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STANDING ORDERS and PROTOCOLSCommonly seen in school nurse/SBHC setting:(Source: Keeton V, Soleimanpour S, Brindis CD: School-Base Health Centers in an Era of Health Care Reform: Building on History/ Curr Probl Pediatr Adolesc Health Care. Jul 2012; 42(6): 132-158. And Massachusetts Dept of Public Health report – Essential School Health Services Program Data Report 2009-2010 School Year) The recommendations in this document are not intended to indicate an exclusive course of treatment or to be applicable in all circumstances. We recommend that you use this document as a guide for developing your policies and protocols. The examples included here have not been reviewed for medical accuracy or up-to-date treatment protocols.38671505080Medications commonly administered PRN (Some examples on page 37 and 38)AnalgesicsAsthma medicationsEpinephrineAntihistaminesOther prescription / OTC medsAntibioticsInsulinAnticonvulsantsPsychotropicAntihypertensiveMedications commonly administered (prescribed) (Some examples page 37 and 38)PsychotropicInsulinAsthma medicationsAntibioticsAnticonvulsantsAntihypertensiveAntihistaminesAnalgesics0Medications commonly administered PRN (Some examples on page 37 and 38)AnalgesicsAsthma medicationsEpinephrineAntihistaminesOther prescription / OTC medsAntibioticsInsulinAnticonvulsantsPsychotropicAntihypertensiveMedications commonly administered (prescribed) (Some examples page 37 and 38)PsychotropicInsulinAsthma medicationsAntibioticsAnticonvulsantsAntihypertensiveAntihistaminesAnalgesicsVisit types and examples:Emergency Procedure Page 4: Serious Accident or InjuryGeneral Health ExamsPage 6: Growth & BMI ScreenPage 12: Hearing ScreenIllness Assessment Page 15: Stomach Ache/Pain, GI upset, HeartburnPage 18: HeadachePage 19: EarachePage 20: Menstrual CrampsPage 21: General PainInjury / First AidPage 24: Scrapes, Cuts, Bruises & PuncturesPage 26: Sprains & Strains Page 30: NosebleedPage 31: Splinter RemovalPage 32 & 34: AnaphylaxisPage 35: BurnsMedication AdministrationPage 37: Medication Protocols Page 38: Emergency MedicationsMedical Management and Health EducationPage 40: Diabetes Management in SchoolMental / Behavioral Health SupportPage 42: Behavioral Health ScreenPage 44: Suicide Protocol357187569215Blood Sugar / Diabetic EventPage 67: Diabetic ConditionsAllergy/Common ColdPage 70: Common Cold, Allergic Rhinitis Oral Health Page 73: Dental ScreenPage 74: Fluoride ApplicationNutrition / Activity / Weight Management Page 77: Overweight or Obese00Blood Sugar / Diabetic EventPage 67: Diabetic ConditionsAllergy/Common ColdPage 70: Common Cold, Allergic Rhinitis Oral Health Page 73: Dental ScreenPage 74: Fluoride ApplicationNutrition / Activity / Weight Management Page 77: Overweight or ObeseVaccinationsPage 47: Flu Vaccine w/ Egg Allergy EvaluationPage 51: MMRV VaccineSexual/Reproductive Health Page 55: Reproductive HealthPage 57: Missed Menstrual CyclePage 59: STI Page 60: Chlamydia Asthma / Respiratory DistressPage 63: Asthma/Bronchospasm STANDING ORDER GENERIC TEMPLATEStanding orders need to have the following categories:Description of condition or symptomsHistoryAssessmentInterventionDocumentationFollow upThe following documents are specific examples from different institutions addressing a variety of commonly encountered issues in school-based health care.We recommend that you use this document as a guide for developing your policies and protocols. The examples included here have not been reviewed for medical accuracy or up-to-date treatment protocols.Emergency ProcedureExampleEXAMPLE EMERGENGY PROCEDUREMultiple source documents* *adapted from Victoria Dept of Education & Training; Bucknell University; Oswego State University of New York; All Family Resources?Emergency Procedure for Serious Accident or InjuryIn the event of a serious injury (or illness) to a student or staff member:Provide appropriate first aid assistance for the injured person – do not move the injured person unless it is a life threatening situation or further injury will result; follow blood/bodily fluid exposure protocols as needed.Depending on the circumstances, contact ambulance, medical practitioner and/or the police (Call 911 and use school contact list). Do not delay in the hope that the person will recover.Protect and comfort the non-injured students.Notify the principal/school contact person who should notify the authorities and the parents of all students:?As the media often reports on situations without full or correct details, it is important that the parents of all students are aware of the incident.Provide students and adults with appropriate first aid.Make sure the entire group is safe and warm.Keep detailed notes for a comprehensive report of the injury and incident, which must be retained by the school for purposes of legal liability.If the media becomes involved, handle them sensitively, isolating the students from reporters and cameras.If the police have attended, consider requesting the police officer in charge to inform and handle the media.For major incidents, assistance from police media liaison can be requested.In the case of a fatality, it is the role of the police, acting for the coroner, to contact the family.IN CASE OF blood/bodily fluid exposure defined as: a specific eye, mouth, or other mucous membrane, non-intact skin or contact exposure with blood or other potentially infectious materials.If you are exposed:Immediately WASH area with soap and water or eye wash for 15 minutes as applicable;Notify your supervisor;Obtain medical help;Immediately report to the emergency roomComplete an Exposure Incident form and notify ____________________.After the event:Post-trauma counselling for students and supervising adults is important and should be organized through the _________________________.Record and file details of the incident that led to the injury and the resultant action.Consider what changes may need to be made through safety and risk management and planning for future activities.General Health ExamsExamplesEXAMPLE GENERAL HEALTH EXAMMultiple source documents* *adapted from Missouri Dept of Education; Iowa School Nurse Toolkit; Pennsylvania Dept of Health Procedures for Growth Screening Program; Health Dept of Northwest Michigan Child & Adolescent Health Centers Overweight and Obesity procedureProtocols for Growth ScreeningCondition for protocol: To monitor growth and development patterns of students and identify students who may be at physical development and / or nutritional risk or who may have a common nutritional problem Policy of protocol: The nurse will implement this protocol for measuring height, weight and calculating BMICondition-specific criteria and prescribed actions:For persons adopting these protocols: The criteria listed below include indications, contraindications, and precautions for implementing the growth screening protocol. However, the criteria must be reviewed and further delineated according to the licensed prescriber’s parameters. Additional criteria and prescribed actions may be necessary. The prescribed actions are examples and may not suit your institution’s clinical situation and do not include all possible actions. A licensed prescriber must review the criteria and actions and determine the appropriate action to be prescribed.Training and expertise requirements: Describe any specific training requirements necessary for this protocol. Goals of the visit: Monitor growth and development patterns of students – compare to individual student’s existing records if available. Identify students who may be at physical development and / or nutritional risk or who may have a common nutritional problem ( For those identified as AT-RISK, proceed to relevant protocol )Compare weight for height ratio (BMI) to norms for ageChart all available measurements to visualize growth patternsAssess contributing factors (Ex. family history, diet, physical activity patterns, financial and community resources)Health promotion for all students and intervention as necessary Address issues of healthy eating and physical activityProvide counseling on healthy weight and physical activity. Notify parents/guardians of screening results with a recommendation to share findings with the student’s health care provider for further evaluation and intervention, if necessary. Standards and Visit Environment Parental consent obtainedEducational materials on healthy eating and physical activities available to all studentsPrivate data collection setting establishedUse a scale that is calibrated on a regular basisSet scale to zero before each individual measurement. Weigh and measure twice to assure accurate measurement.Part I: Growth Screening and BMI calculationCriteriaPrescribed ActionIndication Currently healthy child. Weight measurementWeight Make sure that the scale is on a firm surface, preferably an uncarpeted floor. Set the scale at zero. Have student remove their shoes. Have student remove heavy outer clothing, such as sweater, jacket, or vest. Have the student step on scale platform, facing you, with both feet on platform, and remain still. Read weight value to nearest ? pound or 0.1 (1/10) kilogram. Record weight immediately on the data form before student gets off scale. If using a balance beam scale, return weights to the zero position.Repeat the measurement and record immediately on data form.Again, return weights to zero position before next student. Currently healthy child. Height measurementHeight Have student remove shoes and hat. Have student remove hair ornaments, buns, braids to extent possible Note on chart if unable to obtain an accurate measurement Do not “guesstimate” height of hairdo Have student stand on footplate portion with back against stadiometer rule. Have student bring legs together, contact at some point (whatever touches first). Make sure that the knees are not bent, arms are at sides, and shoulders are relaxed. Make sure that the back of the student’s body touches/has contact with stadiometer at some point. Make sure that the body is in a straight line (mid-axillary line parallel to stadiometer). Check to see if the student’s head is in appropriate position. You should be able to draw a straight (perpendicular) line from the back of the board, past the ear opening and the top of the cheek bone. You can use a pencil or ruler to help check the line. This is called the Frankfort plane. Lower headpiece snugly to crown of head with sufficient pressure to flatten hair. Read value at eye level; read in an upward direction (from lowest to higher number). Measure to nearest 0.1 cm or 1/8 inch and record value. Repeat measurement, having the child line-up again, and record appropriate value immediately on data form.Currently healthy child. BMI calculationCDC BMI calculator is available here: This is for children 2 – 19 years old and provides BMI and the corresponding BMI-for-age percentile on a CDC BMI-for-age growth chart.Procedure for calculating BMI: Metric and English System versionsWeight in kilograms (kg) divided by the square of height in meters squared (m2). Sample calculationCharles is a 10-year-old boy who is 4’7” tall and weighs 100 pounds. What is Charles’ BMI? BMI = (weight [lbs] / [height (inches)]2) x 703 BMI = (100/[55]2) x703 BMI = 23.2BMI = Weight (kg) . Height squared (m2)Weight in pounds (lbs) divided by the square of height in inches squared (in2) then multiplied by 703.BMI = Weight (lbs) X 703 Height squared (in2)Currently healthy child. Blood pressure and pulseStandard blood pressure measurement and recording.Standard pulse measurement and recording.Child is ill.Reschedule as needed.Child is healthy and is non-ambulatory / special needs.Make accommodations or prearrangements as needed. Recumbent length measurements and alternate weighing methods may be needed.ContraindicationParental permission is denied.Do not measure; _____________________PrecautionChild has known ___________.Medical, mental and behavioral issues and other circumstances may already have been identified that could require special protocols. These can be defined here if needed.Part II: Student Nutrition & Physical Activity Evaluation CriteriaPrescribed ActionIndicationCurrently healthy child presenting for growth screenAll student’s nutritional status, eating habits and physical activity patterns should be evaluated:Identify and record BMI percentile rank based on BMI you just calculated using the CDC’s age and gender-specific BMI chartsPhysical activityHours of television / screen timeHours of video gamesFrequency of outdoor play and safety of environmentFrequency of family physical activities and examplesFrequency of one-on-one active play with parent / guardianEating and nutritionFamily diet description – typical dayDoes child eat breakfast and what is consumed?Frequency of eating while watching TV / screen timeFrequency of eating outFrequency of fruits and vegetables as part of meals – examplesTypes of snacks available at homeNumber of sodas / sweetened beverages consumed dailyContraindicationParental permission is denied.Do not evaluate; _____________________PrecautionChild has a managed or prescribed diet.Refer to child’s file / existing documentation. Coordinate with primary care physician as needed.Child is diabetic.Refer to child’s file / existing documentation. Coordinate with primary care physician as needed. Prescription: Refer students whose measurements fall outside the norm (>95% or <5%), based on CDC’s age and gender-specific BMI charts, and whose health history does not reflect evaluation, and who may have other health risk factors.Students identified to be at risk for under-nutrition, failure-to-thrive or suspected eating disordersSchedule with the NP for nutritional counseling and assessment for further complications / disease:Students who