A. Headache

1. Mild headaches may be treated with acetaminophen or ibuprofen for 24 hours. Dosing per manufacturers guidelines.
2. Any headache that is severe, persists for more than 24 hours, or is accompanied by stiff neck or vomiting, should be reported to the physician.

B. Fainting / Lightheadedness / Dizziness

1. Place student in dorsal recumbent position.
2. Elevate feet.
3. Obtain vital signs including postural blood pressure and heart rate.
4. Hydrate
5. Notify Physician.

Note: M.D. and Psychiatrist to be notified of ER trips

Standing medication orders:

Acetaminophen (Tylenol) – Indicated for temporary reduction of fever or for relief of minor aches and pains.
Adults and children over 12: Regular strength (325 mg) Take two tablets every 4-6 hours as needed not to exceed more than 12 tablets in 24 hours.
Children: 48 to 59 pounds: 6 to 8 years: 320 mg
Children: 60 to 71 pounds: 9 to 10 years: 400 mg

Antacids- Indicated for the relief of heartburn, acid indigestion, and stomach upset.
Liquid- Adults and children over 12: take 2-4 teaspoons between meals and at bedtime. No more than 24 teaspoons in 24 hours.
Tablets- Chew 2-4 tablets between meals and at bedtime. No more than 24 tablets in 24 hours.

Benzoyl peroxide- Indicated for the treatment of acne. It can be used alone or with other treatments, including antibiotics and products that contain retinoic acid, sulfur, or salicylic acid.
Cleanse skin thoroughly prior to applying a thin layer to affected area once daily, may increase to 2-3 times if needed. Decrease applications if dryness or peeling occurs. Use sunscreen when outside.

Chlortrimeton (chlorpheniramine maleate) – Indicated for temporary relief of allergy/ hay fever symptoms. This may include runny nose, itchy, watery eyes, and sneezing.
Adults and children over 12: one tablet every 4-6 hours; not to exceed 6 doses in 24 hours
Children 6-12 years: ½ tablet every 4-6 hours; not to exceed 6 doses in 24 hours

Claritin (loratadine)- indicated for the relief of nasal and non-nasal symptoms of seasonal allergic rhinitis and for the treatment of chronic idiopathic urticaria in patients 2 years of age or older.
Adults and children 6 years of age and over: The recommended dose of claritin is one 10 mg tablet or reditab, or 2 teaspoonfuls (10 mg) of syrup once daily.

Colace (ducosate sodium)- indicated for the relief of constipation, irregularity.
Adults and children over 12: Take 1-2 (100-200) softgels daily until first bowel movement, 1 softgel thereafter.

Debrox (carbamide peroxide)- Indicated to soften, loosen and remove ear wax.
Adults and children over 12: Tilt head to the side, place 5-10 drops into ear canal. May use twice daily as needed. May gently flush canal with warm water to remove remaining wax.

Diphenhydramine- Indicated for the relief of runny nose, itchy watery eyes, itchy throat and non-anaphylactic allergic reactions.
Adults and children over 12: 25-50 mg every 4-6 hours not to exceed 6 doses in 24 hours.
Children 6-12 years: 12.5- 25 mg every 4-6 hours not to exceed 6 doses in 24 hours.

Hydrocortisone 1% cream- Indicated for the temporary relief of minor skin irritations, itching, and rashes caused by eczema, insect bites, poison ivy, poison oak, poison sumac, soaps, detergents, cosmetics, and jewelry.
Hydrocortisone cream is applied to affected area one to four times a day for skin issues.

Ibuprofen (Advil, Motrin)- Indicated for temporary reduction of fever or for relief of minor aches and pains as well as inflammation and dysmenorrhea.
Adults and children over 12: (200 mg) Take 1-2 tablets every 4-6 hours while symptoms persist. May use 600mg for more moderate pain not to exceed 2400 mg daily. Any other dosage should be ordered by the physician.
• Children 48 to 59 lb or 6 to 8 y of age, give 200 mg.
• Children 60 to 71 lb or 9 to 10 y of age, give 250 mg.
• Children 72 to 95 lb or 11 y of age, give 300 mg.

