MEDICATION DISPOSAL

Policy:

Medication disposal should follow federal and state laws for all prescription, controlled, vitamins, minerals, herbal supplements and over-the-counter medications.

Practice:

Medications that are no longer needed by the student, have been discontinued, and are unable to be returned to the pharmacy should be disposed of according to applicable laws and guidelines. The Office of National Drug Control Policy (ONDCP) and the Environmental Protection Agency (EPA) jointly released guidelines for disposal of prescription medications. Controlled Substances must be destroyed so that they are unusable by another person to prevent diversion of the drugs.

d. Two nurses will verify the medications being disposed of and a
documentation of the disposal will be kept in the controlled
substance logbook.

e. Two nurses will then place all medications to be disposed of into a
2-millimeter, zip-lock bag. Hot tap water will then be added and
bag sealed. Let the medications dissolve for 5-15 minutes before
adding Absorb-all. Manipulate the sealed bag and its contents until
all moisture is absorbed.

f. Place the sealed bag and its contents into a garbage container in
the nursing area. Housekeeping can then discard the garbage bag
into the campus dumpster.

9. The 2-millimeter, zip-lock bags should be obtained through the food service supplier (Eastern Bag Company).

10. The Absorb-All should be obtained through the maintenance department supplier (Burnell Auto Parts).

1. Student Vacations/Leaves
Upon notification of an upcoming leave or student vacation, nursing orders a supply of medication from the pharmacy for the length of the leave plus two extra days to cover loss, spillage or extra days added onto the leave. Nursing packs medications and documents all those sent on the Medication Administration Log
All medications and instructions will be reviewed by nursing with staff or parent responsible for transport. Staff will review with parent/guardian upon arrival for visit.
When student travels unaccompanied, one of the three following options will be exercised:
Prescription for vacation medications will be mailed to student’s parent/guardian in time for it to be filled at a local pharmacy. A copy of the student’s insurance card will be sent with the prescription.
In an emergency, and as permitted by state law, physician may call prescription in to local pharmacy.
Medications can be mailed via Federal Express overnight service. Parents should be notified as to when medications are due to arrive.

2. Procedure for Dispensing by Non-Licensed Personnel
Medications cannot be dispensed by unlicensed personnel without their successful completion of the “Medication Certification Program” given by HEC registered nurses.
Staff will supervise medication administration only when an off-campus trip is necessary and student involved is unable to return to campus at medication time or when a nurse is not available.

Procedure for certifying staff is as follows:
1) Staff must have been employed by Hillcrest Educational Centers for at least three months to be considered for certification. He/she must have current certification in First Aid and CPR.
2) The decisions about whom to credential will be made by the head nurse of each campus after having consulted with the Program Director/Manager, supervisors, and others who might be in a position to evaluate the capabilities of that staff member.
3) Only R.N.s may certify staff.
4) Training sessions for certifying staff will include:
a) Review of medication procedure by nurse trainer.
b) Administration of test to staff: Staff must pass test with 100% correct score. If staff fails to pass test, nurse trainer may review missed material and re-administer test one time. If second attempt failed, staff must wait for at least one month and begin procedure again. If, after one month staff fails test again, he/she will no longer be considered eligible for credentialing.
5) When staff successfully passes training, nurse trainer will complete the “Certificate of Credential and Privilege to Supervise Medication Administration. Trainer will keep that record with guidelines in a special file in the nurses’ station. A copy of the certificate, along with guidelines will also be kept in the staff’s personnel file. Training coordinator should be notified of training. Recertification takes place on a yearly basis.

6) In the event that certified staff fails to follow medication procedure, an incident report and Medication error report must be filled out by the staff involved in the incident. Immediate notification of the circumstance must be provided to the supervisor on duty and the nursing department. Depending on the nature of the error and the staff understanding, certification can be withdrawn at any time.

