LAKE COUNTY SCHOOL DISTRICT NURSING CARE PLAN MANUEL

TABLE OF CONTENTS

A ACHONDROPHASIA / DWARFISM ADDISON’S DISEASE AGENESIS CORPUS CALLOSUM ALLERGIC RHINITIS ALLERGIC REACTION ANOREXIA NERVOSA AORTIC STENOSIS AND AORTIC VALVE REGURGITATION ASTHMA ASTROCYTOMA B BILIARY ATRESIA BLEEDING DISORDER PROCEDURE BRACHIAL PLEXUS PALSY BRAIN TUMOR BURKITT’S LYMPHOMA C CARIDIA ANOMALIES

CARDIAC ARRHYTHMIA’S CELIAC DISEASE / CELLIAC SPRUE CEREBRAL PALSY CHARCOT – MARIE TOOTH CHOLESTEROL CYSTIC FIBROSIS CYSTINOSIS D DEHYRATION DEJERINE – SOTTAS DISEASE DEXTROCARDIA DIABETIES DIABETIES INSIPIDUS DOWN SYNDROME – TRISOMY 21 DUANE PALSY DYSTONIA / PARKINSON SYNDROME E EHLERS DANLOS SYNDROME (CUTIS HEPEREASTINA) ENCOPRESIS ENURESIS EPILEPSY F FAILURE TO THRIVE

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FETAL ALCOHOL SYNDROME FIBROMYALGIA FOOD ALLERGIES FRAGILE X SYNDROME FRIEDREICH’S ATAXIA G GASTROESOPHAGEAL REFLUX

GASTROSTOMY TUGE CARE PLAN GASTROSTOMY BUTTON TUBE FEEDING BOLUS METHOD GUILLIAN BARR’E SYNDROME H HEART MURMURS HEMOLYTIC ANEMIA HEMOPHILIA HERNIA HERPES SIMPLEX HIRSCHSPRUNG DISEASE HIV HODGKINS LYMPHOMA HUMAN IMMUNODEFICIENCY VIRUS HYDROCEPHALUS HYDROHEPHROSIS

HYPERTENSION HYPERTHYROIDISM HYPOGLYCEMIA HYPOPITUITARY HYPOPLASTIC LEFT HEART SYNDROME

I IMMUNODEFICIENCY

IMMUNOSUPPRESSION INCONTINENT OF BOWEL/URINE INFLAMMATORY BOWEL DISEASE INSECT BITE AND STING

J JUVENILE RHEMATOID ARTHRITIS K KIDNEY TRANSPLANT L LEGG-CALVE’-PERTHES DISEASE LEUKEMIA M MALE / FEMALE CAUTHERIZATION MALIGNANT HYPERTHEMIA SUSCEPTIBILITY

MANIC DEPRESSIVE DISORDER (BIPOLAR DISORDER)

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MEDULLARY SPONGE KIDNEY MITRAL VALUE PROLAPSE MONONUCLEOSIS – EPSTEIN BARR VIRUS MUSCULAR DYSTROPHY N NASOGASTRIC TUBE FEEDING NEPHROTIC SYNDROME O OSTOMIES P PACEMAKER PAN HYPOPITUITARY PANCRETITIS POISON IVY / OAK PYELONEPHRITIS Q R RENAL DISEASE

RESPIRATORY DYSFUNCTION RHABDOMYOMA & WOLF PARKINSON WHITE S SCOLIOSIS SEIZURE DISORDER SHORT BOWEL SYNDROME SICKLE CELL ANEMIA SPINA BIFIDA STROKE SYNCOPE T TACTILE DEFICIT TETROLOGY FALLOT THALLASSEMIA

TOURETTE SYNDROME TRACHEOSTOMY

U URINARY DIVERSION V VON WILLEBRANDS DISEASE W WOLF PARKINSON – WHITE SYNDROME

RVS 11/2011 Page 1 of 2

Student'sName D.O.B: Teacher:

ALLERGY TO

Asthmatic YES* NO *Higher risk for severe reaction

Symptoms: Give Checked Medication****(To be determined by physician authorizing treatment)

If a food allergen has been ingested, but no symptoms: Epinephrine Antihistamine

Mouth Itching, tingling, or swelling of lips, tongue, mouth Epinephrine Antihistamine

Skin Hives, itchy rash, swelling of the face or extremities Epinephrine Antihistamine

Gut Nausea, abdominal cramps, vomiting, diarrhea Epinephrine Antihistamine

Throat# Tightening of throat, hoarseness, hacking cough Epinephrine Antihistamine

Lung# Shortness of breath, repetitive coughing, wheezing Epinephrine Antihistamine

Heart# Thready pulse, low blood pressure, fainting, pale, blueness Epinephrine Antihistamine

Other# Epinephrine Antihistamine

If reaction is progressing (several of the above areas affected), give Epinephrine AntihistamineThe severity of symptoms can quickly change. # Potentially life-threatening.