Milk of Magnesia- for relief of mild constipation, heartburn and upset stomach.
Adults and children over 12: 2-4 tablespoons every 8 hours (laxative); 1-3 teaspoons up to 4 times daily (antacid) not to exceed more than 12 teaspoons in 24 hours.
Children 6-12 years: 1-2 tablespoons every 8-12 hours as laxative only.

Miralax (polyethylene glycol)- Indicated for relief of occasional constipation.
Adults and children over 12: 17 grams of powder mixed with 4-8 oz of fluid daily for up to 2 weeks or as directed by physician.

Mucinex- Guaifenesin Extended-Release 600 mg Tablets. Indicated to loosen phlegm (mucus) and thin bronchial secretions to rid the bronchial passageways of bothersome mucus and make coughs more productive.
Adults and children 12 years of age and over:1 or 2 tablets every 12 hours. Do not exceed
4 tablets in 24 hours.Children under 12 years of age: do not use.
Mucinex D- Guaifenesin 600 mg Pseudoephedrine HCl 60 mg. Indicated to loosen phlegm (mucus) and thin bronchial secretions to rid the bronchial passageways of bothersome mucus and make coughs more productive, along with temporary relief of nasal or sinus congestion.
Adults and children 12 years of age and over:1 or 2 tablets every 12 hours. Do not exceed
4 tablets in 24 hours.Children under 12 years of age: do not use.
Mucinex liquid for kids- (grape)-Guanifensin 100 mg. Children age 6-12 years: 1-2 teaspoons every four hours.
Mucinex cough mini melts- Guanifensin 100 mg, dextromethorphan 5mg. Children age 6-12 years: 1-2 packets every four hours.

Orasol gel- (benzocaine) Indicated for the temporary relief of minor pain and sore mouth associated with toothache, dental procedures and irritations.
Dry affected area and apply medication with cotton swab. May use up to four times daily, but no more than every two hours.

Phenylephrine- Indicated for temporary relief of nasal congestion and sinus pressure caused by allergies, the common cold, or the flu.
Adults and children over 12: Take (1) 10 mg tablet every 4 hours not to exceed more than 6 doses in 24 hours.

Robitussin- Indicated for the temporary relief of cough due to minor throat and bronchial irritation.
Adults and children over 12: 2 teaspoons every 6-8 hours not to exceed 4 doses in 24 hours.
Robitussin DM- Indicated for the temporary relief of cough due to minor throat and bronchial irritation. Also helps to loosen mucous and thin bronchial secretions.
Adults and children over 12: 2 teaspoons every four hours not to exceed 6 doses in 24 hours

Silvadene- Indicated as a topical treatment for prevention of wound infections in second and third degree burns. It is a sulfa derivative and should not be used in anyone with sensitivity to sulfa drugs such as bactrim.
Apply a thin layer to affected area once or twice daily until healed.

Tinactin (Tolnaftate) –
Indicated for treating fungal growth causing skin infections such as athlete’s foot or jock itch. It comes in liquid, powder, cream and spray.
Apply light application to clean, dry affected area twice daily for 2 weeks.

Eye, Ear, Nose, and Throat Conditions

A. Routine
1. Vision Screening- on campus, done with and without glasses.
• Baseline on admission, then annually or as insurance allows (refer for eye exam if less than 20/40)
Students who are taking Quetiapine (Seroquel) need to have ophthalmologic exams at baseline, then q 6 months.
2. Audiologic Screening- on campus
Baseline on admission, then annually

B. Ocular Trauma / Foreign Body in Eye
1. If possible, obtain vision assessment.
2. Assess for presence of foreign body.
3. Attempt to remove superficial foreign body with eye wash solution ,
4. If unable to remove foreign body, or if there is presence of corneal clouding, irregular pupils, severe conjunctival swelling, excessive tearing, pain, photophobia, or significant vision changes, apply eye patch with non-allergic tape, and transfer to E.R.

C. Acid or Alkali Chemical Burn to the Eye
1. Irrigate eye copiously with running water from the nearest available eye wash station for at least 15 minutes.
2. Contact poison control and transport to ER for further evaluation ASAP.

