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.

***********************************

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.