have had unusual weight gain or loss should be referred.Students falling below the 5th percentile should be assessed further to determine if their physical growth has been evaluated by their healthcare provider, or is under medical supervision. If not, they should be referred.Lab tests to be ordered: _______________________Students identified to be at risk for obesity, pre-diabetes or overweight:Students with a BMI between the 85th and 95th percentile should be monitored.Students with a BMI above the 95th percentile for age and gender should be further assessed with an evaluation of diet and health history. These students are usually referred first to their primary healthcare provider. Lab testing to be offered as follows: CriteriaPrescribed ActionIndicationFor BMI between 85th –94th percentile with no risk factorsConsult the student’s primary care physician (using appropriate Overweight/Obesity Letter to Collaborating Physician) and recommend the following laboratory testing:fasting lipid profileFor BMI 85th – 94th percentile with risk factors Consult the student’s primary care physician (using appropriate Overweight/Obesity Letter to Collaborating Physician) and recommend the following laboratory testing:fasting lipid profile AND If 10 years old: fasting glucose AND Aspartate Aminotransferase (AST) ANDAlanine Aminotransferase (ALT) every two yearsFor BMI greater than or equal to 95th percentile, regardless of risk factors Consult the student’s primary care physician (using appropriate Overweight/Obesity Letter to Collaborating Physician) and recommend the following laboratory testing:fasting lipid profile AND If 10 years old: fasting glucose AND Aspartate Aminotransferase (AST) ANDAlanine Aminotransferase (ALT) every two yearsClients who are unable to obtain recommended labs through their provider ANDHave a BMI 85th-94th percentile with risk factors ANDClients with a BMI greater than or equal to 95th percentile, regardless of risk factorsOffer lab testing in the clinic that includes:Total cholesterol, HDL, and blood glucose. If blood glucose is out of the normal range and client is not fasting, they will be asked to return for a fasting lab.PrecautionChild has a managed or prescribed diet.Refer to child’s file / existing documentation. Coordinate with primary care physician as needed.Child is diabetic.Refer to child’s file / existing documentation. Coordinate with primary care physician as needed. DocumentationRecord both height and weight measurements, calculated BMI, percentile rank according to CDC’s age and gender-specific BMI chartsRecord blood pressure and pulse.Record nutrition and physical activity responsesDocument materials provided to parent(s) and parental consent.Document referral / follow-up appointments, program enrollment and recommendationsFollow upSchool health personnel must communicate observations and concerns directly (letter, phone call or face-to-face) to the parent/guardian. Arrange referrals and provide resources for:Family actions and activitiesmedical and psychological treatment ( suspected metabolic disorders and eating disorders ) – PCP and/or behavioral health servicesnutritional counseling – NP and/or RD appointmentsschool support activities – specific program referral and enrollmentQuestions or concerns:In the event of questions or concerns, call Dr. ____________________________at _____________________________.This protocol shall remain in effect for all patients of ______________________________until rescinded or until _____________________________________.Name of prescriber: Signature:Date:ReferencesPublic health impact: accessed Feb 4, 2015CDC safeguards: See Growth Screening Guidelines, Missouri DHSS, March 2005. For BMI calculations, see or EXAMPLE HEARING SCREENPA – Philadelphia School DistrictSUBJECT: MANDATED PROGRAMSNUMBER 104CLASSIFICATION:HEARING SCREENINGPurposeTo identify students with hearing lossTo refer failures for further evaluationFrequencySweep Check Test @25 dBAll students in grades K, 1, 2, 3, 6, 9, and ungraded age-equivalent.All newly admitted students who have not been screened by the sending school.On referral.Pure Tone Threshold TestStudents who have failed the Sweep-Check TestAll students, regardless of grade, whose previous hearing test has shown a loss.Equipment requiredPure Tone AudiometerTesting TableChairsBenzalkonium Chloride 1:5000PreparationAssure that the audiometer is in good working condition by:Checking all wires, knobs, and ear phones.Being certain a threshold done on self is consistent with pre-established data.Assure a setting as free of noise-producing activity as possible. (Do not schedule other health room activities which might impact on the hearing screening)Place a chair for the student to be screened in a direction facing away from the screener.Hearing Screening ProceduresSweep Check TestExplain the screening procedure to student. Allow student to practice “raising their hand” to the sound of the tone. Seat the student to be screened in the chair near the testing table.Instruct the student to remove all objects which might interfere with proper fit of the headband, i.e., eyeglasses, earrings, hair ornaments. Briefly review the procedure with the student.Face the student and place the earphones directly over the external ear canal with the red earphone over the right ear.Be certain the student being screened cannot watch the tester. Screen the RIGHT ear first as below:Decibel LevelFrequencyHears The Tone551000once401000once2510002 out of 32520002 out of 32540002 out of 3251000once255002 out of 3252502 out of 3Then screen the LEFT ear.Decibel LevelFrequencyHears The Tone2510002 out of 32520002 out of 32540002 out of 3251000once255002 out of 3252502 out of 3501000Return machine to red ear.Note: Always screen the right ear first.Record the test results on the HIS, Main Menu #2, Health Inquiry and Maintenance, screen H4. Where HIS is unavailable, use the MEH-3.Pass is the ability to hear all or all except one frequency at 25 decibels.Fail is:Failure to hear two (2) or more frequencies at 25 decibels.Failure to hear the same frequency in both ears.A student who fails requires further assessment by the school nurse.A student who fails should receive a second Sweep Test within one (1) month.Failure of the second sweep test will result in a Threshold Test that same day.Pure-Tone Threshold Hearing Test ProcedureBegin the testing in the right ear. Begin testing at 50 dB, 1000 Hz. If the child hears this tone set the decibel dial to 40 and repeat this procedure, decreasing the decibel dial by 10 dB steps until the child no longer indicates that he hears. Then increase the decibel dial by 5 dB steps until he hears the tone again. This is the threshold for that frequency.Repeat the same procedure until the following frequencies have been tested in the right ear: 250, 500, 1000, 2000, 4000, and 8000 Hz. Use this same procedure in the left ear.Record the lowest decibel level that the student is able to hear on the Student School Health Record/ Health Information System.Failure constitutes any one of the following:Failure to hear 30 dB or more for two or more frequencies.Failure to hear 35 dB or more for one (1) frequency.A referral for a complete ear examination for otologic assessment and audiometric tests should be initiated ____ Hearing Test Report to Parents and Physician) and documented on the Student Health Record/Health InformationIllness AssessmentExamplesEXAMPLE ILLNESS ASSESSMENTHFHSAbdominal: Pain, Stomach Ache, GI Upset, HeartburnRN Protocol for Henry Ford Health SystemSchool Based Health ClinicsDEFINITION: Pain or discomfort located between the bottom of the diaphragm and the top of the pelvic region.Abdominal pain is one of the most common complaints in childhood and one that frequently requires urgent evaluation in the office or emergency department. The cause is typically a self-limited minor condition, such as constipation, gastroenteritis, or viral mon causes considered by age of students: Preschool: constipation, gastroenteritis, viral infection, urinary tract infection, pneumonia, trauma, lactose intolerance, sickle cell episode School age: gastroenteritis, viral infection, constipation, appendicitis, trauma, urinary tract infection, pneumonia, lactose intolerance, sickle cell pain episode Adolescent: appendicitis, in females: mittelschmerz, pelvic inflammatory disease (PID), dysmenorrhea, complication of pregnancy?SUBJECTIVE:Symptoms vary depending on the etiology of the pain.Signs & SymptomsA good assessment will help to differentiate the cause of the abdominal pain.Mildly ill: pain interferes minimally with normal activities.Moderately ill: interferers with normal routine or signs of infection or systemic illness.Severely ill: signs of peritonitis or intestinal obstruction or mental change.ASSESMENT:Onset of pain/severity HistoryLocationIntermittent/constantCharacteristics: sharp, dull, radiating, etc.Aggravating and alleviating factors (including food)Since onset: worsening or improvingTime of last meal/diet history Trauma to abdomenLast bowel movement; changes in stool characteristics; blood in stoolNausea/vomiting/diarrhea/constipation/heartburnLast time voiding; urinary symptomsOther signs of illness (fever, cough, sore throat, etc.)History of abdominal surgeryHistory of previous occurrences Current medications/allergiesSubstance useSexual history; vaginal/penile dischargeUnder stressLast Menstrual Period (LMP)Possibility of pregnancyOBJECTIVE:Vital signs (temp, blood pressure, heart rate, resp. rate, pulse ox., pain score 0-10, and weight)Assessment of Systems: General Appearance/Neuro/MentationSkinHEENT (as applicable) CardiovascularRespiratoryAbdomen (skin color, distention, bowel sounds, rigidity, tenderness, costovertebral angle tenderness). .INTERVENTION/Guided by history/assessment findings: TREATMENT:According to the history, either:Have the student use the bathroomGive the student a snack to eatProvide a basin for vomitingHave the student rest on their side if possible with their knees drawn upApply warm pack to abdomenFor menstrual cramps, follow menstrual cramp protocolIf menstrual cycle >10 days late, see Missed Menstrual Period Protocol)ANTACID/ANTIFLATULANT(Heartburn, gas pain. Not for vomiting)Magnesium/Aluminum/Simethicone combination (Common brand names – Riopan Plus, Maalox Plus, Mylanta II – liquid or tablets): See package directions for dosing.Note: Do not administer within 2 hours of Tetracycline, enteric coated medications or psychotropic medication. Check with physician or pharmacist. Check with physician if condition does not respond within one day.Caution: Do not administer to clients with kidney disease. Check with physician first.Refer the student to MD/PCP for severe pain, guarding and rigidity of abdominal muscles, abdominal distention, decreased bowel sounds, persistent vomiting, constant pain for more than 2 hours, mild pain that comes and goes over 24 hours, fever over 102° F or if the student becomes worse.If signs of appendicitis (the most common serious condition) or moderate-severe illness, notify the parents immediately, and refer to the student’s health care provider. No food or drink by mouth.If mild, may rest for 15-30 minutes. If symptoms persist, refer for evaluation. If symptoms subside, return student to class. Do not give any pain medication or laxative for stomach cramps.Notify the student’s parent/guardian about the student’s condition, as needed.DOCUMENTATION:EPIC/PaperDocument findings from subjective, history, objective, follow-up, intervention and education in EPIC.FOLLOW-UP:If student is sent back to classroom, advise return to clinic if no improvement or worsen in 1-2 hours. In event of a referral to PCP/MD/ER a follow-up will be made.REFERENCES: Clinical Guidelines for School Nurses (2011)Ferry, G. D. (2013). Causes of acute abdominal pain in children and adolescents. Retrieved from did the headache start?Have you had headaches before today?Is this your usual type of headache?How often do recurrent headaches happen?Do you have any other symptoms, such as blurred vision. green or yellow nasal discharge, vomiting or dizziness?Are you sensitive to light?Have you seen a doctor for headaches?Have you had a head injury in the last 24-48 hours?Is there a family member who has frequent headaches?Do you have vision problems with reading or seeing the blackboard?Do you wear glasses? If so, are the glasses with the student?When did you last eat?Assessment:Take vital signs.Determine what the student does at home for headaches and if the headaches improve.Determine when the student last ate a full meal.Assess if the student wears glasses, if so, are the glasses with the student.Rate the student’s pain level.Do vision screening based on history.Intervention:Notify the parent/guardian about the student’s condition, as needed.May give acetaminophen or ibuprofen as needed per Medication Protocol.Refer the student to tele-health provider for headaches that are severe or occur after a head injury or if the headaches occur 2 or 3 times a month.Provide the student with a snack if they have missed a meal.Suggest that the student keeps a headache diary if there are frequent headaches.Documentation:Findings from history, assessment, interventions, and follow- up.Follow- up:Schedule child to see tele-health provider or refer student to their PCP if headaches are reoccurring.In the event of a referral to tele-health provider, a follow-up will be made.467677518605500200977518605500 Physician’s Signature: Date:EARACHEHistory:History of ear infections?Was something inserted into ear?Cold symptoms?Assessment:Vital signs.Pain score 0-10.Appearance of ear canal: drainage, redness, impacted cerumen, or foreign object.Contact tele-health provider. Presence of associated symptoms: sore throat, cough, fever, enlarged cervical