DOSAGEEpinephrine: inject intramuscularly (cirlcle one) EpiPen® EpiPen® Jr . Twinject® M 0.3mg Twinject®TM 0.15mg Adrenaclick® 0.3mg Adrenaclick® 0.15mg(see page 2 for instructions)

Child has been trained to perform this procedure. (Please circle one) YES NO

Child may carry and use the epipen himself/herself. (Please circle one) YES NO

Antihistamine: givemedication/dose/route

Other: givemedication/dose/route

2. Dr. at

3. Emergency contacts:Name/Relationship Phone Number Name/Relationship Phone Number

- - - - EVEN IF PARENT/GUARDIAN CANNOT BE REACHED, DO NOT HESITATE TO MEDICATE OR TAKE CHILD TO MEDICAL FACILITY!

Parent/Guardian Signature Date

My child must carry his/her epipen as ordered by their doctor and we will assure the pharmacy label is on the Epipen. I/we agree to check the Epipen monthly and will replace as needed.

Doctor's Signature Date(Required)

I/We understand that all treatments and procedures may be performed by the student and/or trained unlicensed assistive personnel within the school or by EMS in the event of an allergic reaction. I also understand that the school is not responsible for damage, loss of equipment, or expenses utilized in these treatments and procedures. I have reviewed this information sheet and agree with the indicated instructions.

1. Call 911. State that an allergic reaction has been treated and additional epinephrine may be needed.

IMPORTANT: Asthma inhalers and/or antihistamines cannot be depended on to replace epinephrine in anaphylaxis.

STEP 2: EMERGENCY CALLS

STEP 1: TREATMENT

Allergy Action Plan

Place Child's Picture Here

REV 11/2011 Page 2 of 2

AdrenaclickTM 0.3mg and AdrenaclickTM 0.15mg Directions

Remove GREY

caps labeled “1” and “2”.

Place REDpress down hard until needle penetrates.

rounded tip against outer thigh,

Hold for 10 seconds, and then remove.

Once epinephrine (AdrenaclickTM) is used, call 911 and request an ambulance equipped with epinephrine and a responder trained to administer this medication. Take the used unit with you to the Emergency Room. Plan to stay for observation at the Emergency Room for at least 4 hours.

REV 11/2011 Page 2 of 2

EpiPen Auto-Injector and EpiPen Jr Auto-Injector Directions

First, remove the EpiPen Auto-Injector from the plastic carrying case

Pull off the blue safety release cap

Hold orange tip near outer thigh (always apply to thigh)

Swing and firmly push orange tip against outer thigh. Hold on thigh for approximately 10

seconds.

Remove the EpiPen Auto-Injector and massage the area for 10 more seconds

DEY® and the Dey logo, EpiPen 2-Pak®, and EpiPen Jr

2-Pak® are registered trademarks of Dey Pharma, L.P.

Once epinephrine (EpiPen) is used, call 911 and request an ambulance equipped with epinephrine and a responder trained to administer this medication. Take the used unit with you to the Emergency Room. Plan to stay for observation at the Emergency Room for at least 4 hours.

EpiPen 2-Pak® EpiPenJr2-Pak® (Epinephrine) Auto-Injections 0.3/0.15mg

REV 11/2011 Page 2 of 2

Twinject® 0.3mg and Twinject® 0.15mg Directions

Remove caps labeled “1” and “2”.

Place rounded tip against outer thigh, press down hard until

needle penetrates. Hold for 10 seconds and then remove.

If symptoms don’t improve after 10 minutes, administer second dose: SECOND DOSE ADMINISTRATION:

Unscrew rounded tip. Pull syringe from barrel by holding blue collar at

needle base.