3. Medication Refusal
When a student has failed or refused to take his/her medication, the refusal is documented in the student’s record, including the student’s stated rationale for refusing. When indicated, the nurse notifies the prescribing physician. The neurologist is notified of all refusals involving anti-convulsant medication. In addition, direct care staff is informed of any related safety concerns.

– are to be up-dated according to Mass State Regulations, which follow.

Immunizations

Immunization Catch Up Schedule

As Ordered by the Physician or At Nurses Discretion

A. Level One – Complete Bed rest

1. OOB to bathroom only.
2. Must remain in bed for all meals.
3. Assessment every 3-4 hours.
4. Limited visitors.

B. Level Two – Partial Bed rest

1. OOB to bathroom and for meals.
2. May intermittently engage in watching T.V., and other sedentary activities in the lounge area.

C. Level Three – Partial Activity

1. May attend classes.
2. May participate in all sedentary program activities.
3. May NOT participate in Gym, ABC, Sports, NYPUM or Off Campus Activities.

A. Falls

1. For all falls from greater than a height of 15 feet, encourage the student to lie still.
2. Assess for obvious injuries and treat with appropriate first aid
3. Keep child calm and call an ambulance for transport.

B. Strains / Sprains / Possible Fractures

1. Review history of injury
2. Assess alignment, ROM, and point of tenderness. Document distal pulse and sensation.
3. Apply ice.
4. Immobilize and elevate injured part, using pillows for support.

5. Use Ibuprofen or acetaminophen as directed by the manufacturer Call Physician if indicated and / or seek emergency care

A. Rashes / Acne / Skin Infections

1. When symptoms are observed, a complete skin assessment is necessary.
2. Review medication regimen, diet, and environmental factors.
3. Apply OTC ointments as indicated , observe for improvement
4. For acne, gently wash with anti-bacterial soap twice per day. Apply appropriate topical medication afterwards.
5. If assessment reveals impetigo or mild cellulitis, scrub area gently with antibacterial soap, apply antibiotic ointment BID and cover with a dry dressing. Instruct student and staff on necessary precautions to avoid spread of infection. Examine patient on a daily basis. Report findings to Physician.

B. Bites (Human)

1. Encourage bleeding if the skin is broken.
2. Cleanse with soap and warm water for 8 to 10 minutes.
3. Apply a dry sterile dressing.
4. Assess hepatitis status of both students involved
5. Report incident to the Physician and follow exposure procedure below:

1. The Campus Nursing Department will contact the Guardians of both students and inform them of the incident.
2. The Campus Nursing Department will attempt to obtain Consent from the Guardians for HIV testing as recommended by HEC pediatrician.
3. Documentation of the incident and notification of the physician, will be added to the student’s Progress Notes. The HIV testing report will be placed in a sealed envelope, labeled as confidential and placed in the “laboratory” section of the chart. Any medical follow-up will be coordinated by the physician.

C. Scratch; Break in Skin Integrity
Protocol following a break in skin integrity between students or student/staff.

Due to the possible complications from any break in skin integrity it is imperative that employees take appropriate measures to minimize exposures to blood for both students and staff.

Following a break in skin integrity:

Students:
4. Student should wash their hands with soap and water thoroughly if they were scratching, paying special attention to under the fingernails.
5. Check student for any broken skin areas; these areas should be cleaned with soap and water, and treated with a topical antibacterial cream/ointment.
6. Document the incident and any injuries to students.

Staff:
3. Staff should wash all abrasions, scratches, or broken skin areas thoroughly with soap and water, if available apply antibiotic cream.
4. Staff must complete an ART form to be filed with AO, regardless of the seriousness of the injury. This documents the injury in case a complication occurs.

When dealing with a student who is known to scratch as a defense or mode of aggression, staff should take appropriate precautions to protect themselves. Some suggestions would be to wear long sleeve shirts and pants, the use of gloves (vinyl or padded) or changing the positioning of student’s hands to minimize the ability to scratch skin.

D. Puncture Wounds

1. Assess bleeding, need for sutures or foreign body
2. Soak wound with antibacterial soap and water.
3. Apply antibiotic ointment with dressing.
4. Check status of Tetanus Immunization.
5. Monitor daily for possible signs of infection. Notify physician as needed.