D. Conjunctivitis / Inflammation
1. Can be bacterial, viral, or allergic.
2. Bacterial is usually associated with purulent discharge; common pathogens are
staph aureus, strep pneumo, and H. influ-non-typeable. Notify physician for prescription for antibiotic eye drop / ointment.
3. Viral tends to be more uncomfortable for the patient, discharge is watery, and preauricular nodes are slightly tender. Instruct patient to wash hands frequently and to avoid touching their eyes. Call physician for recommendations. .
4. Allergic tends to be marked by prominent itching and a very boggy-looking conjunctiva. It can have a stringy, mucoid discharge so sometimes difficult to distinguish from bacterial. Usually bilateral. May give a trial of Chlortrimeton or Claritin by mouth and notify physician if no improvement.

F. Otic exam

1. Examine both ears with an otoscope. If able to visualize T.M.’s, and no obvious pathology is noted, treat symptomatically, and reexamine in 24 hours.
2. If unable to visualize T.M.’s due to wax, may administer 4-6 drops of Debrox qhs x3 days. Irrigate PRN. Reexamine in 3 to 5 days; may repeat Debrox if persistent wax.

3. Report any redness, drainage, or swelling of canals or T.M.’s to the
F. Epistaxis [Nose Bleed]
.
1. Have student sit upright at a 45 degree angle.
2. Place gentle pressure against septum x10 minuets by the clock.
3. Rinse mouth with cool water
4. Place ice pack on back of neck.
5. If bleeding persists, check B/P and call physician.

G. Sore Throat
1. Examine throat and glands. Take temperature.
2. If mild ST or from irritation or overuse, use salt water gargles, push fluids, rest voice, and use acetaminophen or ibuprofen PRN.
3. A strep assay with the ICON Fx Strep A should be done if accompanied by a T of 101 or greater and other symptoms of illness such as tender cervical nodes. Notify physician if positive. If negative and there is high suspicion for strep, send throat culture to lab to rule out strep.
4. Warm compresses may be applied to the neck to reduce the discomfort of enlarged neck glands.
5. Notify physician immediately if patient is unable to manage own secretions (drooling), uvula is shifted beyond midline (tonsillar abscess), or if patient appears toxic.