Slide yellow collar off plunger.

Put needle into thigh through skin, push plunger down all the way, and remove.

Once epinephrine (Twinject®) is used, call 911 and request an ambulance equipped with epinephrine and a responder trained to administer this medication. Take the used unit with you to the Emergency Room. Plan to stay for observation at the Emergency Room for at least 4 hours.

REV. 11/2011

Name: Grade: Age:

Teacher: Room:

Parent/Guardian Name: Ph:(H)

Address: Ph:(W)

Parent/Guardian Name: Ph:(H)

Address: Ph:(W)

Emergency Phone Contact #1

Emergency Phone Contact #2

Asthma Healthcare Provider Ph:

Other Healthcare Provider Ph:

Daily Asthma management Plan

Other

Comments

(list any environmental control measures, pre-medications, and/or dietary restrictions that thestudent needs to prevent an asthma episode.)

Personal Best Peak Flow number:

Monitoring Times:

Adapted form NIH Publication No. 95-3651

Nursing Guidelines for the Delegation of Care for Students with Asthma in Florida Schools

Control of School Environment

Identify the things That start an asthma episode (Check all that applies to the student.)

Student Asthma Action Card

PLACE I.D.

PHOTO HERE

Phone

Relationship Phone

Respiratory Infections

Name Relationship

Name

Pollens

Molds

Animals

Exercise Strong odors or fumes

Chalk dust

Carpets in the roomChange in temperature

Peak Flow Monitoring

Food________________________

4

5

1

2

3

AmountName When to Use

REV. 11/2011

Emergengy Plan

Emergency action is necessary when the student has symptoms such as:

, , ,

, or has a peak flow reading of

Give medications as listed below

Have student return to classroom if

Contact parent if

Seek emergency medical care if the student has any of the following:

No improvement 15-20 minutes after initial treatment with medication and a relative cannot be

reached

Peak flow of

Hard time breathing with:

Chest and neck pulled in with breathing

child is hunched over

child is struggling to breathe

Trouble walking or talking

Stops playing and can't start activity again

Lips or fingernails are gray or blue

Comments / Special Instructions

For Inhaled Medications

medication by him/herself.It is my professional opinion that ______________________ should not carry his/her inhaled

medication by him/herself.

Parent Date

I have insturcted ________________________________________ in the proper way to use his/her medications. It is

my professional opinion that ___________________________ should be allowed to carry and use that

I/We understand that all treatments and procedures may be performed by the student and/or trained unlicensed assistive personnel within the school or by EMS in the event of an allergic reaction. I also understand that the school is not responsible for damage, loss of equipment , or expenses utilized in these treatments and procedures. I have reviewed this information sheet and agree with the indicated instructions.

Nursing Guidelines for the Delegation of Care for Students with Asthma in Florida Schools

3

4

When to Use

1

2

3

4

Emergency Asthma MedicationsName Amount

1

2

Steps to take during an asthma episode:

Healthcare Provider Date

DIABETES MEDICAL MANAGEMENT PLAN (School Year ____________-_____________)

Student’s Name: Date of Birth: Diabetes Type 1 ; Type 2 Date of Diagnosis :

School Name: Grade Homeroom Plan Effective Date(s) :

CONTACT INFORMATION Parent/Guardian #1: Phone Numbers: Home Work Cell/Pager

Parent/Guardian #2: Phone Numbers: Home Work Cell/Pager

Diabetes Healthcare Provider Phone Number;

Other Emergency Contact Relationship: Phone Number: Home Work/Cel/Pager

EMERGENCY NOTIFICATION: Notify parents of the following conditions (If unable to reach parents, call Diabetes Healthcare Provider listed above) a. Loss of consciousness or seizure (convulsion) immediately after Glucagon given and 911 called. b. Blood sugars in excess of mg/dl c. Positive urine ketones. d. Abdominal pain, nausea/vomiting, diarrhea, fever, altered breathing, or altered level of consciousness.