E. Burns

1. 1st Degree- injury to top skin layer causing redness, pain and minor swelling healing in 3-6 days– cool compress / aloe or burn gel topically/ Tylenol or Motrin for pain
2. 2nd Degree- injury to skin layers beneath the top layer producing blisters, severe pain and redness with healing taking up to 2-3 weeks– cool compress / bacitracin or Silvadene topically followed by a sterile dressing. Do not puncture blisters. Monitor daily at dressing change for signs of infection. (SILVADENE SHOULD NOT BE USED FOR PATIENTS WITH SULFA ALLERGY ) Notify Physician.
3. 3rd Degree- injury to all the layers of the skin and underlying tissue making the skin appear waxy, leathery or brown– cool sterile compress. Transport to ER; notify Physician.

F. Eczema

1. Shower with tepid water once or twice a day.
2. Use mild soap (Dove unscented or generic equivalent).
3. Pat dry.
4. Apply topical prescription meds if any.
5. Apply hypo-allergenic moisturizer.
6. Notify physician if worse or no improvement in 2 weeks.

A. Painful or difficulty Urinating

1. Assess symptoms to include frequency, type of discomfort and duration. Obtain vital signs.
2. Obtain clean catch urine.
3. Dip urine or send to lab for urinalysis. If positive leucocyte esterase or the presence of WBCs are noted in the dip or urinalysis, send for culture. Report the results to M.D.

B. Nocturnal Enuresis Protocol

Nocturnal enuresis is repeated, accidental bed-wetting during the night. Children will vary in the age at which they are physically ready to have complete control over their bladders. About thirty percent of 4 year olds, ten percent of 5 year olds, five percent of 10 year olds, and one percent 18 year olds wet the bed.

a. Of those children with night time wetting, only a small proportion (~ 1-2%) have a problem that requires medical attention. Such medical conditions may include anatomical abnormalities, chronic infections, nerve abnormalities or diabetes.
b. Symptoms that may indicate an underlying medical condition include persistent or new wetting, painful or difficult urination and constant thirst.
It is important for team members to notify the medical department if a student develops any new symptoms.

c. Nocturnal enuresis may also have psychological causes, as bed-wetting tends to be more common in children who have suffered traumatic or stressful life experiences.

4. Protocol:
a. After the initial evaluation, which includes a visit with the pediatrician, psychiatrist and urine specimen for testing, each student will be educated about the nature of nocturnal enuresis and possible treatments including alarms and or medications. Education will be provided in an individualized manner by either a nurse or professional. Youth Development Professionals involved in student’s care will also have an opportunity to review specifics of treatment plan with team.
b. Extra linen and a way to discreetly dispose of dirty linens will be provided for each student.
c. Student should avoid all carbonated drinks, caffeine or chocolate containing drinks throughout the day. These have been associated with bladder irritation and/or increased urine production and may make bed-wetting worse.
d. Student should restrict fluids of all kinds after 7 PM. ~ 4 oz. of water or juice with medication or during athletic events is acceptable.
e. All students should empty their bladder just prior to going to bed.
f. “Tripping” at certain times through the night should ideally be coordinated with the student and team
g. When a student wets the bed (e.g. student wakes on own or bed-wetting alarm goes off), student should be encouraged to change clothes and sheets as well as shower. This will decrease urine smell and help preserve student’s self-esteem.
h. Behavior modification plan will reward dry nights as well as cooperation with changing wet bedding, restricting fluids, and emptying bladder before bed. This may be worked into student’s motivational plan from discussions in team.

6. Treatment:

Treatment of nocturnal enuresis can be difficult and usually involves a multifaceted approach that includes all members of the treatment team. Various combinations of suggested interventions may be necessary to support the student’s individual needs. Options regarding the use of alarms and medications along with staff support in waking and maintaining a clean environment should be discussed and changed when indicated.
In extremely difficult cases, it may be appropriate to have a student wear pull-ups while sleeping. This might be necessary after other measures had been exhausted and only with involvement of student and student’s guardian.