nodes, or nasal drainage.Intervention:May apply cold or warm compress to ear with the student lying on the affected side. Some prefer to have the head elevated to decrease pressure in the ear canal.May give ibuprofen or acetaminophen as needed according to Medication Protocol.Notify the student’s parent/guardian about the student’s condition, as needed.Refer to doctor if any dizziness, severe headache, swelling around ear, weakness of face muscles, pain or fever that worsen or do not improve.Refer to tele-health provider for antibiotics, foreign object, or any other concerns.Documentation:Findings form history, assessment, intervention, and follow-up.Follow-up:Instruct child to not insert anything into ear canal.In the event child referred to tele-health provider a follow-up will be made.465772517653000200025017653000 Physician’s Signature: Date:MENSTRUAL CRAMPSHistory:Where is the pain located?What does it feel like (sharp, dull, cramping)When did the pain start?Have you had this pain before?Are you having your menstrual cycle?Are the cramps continual or periodic?Are you using more sanitary pads than usual?Assessment:Take vital signs.Rate the student’s pain level.Determine if there are other symptoms, such as nausea, vomiting, constipation, diarrhea, or headache. Intervention:Give the student sanitary pads as needed.May apply warm pack to student’s lower abdomen for 20 minutes for comfort. May be repeated.May give acetaminophen or ibuprofen if needed per Medication Protocol.Refer the student to tele-health provider if pain is severe and not relieved by ibuprofen, or, fever over 100*F, bleeding is extremely heavy, or if the student feels very sick.Notify the student’s parent/guardian about the student’s condition, as needed. Documentation:Findings from history, assessment, interventions, and follow-up. Follow-up:Instruct the student to exercise regularly to reduce cramps during next cycle.Instruct the student to start taking Ibuprofen the day before her next cycle is due to start for better pain control.Instruct the student to continue her usual activities during her menstrual cycle.In the event of a referral to tele-health provider, a follow-up will be made.454342518478500196215018478500Physician’s Signature:Date:General PainChest PainNeck PainGrowing PainsHistory:When did the chest pain start?What does it feel like (sharp, crushing, dull, aching)?What were you doing when the pain started?Did you have any trauma to your chest?Does the pain come and go or is the pain constant?Where exactly is the pain located?Does anything make the pain increase or decrease?Do you have a history of asthma, heart disease, heart murmur, or does anyone in your family?Do you have any other symptoms, such as arm pain, nausea, abdominal pain, difficulty breathing, coughing, or wheezing?Do you have a history of anxiety or hyperventilation?Has this pain happened before today?History:Did you wake up with a sore neck?Were you injured recently?Have you been in an accident?Has this ever happened before?Have you been ill?History:Where is the pain located?When did the pain start?What does it feel like (sharp, crushing, dull, aching)?What were you doing when the pain started?Were you injured recently?Assessment:Take vital signs.Assess respiratory status.Rate pain level.Assessment:Vital signs.Pain score 0-10.Any other symptoms: headache, vomiting, fever, sore throat, photophobia, or pain when touching chin to chest.Appearance of neck: swollen or “knot” present, bruised, or guarded position.AdenopathyAssessment:Vital signs.Pain score 0-10.Located in calves or thighs with no Hx of injuryIntervention:Call 911 immediately if student is having severe difficulty in breathing or is too weak to stand or has a history of heart disease.Notify the student’s parent/guardian about the student’s condition, as needed.Make referral to tele-health provider if the student has a fever, nausea, cough or if chest pains occur with vigorous exercise or the chest pains are a recurrent problem.Apply warm pack to area for 20 minutes to soothe sore muscles. Can be repeated 3 times throughout the day if needed.Suggest that the student does stretching exercises before vigorous activity to decrease sore chest muscles in the future.Intervention:May apply warm or cold compress for 20 minutes.May give Ibuprofen or Acetaminophen as needed according to Medication Protocol.If you suspect Meningitis refer to ER immediately.Refer to tele-health provider if they were involved in a car accident or as nursing judgment warrants. Positive findings or assessment.Call parent if pain did not improve after treatment.Intervention:Gently massage the area or have the patient massage it.Notify parent and advise medical follow-upDocumentation:Findings from history, assessment, interventions and follow-up. Documentation:Findings from history, assessment, interventions and follow-up.Documentation:Findings from history, assessment, interventions and follow-up.Follow-up:Schedule child to see the tele-health provider within one week, or refer student to their PCP. In the event of a referral to tele-health provider, a follow-up will be made.Follow-up:In the event of a referral, follow-up will be made.Follow-up:In the event of a referral, follow-up will be made.435292515684500169545015684500 Physician’s Signature: Date:Injury / First AidExamplesEXAMPLE FIRST AID HFHSAbrasions/Lacerations/BruisingRN Protocol for Henry Ford Health SystemSchool Based Health ClinicsDEFINITION: Disruption of the normal structure and function of the skin. Management of minor wounds has two goalsAvoidance of infection Achievement of a functional scar. SUBJECTIVE:Non-Urgent/Minor: Superficial abrasion, scrape or wound. Small splinter or foreign body. Minor bruises. Signs & Symptoms:Urgent: Significantly contaminated lacerations, Facial lacerations, Puncture wounds of the foot or hand, wounds requiring suturing, pulses present distal to injury, controllable bleeding. Serious bruising.Emergent: Crush injury, amputation, penetrating wound, absent distal pulses, significant blood loss, capillary refill exceeds 2 seconds, altered LOC, signs/symptoms of respiratory distress. Signs of infection, fever, chills, drainage, rednessASSESMENT:How and when did the injury occur?HistoryWhat caused injury? (possible contamination of wound or foreign body presence). Allergies (antibiotics, local anesthesia, or latex). Secondary injuries. Date of last tetanus (within 5 years).OBJECTIVE: Vital signs (blood pressure, pulse, respirations, temperature, pulse ox. Height and weight if able)Assessment of Systems:Appearance of injury:?for bruising, note location, size, color, shape?location, depth, length, any foreign debris in wound.Mentation/LOC/Neurovascular assessment distal to injury: ?pain, pulse, pallor, paresthesia, paralysis. capillary refill, edema, skin temperature.Amount of bleeding.INTERVENTION/Non-Urgent/Minor: Cleans area with soap and water/saline to TREATMENT:remove any foreign material (gravel, dirt, etc.) If necessary, gently rub abrasions with moistened 4x4 gauze to remove debris. Cover area with non-adherent dressing. Apply butterfly bandage to lacerations after bleeding has been controlled. Notify parent/guardian about the student’s condition, as needed. Refer to PCP/ER if bleeding difficult to stop, stitches needed, wound near eye area or any other concerns.Minor Puncture Wounds: Irrigate with saline or clean water and dress. Inspect daily for redness, swelling or increased pain. Minor bruising: Apply cold compress to newly acquired bruises for 10 – 15 minutes.*Bruises noted in unusual location or specific pattern should be evaluated for potential child abuse and reported to agencies as established in __________protocol.Urgent: Support ABC’s, determine need for EMS, control bleeding with direct pressure, contact Parent/guardian to transport student to medical care.All significant puncture wounds (other than slivers) should be cleaned carefully, irrigated with saline or sterile water, and transported for physician evaluation.Emergent: Support ABC’s, Activate EMS, Control hemorrhage, elevate/immobilize extremity, observe student closely until transported by EMS.For all punctures, cuts, abrasions: If tetanus immunization/booster necessary, refer to PCP/NPDOCUMENTATION:Arrival in Health CenterEPIC/PaperTime Parent/guardian or School staff notifiedAssessment and treatment of injuryEducation given regarding dressing change, care of wound, pain management, signs and symptoms of infection.Document findings from: subjective, history, objective, follow-up, intervention and education in EPIC FOLLOW-UP:In event of a referral to PCP/MD/ER a follow-up will be made with the Health Center Provider. REFERENCES: Guidelines for the Nurse in the School Setting, First edition (2010)Armstrong, David G., Meyr, Andrew J, Basic Principles of Wound Management, (2013, October 11)Brancato, John C, Minor Wound Preparation and Irrigation, (2013, September 17) #2 and #3 Retrieved from School Health Alert, Clinical Guidelines for School Nurses, Fifth edition (2002)SPRAINS & STRAINS PROTOCOLHistory:Activity when injury occurred?Re-injury?When and where did injury occur?Assessment:Pain score 0-10.Vital signs.Type of pain: throbbing, stabbing, aching, weight bearing.Appearance of injured area.Level of R.O.M.Intervention:Ice for 15-20 minutes.Wrap area with an ace wrap if needed.Elevate affected limb.May give Ibuprofen or Acetaminophen as needed per Medication Protocol.Notify the student’s parent/guardian about the student’s condition, as needed.Give home care instructions to parent and child according to R.I.C.E. guidelines.If any question of severe sprain or fracture refer to tele-health provider or ER.Documentation:Findings from history, assessment, intervention, and follow-up.Follow-up:In the event of a referral to tele-health provider, a follow-up will be made. 456247518097500197167518097500 Physician’s Signature:Date:Eye Drainage, Foreign Body, Irritation and RednessRN Protocol for Henry Ford Health SystemSchool Based Health ClinicsDEFINITION: Inflammation and/or infection of the conjunctiva (mucous membrane lining the eye), caused by allergens, irritants (e.g dust, smoke, perfume, foreign object, pepper spray), bacterial (staphylococcal, streptococcal, haemophilus) or viral (usually adenovirus, but also herpes simplex) infections. SUBJECTIVE:Signs & Symptoms:Allergic?Discharge is watery; bilateral?No contagious period?May occur with common cold?ItchingBacterial?Purulent drainage (thick, yellow to green-yellow) and crusting during sleep?Often begins unilateral and progresses to bilateral. Spread from hand to hand contact, sharing makeup etc.?Contagious period ends 24 hours after medication is started and symptoms are no longer present?May occur with common coldViral?Usually less severe, watery discharge (may be thick and white to pale yellow)?Lasts 3-5 days?Most often bilateral?Highly contagious, no antibiotics needed?May occur with common cold?Contagious period continues while symptoms are presentChemical?Appears shortly after contact with irritating substance?No contagious periodForeign body?Pain, tearing, irritation and inflammation?No contagious periodASSESSMENT:Allergies to food/medication/environmentHistoryCurrent medicationsRecent Injury to eyeAny burning, itching, watering, dischargeForeign body in eyeTrauma to eye (i.e. projectile object, foreign body, etc.)Current contact lenses useVisual DisturbanceEye PainDrainage/blood from eye, swelling, rednessRecurrent problem?History of seasonal allergies/environmental allergiesOnset of irritation/drainageBilateral, unilateralContact lenses wornRecent illnessVisual disturbancesOBJECTIVEVital signs (Blood Pressure, Heart Rate, Temp, Pulse Ox, & Resp)Assessment of systems: Neurological/GeneralSkinHEENTRespiratoryCardiovascularINTERVENTION/?In cases of severe pain, puncture wound, and cases of vision TREATMENT: change refer to PCP/NP/MD/ER immediatelyEye: Never remove a intraocular foreign body or if history indicates there was a projective object involved – refer to ER.?Chemical substance in the eye is serious emergency. Flush with large amounts of water / saline and refer to ER.?Have student remove contact lenses if applicable (unless excessive heat involved).?Pull lower lid downIf foreign body can be seen (not embedded) in sac of lower lid, remove with moistened cotton-tipped applicator.?For glitter, sand, etc. in eye:Fill paper cup to brim with tap water and have student position irrigated eye in water, look into cup and blink eye, also you can flush eye at eye wash station or with a hand held eye wash bottle.?Depending on irritant it may be necessary to flush eye up to 20 min. with eye rinse solution. (Poison control can be called for added assistance).?Make a referral to MD/PCP/ER if pain continues, feeling of grittiness continues after rinsing, or vision is not normal??If antipyretic given, recheck temperature 30-60 minutes after administration and note if medication was effective.?Cool compress may be applied for 10-20 minutes to ease discomfort?May give loratadine/diphenhydramine as needed per medication protocol?Vision exam if visual disturbances ?May apply a lubricating eye drop like Hypo Tears or Naphcon A drops as needed per medication protocol?In cases of suspected infection refer to NP/PCP/MD?School exclusion guidelines as they apply at individual siteDOCUMENTATION:Arrival time in clinicEPIC/PaperDocument findings from history, assessment, intervention, and follow-up, interventions, and education FOLLOW-UP: In event of a referral to PCP/MD/ER a follow-up will be made.REFERENCES:Clinical Guidelines for School Nurses (2013) NOSEBLEEDSHistory:When did bleeding start?Any sudden temperature change, or dry air?Any trauma or injury?Foreign body in nose?Frequent nosebleeds?Inquire about any clotting abnormalities and use of