MEALS/SNACKS: Student can: Determine correct portions and number of carbohydrate serving Calculate carbohydrate grams accurately

Time/Location Food Content and Amount Breakfast Midmorning Lunch

Time/Location Food Content and Amount Mid-afternoon Before PE/Activity After PE/Activity

If outside food for party or food sampling provided to class: _

BLOOD GLUCOSE MONITORING AT SCHOOL: Yes No Type of Meter: If yes, can student ordinarily perform own blood glucose checks? Yes No; Interpret results Yes No; Needs supervision? Yes No

Time to be performed: Before breakfast Before PE/Activity Time Midmorning: before snack After PE/Activity Time Before lunch Mid-afternoon Dismissal As needed for signs/symptoms of low/high blood glucose

Place to be performed: Classroom Clinic/Health Room Other __________________________________

OPTIONAL: Target Range for blood glucose: mg/dl to mg/dl (Completed by Diabetes Healthcare Provider).

INSULIN INJECTIONS DURING SCHOOL: Yes No Parent/Guardian elects to give insulin needed at school) If yes, can student: Determine correct dose? Yes No Draw up correct dose? Yes No Give own injection? Yes No Needs supervision? Yes No Insulin Delivery: Syringe/Vial Pen Pump (If pump worn, use “Supplemental Information Sheet for Student Wearing an Insulin Pump”)

Correction Dose of Insulin for High Blood Glucose: Yes No If yes: Regular Humalog Novolog Time to be given: _____________________

Standard daily insulin at school: Yes No Type: Dose: Time to be given: _________ __ ___________ _

Calculate insulin dose for carbohydrate intake: Yes No If yes, use: Regular Humalog Novolog # unit(s) per grams Carbohydrate

Add carbohydrate dose to correction dose

Determine dose per sliding scale below (in units): Blood sugar:_______________ _ Insulin Dose: Blood sugar:_______________ _ Insulin Dose: Blood sugar:_______________ _ Insulin Dose: Blood sugar:_______________ _ Insulin Dose: Blood sugar:_______________ _ Insulin Dose:

Use formula:

(Blood glucose − ____________) ÷

____________ =

units of insulin

OTHER ROUTINE DIABETES MEDICATIONS AT SCHOOL: Yes No Name of Medication Dose Time Route Possible Side Effects

EXERCISE, SPORTS, AND FIELD TRIPS Blood glucose monitoring and snacks as above. Quick access to sugar-free liquids, fast-acting carbohydrates, snacks, and monitoring equipment. A fast-acting carbohydrate such as should be available at the site. Child should not exercise if blood glucose level is below mg/dl OR if _

SUPPLIES TO BE FURNISHED/RESTOCKED BY PARENT/GUARDIAN: (Agreed-upon locations noted on emergency card/nursing care plan)

Blood glucose meter/strips/lancets/lancing device Ketone testing strips Sharps container for classroom

Fast-acting carbohydrate ____ __ Carbohydrate-containing snacks Carbohydrate free beverage/snack

Insuln vials/syringe Insulin pen/pen needles/cartridges Glucagon Emergency Kit

Page 1 of 2

MANAGEMENT OF HIGH BLOOD GLUCOSE (over mg/dl) Usual signs/symptoms for this student: Indicate treatment choices: Increased thirst, urination, appetite Sugar-free fluids as tolerated Tiredness/sleepiness Check urine ketones if blood glucose over mg/dl Blurred vision Notify parent if urine ketones positive. Warm, dry, or flushed skin May not need snack: call parent Other See “Insulin Injections: Correction Dose of Insulin for High Blood Glucose”

Other _________________________

MANAGEMENT OF VERY HIGH BLOOD GLUCOSE (over mg/dl) Usual signs/symptoms for this student Indicate treatment choices: Nausea/vomiting Carbohydrate-free fluids if tolerated Abdominal pain Chcck urine for ketones Rapid, shallow breathing Notify parents per “Emergency Notification” section Extreme thirst If unable to reach parents, call diabetes care provider Weakness/muscle aches Frequent bathroom privileges Fruity breath odor Stay with student and document changes in status Other Delay exercise.