A. Simple Nausea without Vomiting

1. Assess general condition
2. Avoid irritating diet, ASA, spicy foods, hot sauce, and cold drinks.
3. Encourage appropriate fluids.
4. Maalox 10-15cc may be used as directed.

B. Vomiting

1. Assess possible cause, general associated symptoms, and temperature.
2. Observe amount, quantity, and duration.
3. Keep NPO, x2 hours, then give clear fluids and advance, as tolerated.
4. If vomiting persists, or if there is evidence of abdominal pain, fever, headache, dehydration, or diarrhea, notify physician.

C. Abdominal Pain

1. Assess for location, intensity, duration of discomfort, and any additional symptoms such as painful urination, flank pain, cough, or sore throat.
2. Take vital signs.
3. Palpate for tenderness or rigidity; listen for bowel sounds
4. Ascertain B.M. status and, if appropriate, date of LMP.
5. Obtain and process urine specimen (urine dip, culture) if urinary frequency or discomfort is noted.
6. Notify physician of prolonged pain, rebound tenderness, fever, abnormal U/A or any other concerning symptoms.
7. Ibuprofen may be used, as directed, for menstrual discomfort.

D. Constipation

1. Assess bowel status and bowel sounds; review medication regime.
2. Take temperature.

3. If no bowel movement in 48 hours, administer M.O.M. 15 to 30 cc .
4. If no results are evidenced in 10-12 hours repeat dose Notify the Physician if MOM not beneficial for fiber supplement or stool softener.
5. Increase fluids .
6. Encourage a high fiber diet (limit bananas).

E. Diarrhea

1. Assess frequency and quantity, of B.M.
2. Review medication regime and food intake in the last 24 hours.
3. Take temperature.
4. Encourage a bland, binding diet with adequate fluid intake x24 hours and advance as tolerated.
5. If symptoms persist or if there is any evidence of fever, tiny firm stools, or stools with frank blood or mucous, report to Physician immediately. Explosive diarrhea [9-10 episodes in 3-4 hours] should be reported immediately.

A. Cough/ URI

1. Assess cough.
2. Auscultate chest sounds, examine ears, throat, and cervical nodes.
3. Take temperature and respiration rate.
4. Review PMH for asthma or allergies.
5. If cough is productive and interfering with sleep or daily activities may administer generic Robitussin or Mucinex as noted in the medication list..
6. If cough is non-productive and interfering with sleep or daily activities may administer generic Robitussin DM or Mucinex Das noted in the medication list.
7. If cough is accompanied by chest pain, fever, back pain, or an abnormal lung exam (wheezes, rales or rhonchi) notify physician.

B. Nasal Congestion and Allergies

1. Assess symptoms
2. Encourage fluids and rest as deemed appropriate.
3. If cough or congestion interferes with sleep or activities and physical exam is otherwise normal, may offer Chlortrimeton, Claritin, Mucinex D or Sudafed, as recommended for age / weight.
4. Observe patient, and notify physician if symptoms continue for greater than 10 days, or, within 24 hours if there is fever or patient’s symptoms are worsening.

C. Allergic Reactions

.
1. Mild localized reaction (swelling, itching, redness or hives) may apply ice to site or give appropriate dose of Benadryl. Observe for any signs of systemic reaction for 12-24 hours. May also apply topical remedies such as calamine or hydrocortisone 1%.

D. Asthma

1. Follow patient’s treatment plan for use of inhalers if already in existence.
2. Obtain vital signs, including peak flow measurement.
3. Listen to breath sounds and audible wheezing; observe for retractions or respiratory distress.
4. If no treatment plan, and mild, have patient rest with continued monitoring.
5. Give ventolin/albuterol inhaler if ordered.
6. Notify physician.