aspirin.Assessment:Assess for foreign body or recent trauma.Vital signs.Pain scale 0-10.Intervention:Reassure the young child that he can still breathe through the nose.Have the student sit up and lean forward. This minimizes the amount of blood swallowed that may cause vomiting.Assist the student to firmly pinch his anterior nose (nostrils closed) for 5-10 minutes.Paint nostril with Vaseline.Instruct student to avoid blowing the nose and dislodging the clot the rest of the school day.Restrict excessive physical exertion for the remainder of that day; especially if it is hot and sunny. Notify the student’s parent/guardian about the student’s condition, as needed.Refer to tele-health provider for uncontrolled bleeding, spontaneous appearance of ecchymoses (purplish areas) under the skin, significant nosebleed due to injury or any other concerns.Documentation:Findings from history, assessment, intervention, and follow-up.Follow-up:Repeated nosebleeds: refer to tele-health provider.In the event a referral is made to tele-health provider, a follow-up will be made.453390016573500197167516573500 Physician’s Signature: Date:3409950391795Assessment:Assess for foreign body or recent trauma.Location and depth of wound – for greater than 5 mm suspect retained foreign bodyVital signs.Pain scale 0-10.00Assessment:Assess for foreign body or recent trauma.Location and depth of wound – for greater than 5 mm suspect retained foreign bodyVital signs.Pain scale 0-10.161925429895History:When and where did the injury happen?What kind of material was it?How long has it been painful?Assessment:Assess for foreign body or recent trauma.Location and depth of wound – for greater than 5 mm suspect retained foreign bodyVital signs.Pain scale 0-10.00History:When and where did the injury happen?What kind of material was it?How long has it been painful?Assessment:Assess for foreign body or recent trauma.Location and depth of wound – for greater than 5 mm suspect retained foreign bodyVital signs.Pain scale 0-10.SPLINTER REMOVALIntervention:Do NOT attempt to remove a splinter in the eye or close to the eye. Refer to emergency provider.If splinter can be easily seen, use tweezers to grab the splinter. Carefully pull it out at the same angle it went in. Look for small pieces that may have broken off and irrigate with saline solution to clean.If the splinter is under the skin or hard to grab:Sterilize a pin or needle by soaking in rubbing alcohol.Use the pin to gently remove skin over the splinter.Then use the tip of the pin to lift the end of the splinter out so you can grasp the end with the tweezers. Irrigation with saline solution may also work to wash the material out or loosen it. DO NOT RUB.After the splinter is out, wash the area with soap and water. Pat the area dry (DO NOT RUB). Apply antibiotic ointment per medicine protocol. Betadine or peroxide solution is NOT recommended for lacerated tissues. Bandage the area if it is likely to get dirty.Refer to physician if there inflammation, pus or the splinter is deeply embedded.Documentation:Findings from history, assessment, intervention, and follow-up.Education given regarding dressing change, care of wound, pain management, signs and symptoms of infection.Follow-up:In the event a referral is made to PCP/MD/ER, a follow-up will be made.453390016573500197167516573500 Physician’s Signature: Date:References:Splinter removal – University of Maryland Medical Center Stone DB, Svordino DJ. Foreign body removal. In: Roberts JR, ed.?Roberts and Hedges' Clinical Procedures in Emergency Medicine. 6th ed. Philadelphia, Pa: Saunders Elsevier; 2014:chap 36.Winland-Brown JE: Wound Care: Foreign bodies in the skin. The Nurse Practitioner: The American Journal of Primary Health Care. Jun 2010. 35(6): 43-47. Accessed 5/6/2015 at EXAMPLE ANAPHYLAXIS FIRST AID School Health Services NYuploads/Anaphylaxis%20Protocols.doc ANAPHYLAXIS PROTOCOL FOR REGISTERED NURSES #1Standing ordersMedical Director Physician Name ( Printed )___________________________________________________Physician Signature___________________________________________________License Number___________________________________________________ - OR- - OR –Nurse Practitioner Name( Printed )___________________________________________________Nurse Practitioner Signature___________________________________________________License Number___________________________________________________Prescription: EPI-PEN: Epinephrine Auto-Injector, 0.3 mg/Adult Unit Dose, IM. Prn for emergency treatment of anaphylaxis. RN non-patient specific orders:RNs must maintain or ensure maintenance of a copy of the standing orders and protocol authorizing them to administer anaphylactic treatment agents.Ensure that a record is kept of all persons who received epinephrine and/or other agents to treat anaphylaxis including but not limited to: the non-patient specific standing order and protocol utilized, the recipients name, date, address of administration site, administration nurse and anaphylactic treatment, manufacturing and lot number.Arrange for appropriate follow up by calling 911. (or ensure equivalent follow-up is provided) Report to EMS information of event, treatment provided (including when and time administered, dose, strength, which anaphylactic agent and route of administration).Report information to staff's primary care provider unless unable to obtain information from the recipient.Follow treatment guidelines: see attachedTreatment for Allergic ReactionsSevere to Moderate Reaction:Generalized hives or itching: swelling of lips, tongue, face or extremities: throat tightness, coughing or breathing difficulty; dizziness or headache; abdominal cramping or nausea; elevated temperature; unstable or falling pulse or blood pressure all constitute a potential Life Threatening Emergency.Administer epinephrine per family physician orders if available or use Non Patient Specific Standing Orders.If no personal kit is available, the nurse will make the decision to administer stock epinephrine, subcutaneous injection on outer thigh, based on the severity of the reaction at the approximate doses: AgeEPI-PENANA-KIT>130.30 ml AdultEpi 0.3 ml, 4 TabletsOnce Epinephrine has been given, someone, ideally a RN should stay with patient until help arrives.Call or have an assistant call 911 immediately and indicate "life threatening emergency" and provide details of treatment rendered and patient's current status.Notify or have assistant notify the family of the staff member to meet the nurse or designee in the Emergency Department. Ideally notify the private physician prior to the delivery of the medication. However, in a severe life threatening reaction do not delay medication delivery pending such calls. Instead notify them following drug administration and stabilization.If twenty minutes have passed and the person remains unstable and 911 has not responded repeat dose of Epinephrine.Proper record keeping must be done. Records must include agent name, manufacturing and lot numbers, date, site, nurse's name and address and recommendations for follow-up. The record must be done in duplicate, signed and the duplicate given to the patient or family with verbal instructions to give the certificate to the emergency room physician or private provider. Proper adherence to sterile technique with careful attention to Standard Precautions, including safer needle systems when feasible and proper disposal of needle and syringes will be strictly followed. ANAPHYLAXIS PROTOCOL FOR REGISTERED NURSES #2Standing ordersMedical Director Physician Name ( Printed )___________________________________________________Physician Signature___________________________________________________License Number___________________________________________________ - OR- - OR –Nurse Practitioner Name( Printed )___________________________________________________Nurse Practitioner Signature___________________________________________________License Number___________________________________________________Prescription: EPI-PEN: Epinephrine Auto-Injector, 0.3 mg/Adult Unit Dose, IM. Prn for emergency treatment of anaphylaxis. RN non-patient specific orders:RNs must maintain or ensure maintenance of a copy of the standing orders and protocol authorizing them to administer anaphylactic treatment agents.Ensure that a record is kept of all persons who received epinephrine and/or other agents to treat anaphylaxis including but not limited to: the non-patient specific standing order and protocol utilized, the recipients name, date, address of administration site, administration nurse and anaphylactic treatment, manufacturing and lot number.Arrange for appropriate follow up by calling 911. (or ensure equivalent follow-up is provided) Report to EMS information of event, treatment provided (including when and time administered, dose, strength, which anaphylactic agent and route of administration).Report information to staff's primary care provider unless unable to obtain information from the recipient.Nursing DiagnosisAssessmentsInterventionExample: Potential for altered respiratory status/anaphylaxis due to immunizationItching and swelling of lips, tongue and mouthTightness in the throat, hoarseness, hacking coughHives, itchy rash, or swelling about the face or extremitiesNausea, abdominal cramps, vomiting and/or diarrheaShortness of breath, repetitive coughing or wheezingThready pulse, unconsciousnessHave person sit downAdminister Epi-pen to outer thighCall 911Inform EMS of event, including when and time administered, dose, strength, which anaphylactic agent and route of administrationDocument event in writing (see above for information)Call staff person’s primary care provider if can obtain such information from recipientFill out incident report formBURNSHistory:How and when did burn occur?Be alert to possible child abuse, self-tattoo, or deliberate injury.Are parents aware of burn?Assessment:Vital signs.Rate pain level 0-10.Type of burn: 1st, 2nd, or 3rd degree.Source of burn: chemical, electricity, sunlight, heat, fire.Assess for anxiety, agitation, dehydration, infection or shock.Date of last Tetanus shot. Interventions: First-Degree Burn:Apply cool compress or soak in cool water for 15 minutes.Wash with mild soap and water.Place a dry, gauze bandage over burn.May give Acetaminophen or Ibuprofen as needed per Medication Protocol.Notify the student’s parent/guardian about the student’s condition, as needed. Second-Degree Burn: Contact tele-health providerApply cool compress or soak in cool water for 15 minutes.Wash with mild soap and water. If blister is present, do not break.Cover burn with a dry, non- stick dressing (telfa), held in place with gauze or tape.May give Acetaminophen or Ibuprofen as needed per Medication Protocol.Notify the student’s parent/guardian about the student’s condition, as needed.Refer the student to tele-health provider. Third-Degree Burn:Do not soak or apply ointment.Cover area with sterile bandage or clean cloth.Notify the student’s parent/guardian about the student’s condition, immediately.Refer all 3rd degree burns to ER immediately.*SPECIAL CONSIDERATIONS*Refer the following to tele-health provider immediatelyAny 1st or 2nd degree burn that covers an area larger than 2-3 inches in diameter.Any burn that is on a student’s face, hands, feet or genitals.Any chemical or electrical burn.Any burn considered suspicious for abuse Physician’s Signature: __________________________________ Date: ___________________________Medication AdministrationExamples EXAMPLE MEDICATION ADMINISTRATION Branch County, MichiganCommunity Health Center of Branch CountyCardinal ConnectMedication Protocols and Standing Orders*Allergy status must be asked at each visit before administering any medications.*-Acetaminophen: 10-15mg/kg/dosage instructions on medication bottle. Can be given every 4 hours as needed. Maximum of 5 doses every 24 hours.-Antacid: (aka Maalox, Mylanta) 5-15ml/dose or per dosage instructions on medication bottle. Can be given as needed every 4 hours.-Bacitracin Ointment: Apply topically to affected area up to 3 times a day as needed.-Cough and Throat Drops: May give 1 lozenge every 2 hours as needed.-Ibuprophen: 10mg/kg/dose or per dosage on medication bottle. Can be given every 6 hours as needed. Maximum 40mg/kg/24 hours.-Loratadine: (aka Claritin) 10mg PO QD-Visine eye drops: 1-2 drops in affected eye up to 4 times a day.-Polysporin Ointment: Apply topically to affected area up to 3 times a day as needed.-Sudafed: 60mg/dose every 4-6 hours as needed or medication bottle instructions. Not to exceed 240mg in 24 hours.