
- renew every 2 years.
Know where your AEDs are in your building.
1. Participants will:
1. Identify signs and symptoms of asthma.
2. Understand how to administer inhaler and/or with spacer.
3. Identify an asthma emergency and how to respond.
Always refer to individual student care plan
Source: National Asthma Education and Prevention Program (NAEPP)
Source: National Asthma Education and Prevention Program (NAEPP)
Source: National Asthma Education and Prevention Program (NAEPP)
Source: National Asthma Education and Prevention Program (NAEPP)
Source: National Asthma Education and Prevention Program (NAEPP)
Source: National Asthma Education and Prevention Program (NAEPP)
Source: National Asthma Education and Prevention Program (NAEPP)
Source: National Asthma Education and Prevention Program (NAEPP)
Source: National Asthma Education and Prevention Program (NAEPP)
Source: National Asthma Education and Prevention Program (NAEPP)
Source: National Asthma Education and Prevention Program (NAEPP)
Source: National Asthma Education and Prevention Program (NAEPP)
Source: National Asthma Education and Prevention Program (NAEPP)
Source: National Asthma Education and Prevention Program (NAEPP)
Source: National Asthma Education and Prevention Program (NAEPP)
Source: National Asthma Education and Prevention Program (NAEPP)
Source: National Asthma Education and Prevention Program (NAEPP)
Source: National Asthma Education and Prevention Program (NAEPP)
Asthma Emergency Plan
Call 911 if you see ANY ONE of the
emergency signs:
*Trouble walking or talking without stopping to
* Child is hunched over
*Child is struggling to breathe
*Lips or fingernails are gray or blue
Asthma Emergency Plan continued
*Tightness in chest, or tickle in throat
* Shortness of breath
* Wheeze
*Unable to catch their breath-Gasping,
*Rapid breaths
*Nostrils flaring
*Feelings of fear or confusion
After calling 911, call the office and tell them
to contact a parent or guardian.*
Source: National Asthma Education and Prevention Program (NAEPP)
Asthma: Scenario 1
Student walks into Health Room. Student
says they feel "tight" and would like to use
their inhaler.
They do not appear to be in distress and are
able to speak to you.
Student says they last used their inhaler
before school. It is now 1pm.
How do you respond?
Asthma: Scenario 1
1. Student has a medication order and an inhaler in the
Health Room. Verify time of last inhaler administration Call parents if needed.
2. Following appropriate medication administration
protocol - administer inhaler.
3. Document medication administration and health office
4. If you did not need to call parents to verify when inhaler
was last used - notify parents of inhaler use, as
Asthma: Scenario 2
Called to cafeteria for a student who is
having an asthma attack, they are unable to
walk to the Health Office.
Student unable to talk/ speak because of
poor air movement.
Lips blue.
How do you respond?
Asthma: Scenario 2
1. Call 911 - It is better to have too much help then not enough.
2. Student has an inhaler in the Health Room.
3. Stay with the student. Have another staff member obtain the
4. Administer the inhaler, using appropriate medication administration
5. If the student improves - GREAT! Call parents. Medics will evaluate
the student on their arrival and make appropriate determination.
6. If student does not improve - Medics will assume responsibility for
student's care.
Anaphylaxis &
Life Threatening
Food Allergies
1. Participants will:
1. Identify signs and symptoms of an allergic reaction and
2. Be able to initiate treatment for an allergic reaction
Always refer to individual student care plan
Prevent a Severe Food Allergy
Reaction:Follow the FAST Formula
FACTS about Food Allergies
*Food allergy reactions can be triggered by a tiny trace of allergen
*A food allergy reaction can cause death within minutes
*Children with asthma are at the highest risk of dying
*know every child's emergency treatment plan
AVOID the Allergen
*Read food ingredient labels
*Clean tables, desks and other surfaces
*Wash hands often
*check ingredients of art supplies and personal care products
SIGNS and Symptoms
*Itching of the mouth, swelling of lips and/or tongue
*Tightness of the throat and hoarseness
*Shortness of breath, coughing, wheezing
*Vomiting, diarrhea, cramps
*Weak pulse, dizziness, fainting
*Symptoms vary and can change quickly
TREAT immediately
* Give epinephrine-do not delay!
*Call 9 1 1 and request that a paramedic respond
*Call emergency contacts
Administering Epi-Pen
Administering Epi-Pen
Anaphylaxis: Scenario
Student comes to Health Room complaining
of tingling, scratchy throat, hacking cough,
upset stomach/ nausea, saying they don't
feel right after eating lunch at school. They
say they traded their chips for their friend's
How do you respond?