A. Admission Standing Orders

1. Laboratory – Obtain U/A, General Health Panel (GHP contains CBC, Comprehensive Metabolic Panel, TSH), Hepatitis C AB, Hepatitis B AB, Hepatitis B Surface Antigen, Lipid Panel, Lead Level if < than 10 y.o. and none documented in chart, RPR, U/A for HCG if have had menarche, medication levels if indicated, varicella titer if exposure history is unknown. If on atypical antipsychotics get Prolactin Level, Glucose and Insulin levels on admission, at six months, and then annually. Other labs as ordered by M.D. Some labs may be omitted if testing within 6 months or less is provided at intake. 2. PPD Testing – On admission if not done within the previous 60 days, then annually. 3. Routine Height/Weight/Blood Pressure/Pulse Monitoring – a) Heights – every 6 months, please plot with corresponding weight b)Weights 1) Once a month for all students- more frequently on students with BMI <19 or as orders by physician 2) Notify nutritionist of any changes (up or down) of greater than 10 pounds in < than 8 weeks OR if BMI < 19. b) Blood Pressure and Pulse 1) Every month for all students a. B/P & P q week As directed by physician. 4. EKG – Baseline EKG for all students. If EKG done prior to admission is available, review with M.D. prior to scheduling. B. Routine Lab Orders 1. Annual Labs – CBC, U/A, Medication levels if indicated. Other labs as ordered by physician or psychiatrist. Previously drawn labs are acceptable if dated in the past 60 days. 2. Other Orders Related to Medications Atypical Antipsychotics – Prolactin levels at baseline and every 6 months. Glucose and Insulin levels at baseline 3 months later then annually, per MD if results are abnormal. Fasting Lipid Profile annually. Trileptal – Sodium level at 4 weeks and 12 weeks Tegretol – Tegretol level, CBC, LFT’s q 6 months Lithium – Lithium level, TSH, BUN, Creatinine, U/A q 3 months. Depakote – Depakote level, CBC, LFT’s, q 3 months. Dilantin – Dilantin level, CBC, LFT’s q 3 months. . Clonidine, Tenex Risperidone(Risperdal), Ziprasidone(Geodon), B-Blockers, Tryciclics, Venlafaxine(Effexor ) and any other medication known to induce arrhythmia. Review with MD re: future EKG monitoring. Clozapine - weekly WBC done and entered into the national database. AIMS testing q 6 months if on neuroleptics, including atypical antipsychotics. 3. Hepatitis C Exposure Protocol for Students – In the event of a student having a possible exposure to Hepatitis C, the following blood work should be obtained: Time after Exposure Blood Work 2 Weeks or less Baseline Liver Function Tests 4 Weeks Qualitative Hep C V PCR TMA 6 Weeks Hep C Antibody, Liver Function Tests 3 Months If Hep C PCR TMA is positive repeat, Hep C antibody, Liver Function Tests 6 Months Hep C antibody, Liver Function Tests In addition, every effort must be made to maintain the highest level of confidentiality possible. Guidelines include but are not limited to the following: a) Source of Exposure should NEVER be explicitly identified in a Hillcrest chart. b) All health referrals for staff made to Occupational Health for counseling need to be made in as confidential a manner as possible. c) If exposed student is a minor, his / her legal guardian needs to be contacted and advised of the possible exposure to Hepatitis C. They also need to be notified of our wish to follow the patient closely with the above mentioned lab work. Hepatitis C is a treatable illness especially when detected in its earliest stages. d) If student had baseline liver function tests within one (1) month prior to exposure, additional liver function tests do not need to be done. C. IDENTIFYING AND COMMUNICATING CRITICAL VALUES AND INTERPRETATIONS OF MEDICAL TESTING RESULTS Purpose: To describe the process of reporting abnormal values and interpretations from laboratory, cardiology and radiology to HEC medical providers. Laboratory results: Critical tests are those tests that always require rapid communication of the results, even if normal Critical tests are ordered specifically by the physician. The physician also indicates the timeframe of the reported results at the time of the written or verbal order. However, results should be obtained and reported to the ordering physician within 8 hours of the test having been performed. Critical results, also known as “critical values,” are test results that fall significantly outside the normal range and may represent life-threatening values even if from routine tests. As per the policy of Berkshire Medical Center, the time period for notification to the Licensed Caregiver must be immediate, occurring within 30 minutes from receipt of the result. This communication will occur directly to the ordering physician. If the physician cannot be notified in their office, the RN or LPN for the physician will be notified with the understanding of the urgent need to report the result immediately to the physician. The following are suggested critical values of routine lab testing and should be reported directly and immediately to the ordering physician: Liver Enzymes: SGOT- greater than 150 SGPT- greater than 150 AST- greater than 3 times normal ALT- greater than 3 times normal Bilirubin- greater than 3 Complete Blood Count: HCT –less than 20 WBC- less than 3,000 or greater than 20,000 Platlets- less than 60,000 ANC- less than 1.5 Glucose- greater than 200 Creatinine- greater than 2.0 Prolactin- greater than 100 Amonia- Any elevation above normal level Urine: Positive for STD Positive for beta HCG Positive for blood or bacteria RPR- any positive result Anti- HIV AB- any positive result Blood culture- any positive result Drug Levels: Lithium- greater than 1.3 Depakote (valproate)- greater than 100 Carbamezapine- greater than 12 Cardiology results: Critical interpretations are those that indicate the patient may be in imminent danger of death or serious adverse consequences unless treatment is initiated immediately. These interpretations will be reported, by the cardiologist, immediately (within 30 minutes) to the ordering physician. Other urgent or significant interpretations that are not considered life threatening but may need medical intervention will be reported by the cardiologist to the ordering physician within 48 hours. Radiology results: Critical interpretations are those that indicate the patient may be in imminent danger of death or serious adverse consequences unless treatment is initiated immediately. These interpretations will be reported, by the radiologist, immediately (within 30 minutes) to the ordering physician. Other urgent or significant interpretations that are not considered life threatening but may need medical intervention will be reported by the radiologist to the ordering physician within 48 hours.

All toxic substances are kept out of the reach of students in locked cabinets. Medical supplies and medications will not be stored in the same storage cabinet with toxic substances. All toxic substances are labeled with contents and antidote. The telephone number for the Poison Control Center is clearly posted near the telephone in each Nurses’ Station, in each supervisor’s office, and in the Emergency Manual.
Over the counter and/or prescription medication may not be stored in staff’s clothing or in personal possessions on campus. All medications for staff’s personal use must be stored in a secure, locked area.