-Hydrocortisone Ointment: Apply topically to affected area up to 3 times a day as needed.Physician’s Name Printed:_________________________________________________________________Physician’s Signature_____________________________________________________________________Physician’s License Number________________________________________________________________Date Effective FROM__________________________________TO_________________________________Community Health Center of Branch CountyCardinal ConnectEmergency Medications Albuterol: Pre-Mixed nebulizer solution 2.5mg/3ml. 1 dose per mild asthma exacerbation, up to 3 doses every 20 minutes for severe asthma exacerbation.Epi-Pen: (0.3mg) injection for life threatening allergic reaction in outer aspect of thigh.Benedryl: Ages 12 – adult: 25-50mg or per dosage instructions on medication bottle. Can be given 3-4 times a day. Not to exceed 300mg per 24 hours.Glucagon Emergency Kit: 1mg IM or SQ for severe hypoglycemia under 40 in an unconscious patient.Physician’s Name Printed:_________________________________________________________________Physician’s Signature_____________________________________________________________________Physician’s License Number________________________________________________________________Date Effective FROM__________________________________TO_________________________________Medical Management& Health EducationExamplesEXAMPLE MEDICAL MANAGEMENT/ EDUCATIONVirginia Diabetes Mgmt(adapted from Virginia Diabetes Medical Management Plan and Protocol: pgs 26-29) DIABETES MANAGEMENT EDUCATIONGOAL: Facilitate student self-management competence appropriate to maturity-level, age, capability and willingness. Background Nurse ResponsibilitiesObtain and review the student’s current DMMP from the medical provider and review pertinent information with the family.Conduct a nursing assessment of the student and develop an Individualized Health Care Plan (IHP) as indicated (Institution Specific).Participate in the development and implementation of the student’s 504, Individualized Educational Program (IEP), or other education plan as indicated. (Institution Specific)Conduct ongoing, periodic assessments of students with diabetes and update the nursing care plan. Obtain materials and medical supplies necessary for diabetes care tasks from the parent/ guardian and notify the student or parent/guardian when supplies need to be replenished (Appendix C & G).Promote and encourage independence and self-care consistent with the student’s ability, skill, maturity, and developmental level. Communicate to parent/guardian concerns about the student’s diabetes management or health. Respect the student’s confidentiality and right to privacy. Act as an advocate for students to help them meet their diabetes health care needs and facilitate care to minimize the amount of class time missed.Act as liaison between the school and student’s health care provider/team regarding the student’s diabetes management at school with parental permission.Identify available resources and make a contact sheet. These might include: Physicians, Nurse Practitioner and or Physician Assistant Nurse Dietitian Certified Diabetes Educator Social Worker Education ConsultantAS PART OF ONGOING, PERIODIC ASSESSMENT:Review student’s responsibilities for their own care ( as appropriate to age, maturity level, capability and willingness ):Learn age-appropriate diabetes care.Know the following:Who to contact and what to do when you feel symptoms of low or high blood glucose.What the written school plan says to help manage your diabetes.When you should check blood glucose levels, give insulin, have a snack, and eat breakfast/ lunch.Where the diabetes supplies are stored, if you do not carry them, and who to contact when you need to use them.Take charge of your diabetes care at school as the DMMP allows. This may include:Monitoring and recording blood glucose levels.Calculating accurate insulin doses, if applicable.Self-administration of insulin/medications.Proper disposal of needles, lancets, and other supplies .Eating meals and snacks as prescribed and reporting intake as necessary for insulin dosing.Treating hypoglycemia and hyperglycemia (low & high blood glucose).Carrying and using diabetes equipment and supplies as directed.Cooperate with school and healthcare personnel who are assisting you with & supervising your diabetes care.Always wear medical alert ID.Always carry a quick-acting source of glucose as recommended by your health care team. Mental & Behavioral HealthExamplesEXAMPLE MENTAL / BEHAVIORAL HEALTH School-Based Health AllianceBehavioral Health Screening and Assessment Best Practice: School-based health center staff (i.e. primary care and/or behavioral health provider) should screen students for behavioral health problems and risk factors as part of the comprehensive health risk assessment. Behavioral health provider should conduct further assessment based on health risks and/or presenting problems. Procedures: Use a comprehensive health risk assessment consistent with recognized, current standards of practice for children and adolescents, using standardized tools [e.g., Bright Futures, Rapid Assessment for Adolescent Preventive Services (RAAPS) Questionnaire]. Ensure that health risk assessment includes screening questions related to physical and behavioral health issues. Review results of risk assessment with attention to problems and risk behaviors related to the following: ? Eating Disorders ? Overweight/Obesity ? Tobacco ? Alcohol, Other Drugs ? Sexual Behaviors ? Depression ? Anxiety ? Harmfulness to self (suicide risk, nonlethal self injury), others, or property ? History of Abuse / Violence ? Learning/School Problems Complete for all new SBHC users initiating behavioral health services, and annually for all established SBHC users. When areas of need are identified on the health risk assessment, the behavioral health provider initiates one or more of the following: Indicated behavioral health assessment to identify behavioral health conditions, beginning with established assessment instruments [e.g. PHQ-9 Modified for Teens (depression); SCARED (anxiety)]. Comprehensive behavioral health assessment (see #3 below) to identify and/or diagnose behavioral health disorders and co-existing conditions and in order to determine appropriate treatment modality and plan for student. Distribution of educational materials on relevant topics Refer student for appropriate services Document risk factors, clinical findings, and recommended interventions, if any, and whether follow up is necessary When conducting a behavioral health assessment, gather information from student and collateral source(s) (including parents and teachers if appropriate) pertaining to the following: Description of presenting problem(s), including the source of distress, precipitating events, exacerbating and alleviating factors, associated problems and/or symptoms Mental status Mental health/psychiatric history: chronological mental health, substance abuse, physical and/or sexual abuse Past treatment history. including psychotropic medication Social History Medical history: relevant physical health history and current status including medication; treatment history Identified biological, psychological, familial, social/employment, educational, legal, developmental and environmental dimensions and identified strengths and weaknesses Identification of non-traditional or natural supports Cultural background, spiritual/religious beliefs, language preference (of student and parents), and other relevant issues Crisis/safety plan, if applicable Care coordination of SBHC providers with other providers Evidence of parental notification if required (or documentation of exemptions for parental notification) consistent with state law Document comprehensive assessment and treatment plan in the format set forth by the health center protocol (e.g. Electronic Medical Record, chart, or agency specific behavioral health assessment document) prior to beginning treatment. (See Protocol 6 – Behavioral Health Documentation) Schedule follow-up session for further behavioral health assessment and treatment planning if necessary. Refer student to SBHC primary care provider for well child exam (e.g. EPSDT) if indicated. EXAMPLE MENTAL / BEHAVIORAL HEALTH LA schools – Baton RougeSuicide ProtocolPolicy: The Health care Centers in Schools professional staff will make an assessment for suicide risk when a student presents emotional, verbal, cognitive or behavioral symptoms which indicate thoughts of suicide or self-destructive behavior. Protocol: 1. Professional staff complete a suicide assessment form ( see form )including: a. verbal, behavior, situational clues regarding suicide. b. current plan (time, place, means, access to means) c. previous attempts/ideation2. Using the information gathered from the assessment and the clinic staff person’s professional judgment, the suicidal ideation/behavior will be classified as either PAST or CURRENT and the corresponding procedure will be followed.3. PAST ideation/behaviora. Single incident of suicidal thought, no plan: (1) the clinic staff person will contact a parent or custodial guardian (see below: Parental notification.) This call will be completed within 2 working days. If the parent cannot be reached by telephone, a certified letter will be mailed to them (see form: Letter to parent regarding suicide.)b. Recurrent suicidal thoughts or previous suicidal thought and a plan. (1) The clinic staff person will contact a parent or custodial guardian (see below: Parental Notification.) This call will be made immediately. (2). The clinic staff person may: (a) request that a parent meet with the staff person to discuss the suicidal ideation and outline a plan to meet the student's immediate psychosocial and safety needs.(b). call a crisis response team from either _________________________ or ____________________ ( includes phone numbers ).(c) contact ______________________ Phn______________ to make an immediate assessment and treatment determination.(d) refer to Family Practice clinic at ______________________ and request an assessment by the psychological assessment team. 4. CURRENT suicidal ideation/behavior. In this situation, the clinic staff person:Will contact a parent or custodial guardian (see below: Parental Notification.) This call will be made immediately.May request the a parent meet with the staff person to discuss the suicidal ideation and outline a plan to meet the student’s immediate psychological and safety needs.May call a crisis response team from either ____________________________ for assessment, referral, and recommendationMay contact ________________________ Phn _______________ to make an immediate assessment and treatment determination.If the parent refuses to follow the clinic staff person’ recommendations, the parent will be asked to sigh a form acknowledging that he/she has been notified of his/her child’s suicidal ideation and/or behaviors. This form will be kept in he student’s medical chart at the school clinic. The clinic staff person may also inform the parent that it is neglectful not to get treatment for a suicidal child and, if the child does not receive treatment, the Child Protection agency is notified.5. Staffing- Cases involving suicidal ideation/behavior will be staffed at either the next regular clinic staffing meeting or at an emergency clinical staffing.6. Follow-up Student will be contacted by clinic staff within 2 working days following a disclosure or suicidal ideation/behavior. Assessment data will e written in SOAP form.7. HCCS Suicide Assessment form is completed.Confidentiality- The student will be told that thoughts of killing or hurting oneself are very serious, and the staff person is required to disclose this information to the student’s parent/custodial guardian.Parental Notification- The parent who has signed the clinic consent form will be contacted when a student exhibits suicidal ideation. If a student does not live with his/her legal guardian, the custodial adult must also be contacted to provided direct supervision for the student. If there is no signed clinic consent form, the parent named on the student’s school record will be contacted. The parent will be contacted even when the student states that his/her parent already knows of the suicidal thoughts/behavior. During this call, the staff person will discuss: 1. current status of the student 2. student’s exact reference to suicide 3. important parental role in providing love, support, help 4. steps to be taken to supervise the student-have someone with them at all times for specific period of time-do not smother, but provide support and express care. 5. remove all means of suicide (weapons, pills, knives, etc.) from the access of the student. 6. assist the student/family in seeking counseling as needed.The local crisis intervention center/suicide hotline ___________________ may be a referral for the student and family.VaccinationsExamplesEXAMPLE VACCINATION Minnesota Dept of HealthAttenuated Influenza Vaccine (LAIV) Vaccine ProtocolPersons Age 2 through 49 Yearshealth.state.mn.us/divs/idepc/immunize/hcp/protocols accessed 1/26/2015Condition for protocol: To reduce incidence of morbidity and mortality of influenza disease.Policy of protocol: The nurse will implement this protocol for live attenuated influenza (LAIV) vaccination.Condition-specific criteria and prescribed actions:Attention persons adopting these protocols: The criteria below list indications, contraindications, and precautions that are necessary to implement the vaccine protocol. The prescribed actions include examples shown in [ ] but may not suit your institution’s clinical situation and may not include all possible actions. A licensed prescriber must review the criteria and actions and determine the appropriate action to be prescribed. (Delete this paragraph before version is signed.)CriteriaPrescribed ActionIndicationsCurrently healthy person age 2 through 49 years.Proceed to vaccinate if meets remaining criteria.Person is age 6 through 23 months of age or 50 years or older.Do not give LAIV. Vaccinate using the age-appropriate IIV protocol.Person has any reported chronic medical condition, including asthma or recurrent wheezing in children age 2 through 4 years. Do not give LAIV. Vaccinate using the age-appropriate IIV protocol.Pregnant woman.Do not give LAIV. Vaccinate using the age-appropriate IIV protocol.Person is a household contact of or healthcare worker for someone who is severely immuno-compromised and who requires protective isolation.Instruct the person receiving LAIV not to come in contact with the immunocompromised person for 7 days following vaccination, OROffer to provide IIV and use the age-appropriate IIV protocol.ContraindicationsPerson had a life-threatening allergic reaction (anaphylaxis) to a previous dose of influenza vaccine.Do not vaccinate; _____________________Child age 2 through 18 years who is currently on aspirin therapy.Do not give LAIV. Vaccinate using the age-appropriate IIV protocol.Person has life-threatening allergic reaction (anaphylaxis) to a component of LAIV. Do not vaccinate; _____________________Person has an egg allergy or allergy testing is suggestive of egg allergy even though the person has never been exposed to eggs.Do not give LAIV.