Flu recommendations, treatment and procedures
(also see Chapter 8, Infection Control)

These ways to prevent the spread of flu illness should be noted and encouraged at every opportunity. These steps include:

• Cover your cough or sneezes into a tissue or inside of arm, not your hands, dispose of the tissue
• Avoid touching your eyes, nose and mouth
• Wash your hands frequently with soap and water or hand sanitizer
• Stay home if you are sick with fever over 100.4F
• Clean surfaces such as desks, tables, counters, and door knobs with antibacterial solutions

On the occasion that the flu reaches our students these procedures should be followed:

• All students will be observed for the following symptoms: fever above 100.4 F, cough, sore throat, body aches, headache, chills and fatigue
• When these symptoms occur, every effort will be made to isolate the student in their room or a designated infirmary area on campus (to be determined by PD and Head Nurse)
• Staff who are assigned to be with ill students will be provided with N95 masks, gloves and disinfectant wipes
• Observation of symptoms will continue. If the BMC diagnostic criteria for testing is fulfilled or if ordered by the physician, then a nasopharyngeal swab will be obtained and sent to BMC Lab
• MC lab will test the swab for Influenza A virus (results available within 24 hours), if present, a repeat specimen will be obtained and submitted to the State lab for subtyping
• Dr. Dempsey will be notified at which time anti-viral treatment may be initiated according to his orders
• If the testing does not reveal type A flu, isolation is not necessary. However, bed rest may be indicated depending on current symptoms assessed by the nurse on duty.
• Symptomatic treatment by staff and nursing will continue throughout the illness. This may include: Tylenol/ ibuprofen, fluids and rest.
• Documentation of information will be completed by nursing on the Student Isolation Log. This information will be used to follow isolation and testing processes. (see attached)
• Staff will use the Student Monitoring Sheet to record pertinent information for each student in the isolation room. (see attached)
• The Head Nurses at each campus will make daily decisions on the students entering and leaving the isolation infirmary area.
• Updates on available information will be relayed to staff in Community Meetings
• Decisions on limiting travel or visitation on and off campus will be made by the SMT

Supplies to have on hand:
Anti-bacterial wipes
N 95 Masks
Gloves
Tissues
Nasopharyngeal swabs
Ibuprofen/Tylenol
Ginger ale
Sports drink/ other clear fluids

A. Influenza Diagnostic Testing

Specimen kits to collect nasopharyngeal samples for Influenza A and B testing are available from the hospital’s main laboratory. The test detects both A and B disease; results will be available within 24 hours.

More specific testing is available from the State laboratory and will be sent to a referral lab. Each site should keep 2 – 3 kits on hand.

Berkshire Pathology Services will continue to send specimens by request to a reference laboratory for influenza and respiratory pathogen testing. Any respiratory specimens are acceptable for the reference laboratory. Please contact the microbiology laboratory for any questions regarding this or other testing for viral diagnosis.
Influenza
Flu recommendations, treatment and procedures
(also see Chapter 8, Infection Control)

These ways to prevent the spread of flu illness should be noted and encouraged at every opportunity. These steps include:

• Cover your cough or sneezes into a tissue or inside of arm, not your hands, dispose of the tissue
• Avoid touching your eyes, nose and mouth
• Wash your hands frequently with soap and water or hand sanitizer
• Stay home if you are sick with fever over 100.4F
• Clean surfaces such as desks, tables, counters, and door knobs with antibacterial solutions

On the occasion that the flu reaches our students these procedures should be followed:

• All students will be observed for the following symptoms: fever above 100.4 F, cough, sore throat, body aches, headache, chills and fatigue
• When these symptoms occur, every effort will be made to isolate the student in their room or a designated infirmary area on campus (to be determined by PD and Head Nurse)
• Staff who are assigned to be with ill students will be provided with N95 masks, gloves and disinfectant wipes
• Observation of symptoms will continue. If the BMC diagnostic criteria for testing is fulfilled or if ordered by the physician, then a nasopharyngeal swab will be obtained and sent to BMC Lab
• MC lab will test the swab for Influenza A virus (results available within 24 hours), if present, a repeat specimen will be obtained and submitted to the State lab for subtyping
• Dr. Dempsey will be notified at which time anti-viral treatment may be initiated according to his orders
• If the testing does not reveal type A flu, isolation is not necessary. However, bed rest may be indicated depending on current symptoms assessed by the nurse on duty.
• Symptomatic treatment by staff and nursing will continue throughout the illness. This may include: Tylenol/ ibuprofen, fluids and rest.
• Documentation of information will be completed by nursing on the Student Isolation Log. This information will be used to follow isolation and testing processes. (see attached)
• Staff will use the Student Monitoring Sheet to record pertinent information for each student in the isolation room. (see attached)
• The Head Nurses at each campus will make daily decisions on the students entering and leaving the isolation infirmary area.
• Updates on available information will be relayed to staff in Community Meetings
• Decisions on limiting travel or visitation on and off campus will be made by the SMT

Supplies to have on hand:
Anti-bacterial wipes
N 95 Masks
Gloves
Tissues
Nasopharyngeal swabs
Ibuprofen/Tylenol
Ginger ale
Sports drink/ other clear fluids

A. Influenza Diagnostic Testing

Specimen kits to collect nasopharyngeal samples for Influenza A and B testing are available from the hospital’s main laboratory. The test detects both A and B disease; results will be available within 24 hours.

More specific testing is available from the State laboratory and will be sent to a referral lab. Each site should keep 2 – 3 kits on hand.

Berkshire Pathology Services will continue to send specimens by request to a reference laboratory for influenza and respiratory pathogen testing. Any respiratory specimens are acceptable for the reference laboratory. Please contact the microbiology laboratory for any questions regarding this or other testing for viral diagnosis.

Comparative Profiles Of Antiviral Agents For Influenza

	Amantadine	Rimantadine	Zanamivir (Relenza)	Oseltamivir (Tamiflu
Influenza Viruses Inhibited	A	A	A and B	A and B
Route of Administration	Oral (tablet, capsule, syrup)	Oral (tablet, Syrup)	Oral Inhalation (Diskhaler)	Oral (Capsule)
Usual Adult Dosage	100mg bid x 5d	200mg qd or 100mg bid x5d	100mg bid x5d	75mg bid x5d*
Approved age For treatment	Greater than 1 year	Greater than 14 yrs	Greater than 7 yrs	Greater than 1 year
Approved age for Prophylaxis	Greater than 1 year	Greater than 14 yrs	Greater than 7 yrs	Greater than 1 year
Adverse Effects	CNS side effects; Increased risk of seizures in pts with history of seizures	CNS side effects (less than with Amantadine	Reduced FEV or peak expiratory flow rate in pts with underlying respiratory disease	Nausea and vomiting

Student Flu Monitoring Sheet

Student Isolation Log

Medical management of head injuries/concussion is evolving. In recent years, there has been a significant amount of research into concussion in school-aged children especially when participating in sports. HEC has established this protocol for staff and school personnel to provide education and guidance about head injuries and concussion. This protocol outlines procedures for staff to follow in managing head injuries, and outlines school policy as it pertains to return to play/gym.

HEC seeks to provide a safe return to activity for all students after injury, particularly after any head injury. In order to effectively and consistently manage these injuries, procedures have been developed to aid in ensuring that head injured/ concussed students are identified, treated and referred appropriately, receive appropriate follow-up care and academic assistance, and are fully recovered prior to returning to activity.

All staff will attend a yearly online training in which procedures for managing these injuries are reviewed.