Other _________

MANAGEMENT OF LOW BLOOD GLUCOSE (below mg/dl) Usual signs/symptoms for this child Indicate treatment choices: Hunger Change in personality/behavior If student is awake and able to swallow, Paleness give grams fast-acting carbohydrate such as: Weakness/shakiness 4oz. Fruit juice or non-diet soda or Tiredness/sleepiness 3-4 glucose tablets or Dizziness/staggering Concentrated gel or tube frosting or Headache 8 oz. Milk or Rapid heartbeat Other _ Nausea/loss of appetite Clamminess/sweating Retest BG 10-15minutes after treatment Blurred vision Repeat treatment until blood glucose over 80mg/dl Inattention/confusion Follow treatment with snack of Slurred speech if more than 1 hour till next meal/snack or if going to activity Loss of consciousness Other Seizure Other

SIGNATURES

I/we understand that all treatments and procedures may be performeEMS in the event of loss of consciousness or seizure. I also undersutilized in these treatments and procedures. I have reviewed this infschool health personnel in developing a nursing care plan. Parent’s Signature: Physician’s Signature School Nurse’s Signature:

This document follows the guiding p

Rev

If student is unconscious or having a seizure, presume t

Call 911 immediately and notify parents.

Glucagon ½ mg or 1 mg (circle desired dos

Glucose gel 1 tube can be administered inside chadministration of Glucagon by staff member at sc

Glucagon/Glucose gel could be used if student hswallow.

Student should be turned on his/her side and maintained

Diabetes Medical Management Plan/ Florida Governor’s Diabetes Ad

IMPORTANT!!

he student is having a low blood glucose and:

e) should be given by trained personnel.

eek and massaged from outside while awaiting or during ene.

as documented low blood sugar and is vomiting or unable to

in this “recovery” position till fully awake”.

d by the student and/or trained unlicensed assistive personnel within the school or by tand that the school is not responsible for damage, loss of equipment, or expenses ormation sheet and agree with the indicated instructions. This form will assist the

Date:

Date: __________

Date:

rinciples outlined by the American Diabetes Association

ised December 5, 2003

visory Council Page 2 of 2

Revised February 3, 2003/Florida Governor’s Diabetes Council

DIABETES MEDICAL MANAGEMENT PLAN SUPPLEMENT FOR STUDENT WEARING INSULIN PUMP

School Year __________-________ Student Name: Date of Birth: _____ Pump Brand/Model: ___ ____

Pump Resource Person: Phone/Beeper (See basic diabetes plan for parent phone#)

Child-Lock On? Yes No How long has student worn an insulin pump?

Blood Glucose Target Range: - Pump Insulin: Humalog Novolog Regular

Insulin:Carbohydrate Ratios: ____

(Student to receive carbohydrate bolus immediately before / _____minutes before eating)

Lunch/Snack Boluses Pre-programmed? Yes No Times ____

Insulin Correction Formula for Blood Glucose Over Target: ____

Extra pump supplies furnished by parent/guardian: infusion sets reservoirs batteries dressings/tape insulin syringes/insulin pen

STUDENT PUMP SKILLS NEEDS HELP? IF YES, TO BE ASSISTED BY AND COMMENTS:

1. Independently count carbohydrates Yes No

2. Give correct bolus for carbohydrates consumed. Yes No

3. Calculate and administer correction bolus. Yes No

4. Recognize signs/symptoms of site infection. Yes No

5. Calculate and set a temporary basal rate. Yes No

6. Disconnect pump if needed. Yes No

7. Reconnect pump at infusion set. Yes No

8. Prepare reservoir and tubing. Yes No

9. Insert new infusion set. Yes No

10. Give injection with syringe or pen, if needed. Yes No

11. Troubleshoot alarms and malfunctions. Yes No

12. Re-program basal profiles if needed. Yes No

MANAGEMENT OF HIGH BLOOD GLUCOSE Follow instructions in basic diabetes medical management plan, but in addition: If blood glucose over target range hours after last bolus or carbohydrate intake, student should receive a correction bolus of insulin using formula; Blood glucose - ÷ = units insulin

If blood glucose over 250, check urine ketones 1. If no ketones, give bolus by pump and recheck in 2 hours. 2. If ketones present or , give correction bolus as an injection immediately and contact parent/ health care provider

If two consecutive blood glucose readings over 250 (2 hrs or more after first bolus given) 1. Check urine ketones 2. Give correction bolus as an injection 3. Change infusion set. 4. Call parent

MANAGEMENT OF LOW BLOOD GLUCOSE Follow instructions in Basic Diabetes Care Plan, but in addition:

If low blood glucose recurs without explanation, notify parent/diabetes provider for potential instructions to suspend pump.