[Follow the attached egg allergy algorithm to determine whether or not to vaccinate with IIV and follow IIV protocol.] [Give RIV if available using the age-appropriate IIV protocol.][Refer to primary care provider for further evaluation.]PrecautionsPerson has had Guillan-Barré syndrome (GBS) within 6 weeks of a previous dose of influenza vaccine.[Proceed to vaccinate after discussing risk and benefit of influenza vaccination and GBS.][Refer to primary care provider for assessment of situation and risk-benefit determination.]Person has nasal congestion that blocks their ability to breathe through the nose.Defer vaccination until congestion resolves or if available, offer an IIV product and use the age-appropriate IIV protocol.Person received another live virus vaccine within the past 4 weeks.[Defer vaccination until 4 weeks have passed.][Give inactivated influenza vaccine if available. Follow the appropriate protocol for age.] Person is currently on antibiotic therapy.Proceed to vaccinate.Prescription: Give FluMist spray: 0.1 mL into each nostril.Follow the algorithm on the next page in order to determine which children age 2 through 8 years* need a second dose of LAIV.Give the 2nd dose at least 4 weeks after the first dose.*This age range applies to LAIV only because LAIV is licensed for children starting at age 2 years. Certain inactivated influenza vaccines allow the second dose for children as young as age 7 months (when dose one was given at age 6 months). Please refer to the: Inactivated Influenza Vaccine (IIV) Protocol, Children Age 6 Months through 8 Years.Medical emergency or anaphylaxis: [Depending on clinic staffing, include one of the two options below.]In the event of a medical emergency related to the administration of a vaccine. RN will apply protocols as described in ______________________________________________________________________________.In the event of an onset of symptoms of anaphylaxis including: rashitchiness of throatswollen tongue or throatdifficulty breathingbodily collapseLPN or unlicensed assistive personnel (MA) will immediately contact the RN in order to implement the___________________________________________________________________________________________.Questions or concerns:In the event of questions or concerns, call ____________________________at _____________________________.This protocol shall remain in effect for all patients of ______________________________until rescinded or until _____________________________________.Name of prescriber: Signature:Date:Document reviewed and updated:____________– sample protocol LAIV –MDH rev 9-2014Algorithm for Evaluation of an Egg Allergy Preceding Influenza Vaccination, 2014 –153115310105410Yes00Yes5334076835Can the person eat lightly cooked egg (e.g., scrambled egg) without reactions? 1, 200Can the person eat lightly cooked egg (e.g., scrambled egg) without reactions? 1, 227965407302500432054063500Give vaccine per usual protocol.00Give vaccine per usual protocol.1110615114300No00No9105909588500432054040640Give IIV and observe for reaction for at least 30 minutes after vaccination.3 ORGive Recombinant Influenza Vaccine (RIV) if patient is 18 through 49 years old00Give IIV and observe for reaction for at least 30 minutes after vaccination.3 ORGive Recombinant Influenza Vaccine (RIV) if patient is 18 through 49 years old3105785127000Yes00Yes72390128270After eating eggs or egg-containing foods, does the person experience ONLY hives?00After eating eggs or egg-containing foods, does the person experience ONLY hives?27965405778500910590133985001101090161925No00No7239019685Does the person experience other symptoms such asCardiovascular changes (e.g., hypotension)?Respiratory distress (e.g., wheezing)?Gastrointestinal (e.g., nausea/vomiting)?Reaction requiring epinephrine?Reaction requiring emergency medical attention?00Does the person experience other symptoms such asCardiovascular changes (e.g., hypotension)?Respiratory distress (e.g., wheezing)?Gastrointestinal (e.g., nausea/vomiting)?Reaction requiring epinephrine?Reaction requiring emergency medical attention?432054061595Give RIV if patient is 18 through 49 years old OR IIV should be administered by a health care provider with experience in the recognition and management of severe allergic conditions00Give RIV if patient is 18 through 49 years old OR IIV should be administered by a health care provider with experience in the recognition and management of severe allergic conditions3124835130175Yes00Yes279146021590001Persons with egg allergy might tolerate egg in baked products (e.g., bread or cake). Tolerance to egg-containing foods does not exclude the possibility of egg allergy.2If there is no previous exposure to eggs but suspicions of egg allergies exist due to prior allergy testing, give RIV if available, or refer to a physician with expertise in management of allergic conditions.3Clinics should ensure that staff are familiar with and have appropriate equipment for responding to anaphylactic reactions.Source: Centers for Disease Control and Prevention: Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practice (ACIP) – United States, 2014-15 Influenza Season, found at mmwr/preview/mmwrhtml/mm6332a3.htm?s_cid=mm6332a3_w Minnesota Dept. of Health – Immunization Program(8/14)2987040-71120Yes00YesInfluenza vaccine dosing algorithm for children 6 months through 8 years old2014 –15 Influenza Vaccination Season496570243205Did the child receive at least one dose of seasonal influenza vaccine in 2013-14?00Did the child receive at least one dose of seasonal influenza vaccine in 2013-14?48075851257301 dose001 dose69881737784No/Don’t know00No/Don’t knowcenter30162Yes00Yes496570128270Did the child receive 2 or more doses of seasonal vaccine since July 2010?00Did the child receive 2 or more doses of seasonal vaccine since July 2010?4744085190501 dose001 dose71151752071No/Don’t know00No/Don’t know2794001466852 dosesat least 4 weeks apart002 dosesat least 4 weeks apart25400017145Additional considerations:If adequate documentation can be found and a child is known to have received at least 2 seasonal influenza vaccines during any previous season, and at least 1 dose of a 2009(H1N1)-containing vaccine (i.e., monovalent H1N1 vaccine or seasonal influenza vaccine from 2010 or later), then the child needs only 1 dose for 2013-14.To summarize, the child, age 6 months through 8 years needs only 1 dose of influenza vaccine this season if they received any of the following:2 or more doses of seasonal influenza vaccines since July 1, 20102 or more doses of seasonal influenza vaccine before July 1 , 2010, and 1 or more doses of monovalent 2009(H1N1) vaccine1 or more doses of seasonal influenza vaccine before July 1, 2010, and 1 or more doses of seasonal influenza vaccine since July 1, 2010.00Additional considerations:If adequate documentation can be found and a child is known to have received at least 2 seasonal influenza vaccines during any previous season, and at least 1 dose of a 2009(H1N1)-containing vaccine (i.e., monovalent H1N1 vaccine or seasonal influenza vaccine from 2010 or later), then the child needs only 1 dose for 2013-14.To summarize, the child, age 6 months through 8 years needs only 1 dose of influenza vaccine this season if they received any of the following:2 or more doses of seasonal influenza vaccines since July 1, 20102 or more doses of seasonal influenza vaccine before July 1 , 2010, and 1 or more doses of monovalent 2009(H1N1) vaccine1 or more doses of seasonal influenza vaccine before July 1, 2010, and 1 or more doses of seasonal influenza vaccine since July 1, 2010.Source: Centers for Disease Control and Prevention: Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practice (ACIP) – United States, 2014-15 Influenza Season, found at mmwr/preview/mmwrhtml/mm6332a3.htm?s_cid=mm6332a3_w Minnesota Dept. of Health – Immunization Program(8/14)EXAMPLE VACCINATION Minnesota Dept of HealthCombination Measles, Mumps, Rubella, and Varicella (MMRV) Vaccine as ProQuad Vaccination ProtocolCondition for protocol: To reduce incidence of morbidity and mortality of measles, mumps, rubella and varicella disease.Policy of protocol: The nurse will implement this protocol for ProQuad (MMRV) vaccination.Condition-specific criteria and prescribed actions:For persons adopting these protocols: The criteria listed below include indications, contraindications, and precautions for implementing the vaccine protocol. However, the criteria must be reviewed and further delineated according to the licensed prescriber’s parameters. Additional criteria and prescribed actions may be necessary. The prescribed actions are examples and may not suit your institution’s clinical situation and do not include all possible actions. A licensed prescriber must review the criteria and actions and determine the appropriate action to be prescribed.CriteriaPrescribed ActionIndicationCurrently healthy child.Proceed to vaccinate if meets remaining criteria.Child is between ages 12 months and 4 years and is due for first dose MMR and varicella vaccines and parent is requesting the MMRV as a combination injection.[Give MMR and varicella as separate injections using the respective MMR and varicella protocols. Explain to parent that institution policy is to give MMR and varicella as separate injections for the first dose in this age range. Refer elsewhere if parent insists on combination vaccine.][Review risks for febrile seizures and if parent consents to vaccination knowing risks proceed to vaccinate with MMRV.][Refer to primary care provider for discussion of risks and benefits to giving MMRV for the first dose at age 12 months to 4 years.]Child is 15 months of age or older and is due for second dose of MMR and second dose of varicella.Proceed to vaccinate with MMRV if meets remaining criteria.Child is between ages 4 years through 12 years and is due for either first dose or second dose of MMR and varicella.Proceed to vaccinate with MMRV if meets remaining criteria.Child is less than age 1 year old.Do not vaccinate. If child is traveling and MMR is indicated, follow MMR protocol. Child is 13 years or older.Do not give MMRV; product is not licensed for persons 13 years or older. Give MMR and varicella separately using respective protocols.Child had a prior infection of measles, or mumps, or rubella.Not a contraindication for MMRV, proceed to vaccinate. [Document date of diagnosis of specific disease.]Child had a prior infection of varicella[Combination product is not necessary, give MMR.][Not a contraindication for MMRV, may give if MMR is not available]ContraindicationChild had a systemic allergic reaction (anaphylaxis) to a previous dose of MMR or varicella vaccine.Do not vaccinate; _____________________Child has a systemic allergy to a component of MMR or varicella vaccine.Do not vaccinate; _____________________Child has family history of congenital or hereditary immunodeficiencies, and child’s immune competence has NOT been demonstrated.Do not vaccinate; _____________________; [refer to primary care provider for further evaluation.]Child has any of the following altered immune conditions: blood dyscrasias, leukemia, lymphomas of any type, or other malignant neoplasms affecting the bone marrow or lymphatic system; primary or acquired immunodeficiency including HIV/AIDS, cellular immune deficiencies, hypogammaglobulinemia, dysgammaglobulinemia; systemic immunosuppressive therapy including oral steroids ≥2 mg/kg or ≥20 mg/day of prednisone or equivalent for persons who weigh >10 kg, when administered for ≥2 weeks; chemotherapy – any kind, or radiation therapy.Do not vaccinate: _____________________; [refer to primary care provider for further evaluation.]PrecautionChild is currently on antibiotic therapy.Proceed to vaccinate.Child has a mild illness defined as temperature less than ____°F/°C with symptoms such as: [to be determined by medical prescriber]Proceed to vaccinate.Child has a moderate to severe illness defined astemperature ____°F/°C or higher with symptoms such as: [to be determined by medical prescriber]Defer vaccination and [to be determined by medical prescriber]Receipt of antibody-containing blood product within past 11 months.Obtain date that person last received product and using the attached “Suggested Intervals Between Administration of Antibody-Containing Products and Measles-Containing or Varicella-Containing Vaccine” table, determine: - Whether there should be a delay time and - What the delay time is. If delay is indicated, defer until interval is completed. If deferral time is expired, vaccinate.Child has history or family history of seizures, including febrile seizures. Do not give combination MMRV; give MMR and varicella as separate vaccines.Person received a live virus vaccine within the past 4 weeks.Defer vaccination until at least 4 weeks have passed since the dose of live virus vaccine.History of thrombocytopenia or thrombocytopenic purpuraDo not vaccinate; [refer to primary care physician]Prescription: Give MMRV, 0.5 ml, SC. Routine administration of MMR and varicella is at age 1 year and age 4-6 years.Separate varicella-containing vaccine doses by 3 months for children through age 12 years. Medical emergency or anaphylaxis: [Depending on clinic staffing, include one of the two options below.]In the event of a medical emergency related to the administration of a vaccine. RN will apply protocols as described in ____________________________________________________________________________________________.In the event of an onset of