Contents:
I. Recognition of head injuries/concussion
II. Management and referral guidelines for all staff
III. Follow-up care during the school day
IV. Guidelines and procedures for coaches
V. Return to play procedures

I. Recognition of concussion

A. Common signs and symptoms of concussion

Signs (observed by others):

• Student appears dazed or stunned
• Confusion (about assignment, plays, etc.)
• Forgets plays or personal details
• Unsure about game, score, opponent, class, staff or peers
• Moves clumsily (altered coordination)
• Balance problems
• Change from baseline or typical mood and behavior
• Responds slowly to questions
• Forgets events that occurred before hitting head
• Forgets events that occurred after hitting head
• Loss of consciousness (any duration)

Symptoms (reported by student):

• Headache
• Fatigue, drowsiness
• Nausea or vomiting
• Double vision, blurry vision
• Sensitive to light or noise
• Feels sluggish
• Feels “foggy”
• Problems concentrating
• Problems remembering
• More emotional than usual

Concussion DANGER SIGNS:

• One pupil larger than the other
• Drowsy or unable to wake up
• Worsening headache
• Weakness, numbness
• Repeated vomiting or nausea
• Slurred speech
• Seizures
• Unable to recognize people or places
• Increasing confusion, restlessness or agitation
• Loss of consciousness

These signs and symptoms are indicative of probable concussion. However, other causes for symptoms should also be considered.

II. Management and Referral Guidelines for All Staff

A. Suggested Guidelines for Management of Head Injury/Concussion

1. Any student with a witnessed loss of consciousness (LOC) of any duration should not be moved and transported immediately to nearest emergency department via emergency vehicle.

2. Any student who has symptoms of a concussion, and who is not stable (i.e., condition is changing or deteriorating), is to be transported immediately to the nearest emergency department via emergency vehicle.

3. A student who exhibits any of the following symptoms should be transported
immediately to the nearest emergency department, via emergency vehicle.
a. deterioration of neurological function (E.g., difficulty responding to verbal stimulation, inability to follow commands, decreased muscle tone, and abnormal movements)
b. decreasing level of consciousness
c. decrease or irregularity in respirations/breathing
d. decrease or irregularity in pulse
e. unequal, dilated, or nonreactive pupils
f. any signs or symptoms of associated injuries, spine or skull fracture, or bleeding (E.g, bleeding or clear drainage from ears or nose, pain in head or neck, inability to move extremities)
g. mental status changes: lethargy, difficulty maintaining alertness, confusion or agitation
h. seizure activity

4. A student who is symptomatic but stable, may be transported by HEC staff. Staff should consult with the nurse on duty/call as to the place of care (primary care physician, or the nearest emergency department). The student’s guardian should be notified about the injury and the plan of treatment.

III. CARE OF THE STUDENT DURING THE SCHOOL DAY

A. Responsibilities of the school nurse after notification of student’s head injury/concussion

1. Evaluate the student utilizing a graded symptom checklist every 15 minutes for at least 30 minutes.
a. provide an individualized health care plan based on both the student’s current condition, and initial injury information

2. If signs and symptoms are present, refer the student to appropriate medical personnel right away. Send a copy of the checklist.

3. If signs and symptoms are not present, the student can return to class but not to physical activity. Continue to observe student in residence and school for any changes. Notify the nurse of any changes immediately.

4. Notify the student’s guardian of the injury and plan of treatment.

5. Monitor the student on a regular basis. Communicate any special accommodations or plans recommended by the physician

IV. Guidelines and procedures for coaches:

RECOGNIZE, REMOVE, REFER

A. Recognize concussion
All coaches should become familiar with the signs and symptoms of concussion
that are described in section I.

B. Remove from activity
If a coach suspects the athlete has sustained a concussion or exhibits signs or symptoms, the athlete should be removed immediately from activity until evaluated medically. The athlete should not return to physical activity that day.

C. C. Refer the athlete for medical evaluation
Coaches should report all head injuries to the nurse on duty/call, as soon as possible, for medical assessment, management, and coordination of instructions for follow-up care.

If at an away contest, Coaches should seek assistance from the host site medical personnel. Review any recommended treatments with HEC nurse by phone. The student’s guardian should be notified.

a. If there is any question about the status of the athlete, or if the athlete cannot be monitored appropriately, the athlete should be referred to the emergency department for evaluation. A staff should accompany the athlete and remain with the athlete until treatment is completed.
b. Athletes with suspected head injuries should not be permitted to enter the game even if they are not having any symptoms.