(Also see the HEC Hazardous Materials and Waste Management Plan.)

In accordance with Hillcrest’s policy on student sexuality, where deemed appropriate, and with the permission of the parent or guardian, Hillcrest provides family planning information to students. Additionally, students who are considered to be at risk for sexually transmitted diseases or unplanned pregnancy may receive health counseling from the nursing staff. In keeping with the philosophy that students should be prepared for transition to a less restrictive environment, students may be referred to the community family planning clinic for specialized counseling and health services, as appropriate.

Hillcrest requires that all students comply with the Massachusetts Department of Public Health regulations regarding routine immunizations.

Students are screened for tuberculosis within 60 days of admission to Hillcrest Educational Centers. Rescreening with Mantoux test will be performed every year from the date of the last testing on all tuberculin negative students.
Students who are known to be tuberculin positive, or who are unable to receive PPD, will be evaluated by Medical Director and referred as appropriate.
Medical management of the student, including communicable disease precautions, will be at the direction of the Medical Director, in cooperation with the Massachusetts Department of Public Health T.B. Control Unit. No facilities for respiratory isolation are available at Hillcrest Educational Centers. Should respiratory isolation be recommended, the student will be immediately transferred to an appropriate health care facility.

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

Staff:
1. Staff should wash all abrasions, scratches, or broken skin areas thoroughly with soap and water, if available apply antibiotic cream.
2. 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.

1) Students are required to have a hepatitis profile with admission lab testing if not submitted with admission documentation.
2) No student will be denied admission on the basis of Hepatitis B carrier status.
3) No student will be denied full participation in the school program on the basis of Hepatitis B carrier status.
4) All staff and students of Hillcrest Education Centers will be offered Hepatitis B vaccine.

Students or staff who have a reportable communicable disease will not be allowed to attend school.
If a reportable communicable disease has been introduced into a campus, the nursing staff will notify parents/guardians of students on that campus. The local Board of Health will also be notified, in accordance with MGL Ch. 71, Sec. 55A.
If diagnosis of a reportable communicable disease is made by a consulting physician, the Medical Director will be notified and consulted regarding appropriate precautionary procedures.

A list of reportable Communicable and other infectious diseases follows.

REPORT DIRECTLY TO THE MASSACHUSETTS DPH
DEPARTMENT OF PUBLIC HEALTH

HIV infection and AIDS (617) 983-6560

Sexually Transmitted Diseases (617) 983-6940

Chanchrold Ophthalmia neonatorum:
Chlamydial infections (genital) a. Gonoccocal
Genital Warts b. Other agents
Gonorrhea Pelvic Inflammatory disease
Granuloma inguinale a. Gonococcal
Herpes, neonatal (onset within 30 days b. Other agents
after birth)
Lymphogranuloma venereum Syphilis

Tuberculosis suspect and confirmed cases: Report within 24 hours to (617) 983-6989 or
Toll Free (1-888) MASS-MTB (627-7682) or
Confidential Fax (617) 983-6990

Latent tuberculosis infection: Confidential Fax (617) 983-6990 or
Mall report to:
Massachusetts Department of Public Health
Division of Tuberculosis Prevention and Control
305 South Street, Jamaica Plain, MA 02130

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REPORTABLE DISEASES PRIMARILY ASCERTAINED THROUGH LABORATORY REPORTING OF EVIDENCE OF INFECTION

Please work with the laboratories you utilize for diagnostic testing to assure complete reporting.

Amebiasis
Babesiosis
Calicvirus infection
Campylobacteriosis
Cholera
Cryptococcosis
Cryptosporidiosis
Cyclosporlasis
Dengue fever virus
Eastern equine encephahtis virus
E. coil 0157:H7
Enteroviruses (from CSF)
Giardiasis
Group A streptococcus, invasive infection
Group B streptococcus, invasive infection
Hepatitis B
Hepatitis C
Hepatitis – infectious, not otherwise specified
Evidence of human prion disease
Influenza
Legionellosis
Listeriosis
Malaria
Salmonellosis
Shiga toxin-producing organisms
Shigellosis
Streptococcus pneumoniae, invasive
infection /
Toxoplasmosis
West Nile virus
Yellow fever virus
Yersiniosis