symptoms of anaphylaxis including: rashitchiness of throatswollen tongue or throatdifficulty breathingbodily collapseLPN or unlicensed assistive personnel (MA) will immediately contact the RN in order to implement the____________________________________________________________________________________________.Questions or concerns:In the event of questions or concerns, call Dr. ____________________________at _____________________________.This protocol shall remain in effect for all patients of ______________________________until rescinded or until _____________________________________.Name of prescriber: Signature:Date:Reproductive & Sexual HealthExamplesEXAMPLE REPRODUCTIVE HEALTHHealth Dept NW MichiganHealth Department of Northwest MichiganPOLICY/PROCEDUREPROGRAM: Reproductive HealthSECTION: Clinic (33)SUBJECT: Family & Community Health NursePAGE: 1 OF 3Standing Orders for Reproductive Health EFFECTIVE DATE: January 30, 1998REVISED: March 7, 2013REVIEWED:ISSUED BY:Joshua Meyerson, MD, MPH, Medical DirectorLisa Peacock, RN, MSN, WHNP-BC, Nurse PractitionerPatricia Fralick, RN, BSN, MBA, Director of Family and Community HealthPURPOSE: To create a process for dispensing prescriptive and non-prescriptive contraceptives and other medications by a Family Health Registered Nurse working in a Reproductive health clinic.POLICY: Family and Community Health Registered Nurses (RN) may dispense prescriptive and non-prescriptive contraceptives and other medications in a Reproductive Health Clinic following the procedures described.PROCEDURE:A current written or verbal order, from the Nurse Practitioner, Physician or Medical Director, has been stated or written for the client.No contraindications to the contraceptives/medications exist. See attached specific contraceptive/medication information for:Combined Oral Contraceptives (COC)Depo Provera (Depo)Progestin Only Pill (POP) NuvaRing (Vaginal Ring)Emergency Contraceptive Pills (ECPs)ChlamydiaGonorrheaBacterial VaginosisYeastTrichomoniasisUrinary Tract Infection.The RN has signed the current ‘Standing Orders for Public Health Nurses at Reproductive Health Clinics’ signature form.The RN has reviewed the client’s chart starting with the last initial/annual visit and all subsequent visits up to current visit.The RN documents the event in the client’s chart on the appropriate form.Pill Pick Up visits are documented on Combined Hormonal Method flowsheet.Depo shots are documented on the Depo Provera flow sheet.Vaginal Ring revisits are documented on Combined Hormonal Method flowsheet.ECP visits are documented on the Emergency Contraceptive Pill Visit Record.Pregnancy tests are documented on the Questionnaire for Pregnancy Determination form, Physical Exam form, Combined Hormonal flowsheet, Depo Provera flow sheet, or Medical Visit form.Episodic visits i.e. treatment for chlamydia, gonorrhea, BV, trichomoniasis, UTI, is documented on the Medical Visit form.Narrative note may be used to document any transaction i.e. telephone call with client, arrangements for client to pick up a pack of pills, that does not involve a visit.The RN consults with a Nurse Practitioner, Physician or Medical Director if there is any finding which may indicate a potential health risk to the client.A blood pressure, weight, hemoglobin, urinalysis, and pregnancy test may be done if indicated.Hepatitis B and Hepatitis A and HPV vaccines may be administered to reproductive health clients per immunization protocol.Evaluation for pregnancy may be done by performing a pregnancy test.Prior to performing a pregnancy test, multistix 7 test, chemstrip GP test, or hemoglobin test, the RN has passed annual competency testing. Results are documented on RH Clinic Lab Sheet.The RN may assess client and dispense medication for ECPs per protocol.The RN may collect urine samples from client for testing or re-testing for chlamydia and gonorrhea testing.Non prescriptive contraceptives may be dispensed without an order.Medications are also documented on the ‘Medications and Supplies’ form N-343_____________________________________________ ___________________ Joshua Meyerson, MDDate_____________________________________________ ___________________ Lisa Peacock, RN, MSN, NP Date_____________________________________________ ___________________ Family & Community Health Nurse DateThe references for this order are Protocols/ Standing Orders for the Nurse Practitioner HDNW:Oral Contraceptives (Combined) COCDepo Provera (DMPA)Progestin Only Pill (POP)NuvaRing (Vaginal Ring)Emergency Contraceptive PillsFemale Urinary Tract Infection Policy and ProcedureBacterial VaginosisTrichomoniasisYeastGonorrheaChlamydiaPublic Health Nurse ResponsibilitiesDrug Formulary EXAMPLE SEXUAL HEALTHHFHSMissed Menstrual Cycle/AmenorrheaRN Protocol for Henry Ford Health SystemSchool Based Health ClinicsDEFINITION Amenorrhea is the absence of menstruation and is often classified as primary (absences of menarche by age 15) or secondary. Pregnancy is the most common cause of secondary amenorrhea. It may occur even in females who claim that they have not been sexually active or are positive that intercourse occurred at a "safe" time. It is also important to note that apparent menstrual bleeding does not exclude pregnancy, since a substantial number of pregnancies are associated with some early first trimester bleeding. SUBJECTIVE:?Missed/No menstrual cycleSigns & Symptoms?Nausea/Vomiting/Abdominal discomfort or pain?Breast Tenderness/weight gain?Menarche delayed beyond age 15?No secondary sexual characteristics (i.e. breast development, etc.)?Runners, gymnasts, athletes, excessive exercise?Female with too little body fat/extreme dieters/vegan?History of unprotected sexual intercourseASSESMENT:LMP/Duration of menstrual cyclesHistoryPrevious History of amenorrheaHistory of eating disorder/vegan/athleticsReproductive History/previous Sexual transmitted diseases OBJECTIVE:Vital Signs (Blood glucose, temp, blood pressure, heart rate, resp. rate, weight/BMI)Pain Scale/AssessmentAssessment of systems:Neurological/AppearanceAbdominal (GI/GU)Sexual Health AssessmentINTERVENTION/?Obtain urinary human chorionic gonadotropin (HCG) TREATMENT:(after completion of SBH Pregnancy Test Consent; Follow SBH policy for positive pregnancy results per pregnancy consent)?Contact parent if child under 14 years old and pregnancy test is positive?Sexual Transmitted Disease/Contraceptive Counsel?Refer/consult with NP/PA/MDDOCUMENTATION:Arrival time in clinic.Epic/PaperTime of notification of parent/school staff if child is sent home.Notification of parent /guardian (if indicated).Document findings from subjective, history, objective, follow-up, intervention and education.FOLLOW-UP:In event of a referral to PCP/MD/ER a follow-up may be made; schedule Appointment with Health Center ProviderREFERENCES: UpToDate 2014: Guidelines for School Nurses (2013)EXAMPLE STI TREATMENT HFHSSexually Transmitted Infection (STI) TreatmentRN Protocol for Henry Ford Health SystemSchool Based Health ClinicsDEFINITION:This protocol is to be used in the absence of the clinic provider when Chlamydia, Gonorrhea or Trichomoniasis has been diagnosis per laboratory report and the patient has not returned to clinic when provider was availableSUBJECTIVE:Confirm detection of STI per laboratory report.Assess medication allergyNutritional Status/Last time eatingOBJECTIVE:Vital Signs (Temp, BP, HR, Resp, Pulse Ox)INTERVENTION/TREATMENT:Ensure patient has eaten prior to receiving treatment.If no allergy to stated medication, administer as followed:Chlamydia: Azithromycin 1 gram orally once (see Medication Protocol)Gonorrhea: Azithromycin 1 gram orally once PLUS Ceftriaxone 250 mg IM once (see Medication Protocol)Trichomoniasis: Metronidazole 2 grams orally once. (see Medication Protocol)If medication allergy, refer to provider for alternative treatment.Education: Partner treatment. Abstain for 7 days after treatment and partner treatment. Avoid consuming alcohol for 24-48 hours after all treatment Return to clinic for follow-up if emesis occurs and refer to providerSTD/Contraceptive Counsel/Risk ReductionAlternative use of contraception if taking OCPRefer to Provider within 24-48 hours for follow-upDOCUMENTATION:Document subjective, history, objective, intervention and education.FOLLOW-UP:Referral to clinic provider will be made.References:CDC (2010). Sexually Transmitted Diseases Treatment Guidelines. Retrieved from STI TREATMENTHealth Dept NW MichiganHealth Department of Northwest MichiganPROCEDUREPROGRAM: Reproductive HealthSECTION: Procedure (1) SUBJECT: Chlamydia (Uncomplicated)PAGE: 1 OF 3RN Treatment of Clients/ContactsEFFECTIVE DATE:January 11, 2008REVISED: March 7, 2013REVIEWED: ISSUED BY: Lisa Peacock, RN, MSN, WHNP-BC, Advanced Practice ClinicianJoshua Meyerson, MD, MPH, Medical DirectorPURPOSE: To provide guidance for Registered Nurses on treatment of uncomplicated Chlamydia.PROCEDURE:RN has reviewed and signed standing orders.RN receives fax of positive results from RH/BCCCP data entry assistant and notifies client of need to be treated for Chlamydia. RN initiates scheduling into next available clinic opening, generally within 1-2 weeks. If difficulty scheduling or reaching client, RN will consult with NP.Treatment is determined by CDC Sexually Transmitted Diseases Treatment Guidelines, current edition. IF CLIENT IS ALLERGIC TO BOTH ZITHROMAX AND DOXYCYCLINE, CONTACT NURSE PRACTITIONER/PHYSICIAN/MEDICAL DIRECTOR.Notify NP/Physician if there is an indication of PID (Pelvic Inflammatory Disease) i.e. pelvic pain, fever, chills, pain with intercourse. Client will need to be referred for further evaluation and treatment.TREATMENT:Zithromax: First choice of treatment is Azithromycin (Zithromax) 1 gram single dose orally, which is a stocked item and received free through MDCH STD program.CONTRAINDICATIONS to ZithromaxAllergy to Azithromycin (Zithromax), clarithromycin (Biaxin), dirithromycin (Dynabac) or erythromycin.Impaired liver function.CONSIDERATIONS to ZithromaxOkay to take if pregnant.If on antacid, advise not to take for two (2) hours post dose. To take on empty stomach and no food for two (2) hours.May cause sun sensitivity.Client to be advised that medication takes seven (7) days to work and needs to abstain from all sexual contact for seven (7) days and not to resume sexual relations until contact(s) adequately treated.DISPENSINGZithromax - 1 Gram single dose (usually 2 tablets) are given to the client to consume in the clinic.Doxycycline: Dispense Doxycycline 100 mg orally BID X 7 days if client not a candidate for Zithromax. Doxycycline is also obtained free from MDCH STD program and is a stocked item.CONTRAINDICATIONS to Doxycycline Allergy to doxycycline or tetracycline.Pregnant, possibly pregnant or trying to become pregnant.Kidney or liver disease.CONSIDERATIONS to Doxycycline Take medication with 10 oz water and with small amount of food if causes stomach upset. Take all of the medication.Do not take with antacids, calcium supplements or iron supplements including multiple vitamins that contain iron.May cause sun sensitivity.May cause GI upset.To abstain from sexual relations until completes medication and until contact(s) are adequately treated.CLIENT EDUCATION: Client is to read handout ‘Facts About Chlamydia’ (N-48) and Zithromax Drug Information Handout (N-352) or Doxycycline Fact Sheet (N-152).All contact(s) in last three (3) months, or previous partner if longer than 3 months, need to be tested and treated and can be seen at this health department. They need to register with CIAS and make an appointment.Client to be advised to get HIV test.Client to avoid direct sunlight for seven (7) days.Client to use condoms. Offer client free condoms.Client to abstain until all contact(s) in last three (3) months have been adequately treated.Client to implement risk reduction behaviors. Client to return/notify clinic or be seen by health care provider if symptoms not improving.FOLLOW UP:Client is advised to return in 3 months for a test of re-infection. This appointment should be scheduled for client when they are seen for treatment. This pertains to positive cases only, not to contacts of a positive case. See Re-testing Positive Chlamydia and/or Gonorrhea policy/procedure.DOCUMENTATION:Record on problem list, date of positive chlamydia test and date of treatment.Record on Medication List, treatment plete Confidential VD reporting form and/or summary sheet received from lab with positive result and forward to STD follow up plete RH Service Information flow sheet marking visit and medication issued. Mark STD encounter.Document visit on medical visit form.REFERENCE:CDC Sexually Transmitted Diseases Treatment Guidelines, current edition REFERENCE:Chlamydia PolicyFORMS:Facts About Chlamydia, N-48Zithromax Drug Information Handout, N-352 Doxycycline Fact Sheet, N-152Asthma & Respiratory DistressExampleEXAMPLE ASTHMA/RESPIRATORY DISTRESSHFHSAsthma/Bronchospasm and Asthmatic Exacerbations/EmergenciesRN Protocol for Henry Ford Health SystemSchool Based Health ClinicsDEFINITION Asthma is a common chronic disorder of the airways that is complex and characterized by variable and recurring symptoms, airflow obstruction, bronchial hyperresponsiveness, and an underlying inflammation. Inflammation causes recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night or in the early morning.Bronchospasm is an abnormal contraction of the smooth muscle of the bronchi, resulting in an acute narrowing and obstruction of the respiratory airway. A cough with generalized wheezing usually indicates this condition.Exacerbations of asthma acute or subacute episodes of progressively worsening shortness of breath, cough, wheezing, and chest tightness—or some combination of these symptoms. The most common cause of severe exacerbations is infection with a respiratory virus, especially rhinovirus, but exacerbations may be brought on by exposures to allergens or irritants, air pollutants, certain medications, and, possibly, emotional stress. Exacerbations also can be triggered by withdrawal of Inhaled Corticosteriods (ICS) or other long-term-control therapy.SUBJECTIVE:WheezingSigns & SymptomsShortness of breath Tightness (or pain) in chestCough/constantDifficulty Breathing/Shortness of Breath/Inability to “catch breath”Use of accessory muscles/suprasternal retractionsInability to talk, walk or run without coughing or wheezingChanges in Level of Consciousness (LOC)History of Asthma/Exercised Induced AsthmaASSESSMENT:?Time of onset of exacerbationHistory?Current medications and allergies?Recurrent use of Rescue Inhaler (Beta-2-Agonists: Albuterol/Ventolin, etc.)