If seizure or unresponsiveness occurs:

1. Call 911 (or designate another individual to do so). 2. Treat with Glucagon (See basic Diabetes Medical Management Plan) 3. Stop insulin pump by:

Placing in “suspend” or stop mode (See attached copy of manufacturer’s instructions) Disconnecting at pigtail or clip (Send pump with EMS to hospital.) Cutting tubing

4. Notify parent 5. If pump was removed, send with EMS to hospital.

ADDITIONAL TIMES TO CONTACT PARENT Soreness or redness at infusion site Detachment of dressing/infusion set out of place Leakage of insulin

Insulin injection given Other

Effective Date(s) of Pump plan:

Parent’s Signature: ________ Date:

School Nurse’s Signature: Date:

Diabetes Care Provider Signature: Date:

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Student Services Nursing Care Plan for Lake County Schools

Name Sex Date of Birth School Grade Parents Parent’s Phone Work Phone Date of Report Reason for Referral

Seizure Disorder A seizure is a sudden uncontrolled episode of excessive electric discharge of brain cells; this discharge is accompanied by sensory motor or behavioral changes. Some of the most common types of seizures are: Absence, Generalized, Tonic-Clonic, Simple partial, and Complex partials. A child with seizures may have more than one type of seizure and the type and pattern of seizures can change at any time. Seizures may occur only during the day, only during the night, day and night, during relaxation or during activity. They may be few and far between or may occur many times during one day.

□ Doctor’s order for activity restriction. Specify:

□ Medication at school_________________________________________________________

□ Medication at home__________________________________________________________ Nursing Diagnosis: Risk of injury related to seizure activity Goal: Student will remain free of injury related to seizure activity. Nursing Diagnosis: Risk for excessive mucus that may result in airway obstruction. Goal: Students airway will remain clear of obstruction.

10/14/09 2 of 3

□ Generalized Seizure Signs and symptoms of a generalized seizure: loss of consciousness, followed by stiffening (tonic) for a few seconds, followed by jerking (clonic). This may last less than one minute to three minutes.

Interventions

1) Keep calm, stay with child, call for assistance. 2) Place the student in a side lying position if possible, avoid holding student down. 3) Cushion head with your hand or a pillow. 4) Move furniture and hazardous objects out of the way. 5) Loosen clothing around neck and waist. 6) Monitor breathing. 7) Nothing should be placed in the mouth. Avoid giving anything by mouth.

Following Seizure Activity 1) Allow student to lie quietly in a darkened environment for 30 minutes or more. 2) Student may be confused following the seizure. 3) Explain to the student he/she had a seizure. 4) Allow student to change clothes if needed. 5) Student may resume classroom activities after recovery period. 6) Notify the parent of the seizure. 7) Complete seizure observation form.

□ Partial Seizures Signs and symptoms of partial seizures: consciousness is not loss, the student is aware that the seizure is occurring. They may have hand, mouth, and eye movements, pick at clothes, or yell out. It may progress to a generalized seizure.

Interventions 1) Speak calmly and reassuringly to the student. 2) Guide the student away from hazards. 3) Help student obtain missed information and assignments. 4) Notify parents. 5) Complete seizure observation form.

□ Absence Seizures Signs and symptoms of a absence seizure: 1-10 second loss of consciousness, staring spells, eye blinking, mild facial twitching and the appearance of day dreaming.

Interventions 1) No action required. 2) Report the event to the parents if it is the first episode. 3) Help student obtain missed information.

10/14/09 3 of 3

If an emergency occurs: 1) Stay with child. 2) Call or designate someone to call the nurse or first responder. 3) State who you are, where you are located, and the problem. 4) The nurse or first responder will assess the student and decide if the emergency

procedures should be implemented. 5) If a nurse is not available the following staff members have been trained to deal with an

emergency, and to initiate the emergency plan. 1. 2. 3. 4. 5. 6. Reasons to call 911

1) Seizure that last longer than 5 minutes. 2) Slower than usual recovery after the seizure. 3) A second seizure. 4) Difficulty breathing. 5) Any signs of injury. 6) Pregnancy 7) One seizure followed by another before recovery.

Fire / Emergency / Evacuation Classroom teacher/designee or responsible adult who is in the room at the time of fire drill or emergency is responsible for the evacuation of all students. Additional Intervention: Physician’s signature Date Parent signature Date Nurse signature RN Date Must be reviewed at least annually by RN