V. RETURN TO PLAY (RTP) PROCEDURES AFTER CONCUSSION

A. Returning to participate on the same day of injury

1. As previously discussed in this document, a student who exhibits signs or symptoms of concussion, should not be permitted to return to play or other activities on the day of the injury.

2. “When in doubt, hold them out.”

B. Return to play after concussion

1. The student must meet all of the following criteria in order to progress to activity:

a. Asymptomatic at rest and with exertion (including mental exertion in school) AND:
b. Have written clearance from primary care physician or specialist.

2. Once the above criteria are met, the student will be progressed back to full
activity following a stepwise process.

3. Progression is individualized, and will be determined on a case by case basis by the nurses.
Factors that may affect the rate of progression include:
• previous history of concussion,
• duration and type of symptoms,
• age of the student, and
• sport/activity in which the student participates.

A student with a prior history of concussion, one who has had an extended duration of symptoms, or one who is participating in a collision or contact sport should be progressed more slowly.

4. Stepwise progression:

a) No activity – do not progress to step 2 until the student has absolutely NO symptoms
b) Light aerobic exercise like walking or riding a stationary bike; if no symptoms then progress to “c”
c) Sport-specific training and gym class which is an increase in activity (e.g., playing basketball, running in soccer or participating in gym); if no symptoms- progress to “d”
d) Non-contact training drills or activity for extended periods of time; if no symptoms-progress to full activity
e) Full-contact training and activity after medical clearance and absence of any symptoms

Note: If the student experiences post-concussion symptoms during any phase, the athlete should drop back to the previous asymptomatic level and resume the progression after 24 hours.

Remember the symptoms you might observe and would prohibit advancement of activity are:
headache, fatigue, drowsiness, nausea, blurry vision, feeling sluggish or “foggy,” problems concentrating in class or problems remembering.
Call the nurse if any symptoms reoccur.

D. Seizure

What to DO During a Seizure:

1. Keep Calm. Ease the person to the floor, if they are standing or sitting. (If in bed, do not move).
2. If possible, clear the area of other students, non-essential staff and obstacles.
3. DO NOT restrain the child’s movements. Loosen his / her clothing. Keep him / her away from any harmful objects. DO NOT force his / her mouth open. DO NOT force anything between his / her teeth. If possible turn the child on his / her side to release secretions from mouth. Observe neck precautions if there is any possibility of head trauma.
4. Treat the occurrence matter-of-factly, and explain to the other children / staff that there is no danger, that the child will not hurt him / herself, and that the seizure will be over in a few minutes.
5. After the seizure stops, and the child appears to be relaxed, let him / her sleep or rest quietly in a place where he / she will not be disturbed.
6. All seizures are to be considered important, and reported immediately to the Nursing Staff.
7. In describing the seizure to Supervisory Personnel, staff should try to be as accurate as possible. An accurate description of any seizure is important to the Physician treating the child. There is a form for reporting the event, which is kept in the Supervisor’s Office.
(See Attachment E)
8. EMS should be called:
• If the seizure lasts more than five minutes
The person has one seizure after another without gaining consciousness between episodes if the seizure stops, but the person does not regain consciousness within 10-15 minutes

E. Fever

1. Assess for additional symptoms – level of alertness, respiratory, GI, or GU symptoms, complaints of pain, chills, or the presence of any infected skin lesions.
2. Temperatures above 101 Degrees, should be recorded every 4 hours. Elevated temperatures at or above 103 Degrees, need to be recorded every 3 hours.
3. For temperatures of 101 Degrees and above, administer acetaminophen every 4-6 hours or ibuprofen every 6-8 hours. Encourage increased fluid intake.
4. Notify Physician for any fever over 101 >24 hours OR if there are additional concerning symptoms at any time.
5. A cool washcloth may be applied to the child’s forehead for comfort.

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