1. Student has a known allergy to peanuts. They have an
epi-pen at school and school care plan on file.
2. Administer epi-pen per medication administration policy.
3. Call 911. Call parents.
4. Remain with student until medics arrive. When medics
arrive they will assume care for the student.
911 Emergency
1. Participants will:
1. Understand procedures and roles when calling 911.
Calling 911 / Procedures
• When to call?
• Who calls?
• Who is immediately notified?
• Who else in the district is
What paperwork to fill out?
When to call 911
Call 911 for medical emergencies:
Severe allergic reaction (anaphylaxis)
Choking or severe difficulty breathing
Deep wound or part of the body that was crushed
Bleeding that is difficult to control
Back and neck injuries or broken bones
Severe head injury
Seizure - if longer than three to five minutes, if there is a second seizure, or if
the student has never had a seizure before
Serious burns
Spill or release of hazardous chemicals
Several students injured or ill at the same time
Calling 911 / Procedures
1. A student’s health could be compromised. When in doubt, call anyway. It is better to have too
much help than not enough.
2. A student is experiencing breathing difficulties, severe bleeding, seizures, severe bee sting
reactions, possible broken bones, and/or is unconscious.
Someone should stay with student at all times while at school.
Do not move student. Provide safe environment. Cover with blanket if needed.
Clear area of all other students.
A designated person in office calls:
a. 911
b. School RN (if not in building)
c. Parents
d. Teacher
e. Principal
Information needed for 911 team:
a. Copy of locator card.
b. Check Health Concerns list for additional health problems that the student may have.
Once the AID care arrives, the 911 team is responsible for the student. DO NOT sign any forms or
waivers provided by the 911 team.
Calling 911 / Procedures
DO NOT accompany student in
AID car. Do not make any
treatment decisions at the hospital
or doctor’s office.
o Fill out the Incident Report
o Fill out 911 Emergency
Medical Notification
a. Call ESC switchboard 425-3351500 to report 911 call
b. Complete accident report and send
original to Teresa Main at ESC
c. Keep copy at building
Incident &
1. Participants will:
1. Become familiar with district procedures and forms.
How to Respond
Know where this
resource is in
your health room.
Source: WA DOH
Head Bumps
EVERY head bump....
1. Needs a head bump
form filled out,
no matter how minor
it seems.
2. Call Parent/Guardian
Incident: Student/
Non-Employee Injury
In google drive for all LSSD Staff
Skyward &
1. Participants will:
1. Will understand their role using the health module in
2. Will understand the obligation to maintain student health
information confidential.
Skyward: Health
Multiple windows - have one for health and one for office
Automatically dates, times and signs who entered what
information. You are responsible for what you write - so don't
let others write under your log in.
Write enough so that you know what happened.
TOAD - what they told you, what you saw (observed), what
action you took, disposition (where'd they go)
Reminder for communication best practice:
- RN needs to know about incident reports, head bumps
and any critical student/staff concerns.
- Call parent/guardian with important information about
their student
All unlicensed health care providers, such as health room aides or
pupil transportation staff who assist the health care provider in the
delivery of health care to students, must be informed of the
confidentiality requirements of the Federal Family Education Rights
and Privacy Act (FERPA) and state requirements under chapter
70.02 RCW, Medical Records - Health Care Information Access
and Disclosure.
Health care information about a student cannot be disclosed
without signed consent of parent, guardian, or student except in
selected situations identified by the licensed health care provider
(such as the nurse).
Everything that happens in the health room, stays in the
health room!!!!
1. Participants will:
1. Recognize head lice.
2. Understand head lice district procedures.
3. Identify information available to assist parents with
Head Lice Procedures
• Each fall, there will be an elementary
school-wide lice screening by
designated employees.
• New students will be screened prior
to starting school.
Students are screened throughout
the year on teacher/parent referrals.
Head Lice Procedures
• Students with nits/head lice are sent
home for treatment.
• Students are checked by school
personnel prior to readmission to
Students are only readmitted to
school if free of live lice.
Head Lice Procedures
• Students are re-examined one week after
• At the school nurse’s discretion,
classrooms will be re-screened by
designated personnel as needed
throughout the school year.
• Classrooms will receive a general letter
regarding head lice as deemed
necessary by the school nurse.
Head Lice Recognition
Thank you for
joining us today
and your
commitment to
keep kids safe.

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