?Emergency/Urgent Care visits (3 or more in past month may indicate poor control)?Hospital (2 or more in past year)/Intensive Care Admissions/Intubations?Recent oral steroid use?Smoking History/Drug use?Comorbidities?Allergies (environmental, food & medication)OBJECTIVEVital signs (temp, blood pressure, heart rate, respiratory rate, &pulse ox)Assessment of systems:Neurological/General (i.e. anxiety, agitation, and color)SkinRespiratory: breathlessness, wheezing, air entry, accessory muscle use, cough, and retraction, breath sounds bilaterally (clear, wheezes, crackles, diminished, absent)PEF/Peak Flow Rate (if possible)*In severe exacerbations, air movement may be so limited that wheezing is NOT audible with or without a stethoscopeEXACERBATION(See Table: Classifying Severity of Asthma Exacerbation Severity)CLASSIFICATIONMild, Moderate, or Severe/Life Threatening Exacerbation presentASSESSMENT?Mild: Dyspnea only with activity, PEF≥70% predicted/personal best?Moderate: Dyspnea interferes with or limits usual activity, PEF 40-69% predicted/personal best?Severe: Dyspnea at rest; interferes with conversation, PEF<40% predicted/personal best?Life Threatening: Too dyspneic to speak; perspiringINTERVENTION/(a) Administer Oxygen for pulse oximetry <92%/TREATMENT: Correction of Hypoxia(b) Follow Asthma Action Plan (If available)(c) Administer Inhaled Short-Acting Beta2 Agonists (SABA): ?1st Drug of Choice: Albuterol Nebulizer Pre-mixed Solution 2.5mg/3ml -Administer every 20-30 minutes up to 3 doses; then every 1-4 hours PRN-Administer via oxygen 6-8L/min if possible; otherwise use nebulizer machine?2nd Drug of Choice (only if 1st line not available): -Albuterol/Ventolin 90 mcg MDI (Metered Dose Inhaler) with chamber/spacer-4 to 8 Inhalations/Puffs every 20-30 minutes up to 3 doses; then 1-4 hours PRN(d) Notify Parent/Guardian as soon as possible(e) Continuous Monitoring (Record):-Vital signs (blood pressure, heart rate, respiratory rate & pulse ox)-Patient (LOC, Response to therapy, accessory muscle use, etc.)-Breath Sounds(f) Notify Health Center Nurse Practitioner (NP)/Physician at all times(g) If no improvements/worsening activate EMS system-See Severe/Life Threatening Exacerbation assessment*NP/Physician may consider administering EPI-Pen Injection as indicated-Administer medication via oxygen 6-8L/min -Update and notify Parents/Guardians-Notify School Administrators/OfficialsDOCUMENTATIONFindings:EPIC/Paper?Arrival time in clinic, Chief complaint, assessment (history & objective sections), ?Exacerbation Classifications, Interventions/treatments?Times of Notification: -Parent/Guardian, NP/Physician, EMS (if applicable-include arrival time of EMS), School Administrators/Officials -Education (triggers/exacerbations, medication use, peak flow, immunizations, etc.)-Condition of patient at discharge/transport (include time of discharge/transport)FOLLOW-UP:In event of a referral to PCP/MD/ER a follow-up be madeAppointment with Health Center Provider-Scheduled Asthma Education session REFERENCES:This guideline is consistent with the National Asthma Education and Prevention Program Expert Panel Report 3: Guidelines for the Diagnosis and management of Asthma (2007). Blood Sugar & Diabetic EventExampleEXAMPLE BLOOD SUGAR ISSUESNew Jersey - Camden City School DistrictDIABETIC CONDITIONSHYPOGLYCEMIA (Low Blood Sugar)PROTOCOL: Care of student with LOW BLOOD GLUCOSESYMPTOMS: intense hunger, shallow respirations, tremors.Follow individual doctor’s orders.If no orders, do the following until orders are obtained:Give 6 oz. fruit juice or regular soda, or 1 tbsp. of sugar, or sugar supplement.Allow patient to rest.May put icing on gumline if available.Notify parent.PHYSICIAN’S AUTHORIZATION FOR ADMINISTRATION OF GLUCAGONThe School Nurse may administer Glucagon for injection to diabetic students who are suffering from severe hypoglycemia leading to severe disorientation, unconsciousness and/or seizure. Give glucagon if the patient is unconscious, unable to eat a sugar-sweetened product, or having a seizure. Call 9-1-1 for an ambulance immediately after administration.The following is the method of administration and dosage for Glucagon:Remove flip-off seal from glucagon bottle.Inject entire contents of syringe into glucagon bottle.Swirl glucagon bottle until solution clear.Withdraw all solution into the syringe (1.0mg).Dosage: Children less than 44lb. (20kg): ? Adult dose: 0.5mgChildren greater than 44lb. and Adults: 1.0mgAdminister glucagon intramuscularly or subcutaneouslyIf the student does not awaken in 15 minutes, another dose of glucagon may be given.Discard any unused solution.Turn student on his/her side, as vomiting may occur. Monitor airway, breathing and circulation. Begin CPR or rescue breathing if needed. Feed them with a fast-acting source of sugar as soon as they are awake and able to swallow. Send to hospital via ambulance. Notify parent.HYPERGLYCEMIA (High Blood Sugar) continued on the next page. HYPERGLYCEMIA (High Blood Sugar) PROTOCOL: Care of student with ELEVATED BLOOD GLUCOSESYMPTOMS: (These were not included in the original document – recommend adding) Measured glucose levels as indicated belowIf Blood Glucose is 350 or greater, recheck in 30 minutes after receiving insulin coverage.If Blood Glucose is 400 or greater, student remains in Health Office until rechecked in 30 minutes. If Blood Glucose is 450, student must be picked up by parent immediately or 9-1-1 called; doctor to be notified.If Blood Glucose is 500, 9-1-1 is to be called; parent and doctor are to be notified.If symptomatic, arrange for medical treatment regardless of Blood Glucose.Call ambulance and parent.Have parent meet ambulance at the hospital with the following information: type of insulin, concentration, dosage, time of last injection, and food intake._______________________________________ ________________________________Physician’s SignatureEffective Period (From: Date – To: Date)_______________________________________ _____________________________________Print Physician’s Name Physician’s License NumberAllergy & Common ColdExampleEXAMPLE ALLERGY / COMMON COLDHFHSCommon Cold/Allergic Rhinitis/Nasal Congestion/CoughRN Protocol for Henry Ford Health SystemSchool Based Health ClinicsDEFINITION: Common Cold: an acute, self-limiting viral infection of the upper respiratory. It involves variable degrees of sneezing, nasal congestion and discharge (rhinorrhea), sore throat, cough, low-grade fever, headache, and malaise. Incubation period is 24-72 hours. Symptoms typically last 7-10 days; gradually improving over 10-14 days.Allergic Rhinitis: characterized by sneezing, rhinorrhea, and nasal congestion. Often accompanied by itching, tearing, and/or burning of inner ear, eyes, nose and palate. Postnasal drip, cough, irritability, and fatigue are other common symptoms.SUBJECTIVE:Symptoms vary from patient (as indicated in definitions) andSigns & Symptomsmay include:Irritability/Decreased Activity or AppetiteNasal Congestion/itchingRhinorrhea/Runny nose Middle Ear abnormality/discomfortSneezing/Cough (productive vs non-productive)Sore (or scratchy/itchy) throat/hoarsenessLow-grade feverMild Headache/MalaiseWatery EyesASSESMENT:Timing and onset of symptomsHistoryCurrent/attempted medicationsAlleviating/aggravating factorsAllergies (environmental, food & medication)Other ill/sick people at home/schoolOBJECTIVE:Vital signs (temp, blood pressure, heart rate, respiratory rate, & pulse ox)Assessment of systems:Neurological/General (anxiety, agitation, and color)SkinHEENTRespiratory CardiovascularINTERVENTION/Anticipatory Guidance: educated about viral infections, TREATMENT:course of illness, etcSupportive Interventions: Ingestion of warm fluids, adequate fluid intake/hydrationHygienic interventions: Hand washing, disposal of tissues, mon Cold: May administer OTC medication as indicated per Medication Protocol(NO OTC medications in children younger than six years; consult provider)Fever: see Fever Protocol for low-grade tempAllergic Rhinitis: Administer Loratadine/Diphenhydramine per Medication ProtocolIf no past medical history of Allergic Rhinitis refer to NP/Provider*Refer to NP/PCP for increased pain/pressure, wheezing (also see Asthma Protocol), or for symptoms lasting greater than ten days.DOCUMENTATION:Arrival time in health centerEPIC/PaperNotification of Parent/guardian or School staff if warrantedDocument findings from subjective, objective, follow-up, intervention and educationFOLLOW-UP:In event of a referral to SBH-Provider/MD/ER a follow-up may be madeREFERENCES:Oral HealthExamplesEXAMPLE ORAL HEALTHMissouri Dept of EducationDENTAL Standards Systematic sequence of visual inspection, using tongue blade and illumination: Face and neck for lesions and palpate for swollen glands; Mucous membranes (lips, tongue, soft and hard palate, tonsillar area, and cheeks) for redness, exudates, swelling, blisters, and growthsTeeth and gums: Evidence of dental caries Broken or chipped teeth Gross malocclusion Infection or swelling Bleeding or inflamed gums Changes in color, texture, position of gums, tissue Poor oral hygieneFoul breath Recommendations ? As time and resources permit, screen students K-7 who do not report routine professional care, using a visual inspection of the mouth with light and tongue blade. ? Screen secondary students who have not reported routine care. ? Dental education should be a part of the inspection process. Referral Refer any student with gross oral or dental problems who is not receiving routine, comprehensive oral health care. Refer to Dental Health Guide for School Nurses, Department of Health and Senior Services, 2014. Guide may be downloaded at: ORAL HEALTHNorth Dakota Dept of HealthSTANDING ORDER FOR PUBLIC HEALTH NURSESAPPLICATION OF FLUORIDE VARNISHESName of Physician, MD, medical advisor to the <health care provider> authorizes the applications of fluoride varnishes for a one-year period of time from month/date/year to month/date/year. This standing order will be reviewed on an annual basis.Program Requirements<The <Agency authorized registered nurse> will provide fluoride varnish to infants and children that present with the following: A signed informed consent has been secured from the parental/legal custodian/guardian of the child AND The child must be under age 21 with documented risk for dental caries* and meets one or more of the following criteria: Enrollment as a North Dakota Medicaid/Health Tracks client; Enrollment in a WIC or Head Start program; orEnrollment in a public, private or parochial school. *Populations believed to be at increased risk for dental caries are those with low socioeconomic status or low levels of parental education, those who do not seek regular dental care, and those without dental insurance or access to dental services. Individual factors that possibly increase risk include active dental caries; a history of high caries experience in older siblings or caregivers; root surfaces exposed by gingival recession; high levels of infection with cariogenic bacteria; impaired ability to maintain oral hygiene; malformed enamel or dentin; reduced salivary flow because of medications; radiation treatment, or disease; low salivary buffering capacity (i.e., decreased ability of saliva to neutralize acids); and the wearing of space maintainers, orthodontic appliances, or dental prostheses. Risk can increase if any of these factors are combined with dietary practices conducive to dental caries (i.e., frequent consumption of refined carbohydrates). Risk decreases with adequate exposure to fluoride. (CDC, MMWR, 2001) An oral health screening shall be conducted and documented and fluoride varnish applied by a public health nurse who meets the criteria set forth in North Dakota Century Code 43-28-02.6 and has successfully completed a fluoride varnish training program approved by the Board of Dentistry.Schedule and DosagesThe <health care provider authorized registered nurse> will apply the initial fluoride varnish application as a thin layer of 5% sodium fluoride varnish to all surfaces of erupted primary or permanent teeth.Repeat the fluoride varnish application at least twice for a high-risk child and up to three times over a period of one year.PrescriptionFluoride varnishes to be used include: (You may choose to list any of the varnishes approved by the Food and Drug Administration as a medical device here.)Omni Cavity Shield, available in unit dosages – One .25 ml unit dose for children 6 months through 5 years of age. One .40 ml unit dose for children 6 years of age and older. Colgate Oral Pharmaceuticals Duraphat – 1-2 drops per child depending onnumber of erupted primary or permanent teeth.One drop for 4-8 erupted primary teethTwo drops for full compliment of primary/permanent teethContraindicationsGingival stomatitis Ulcerative gingivitis Intra-oral inflammation Known sensitivity to colophony or colophonium or other product ingredients which include: Ethyl alcohol anhydrous USP 38.58% Shellac powder 16.92% Rosin USP 29.61% Copal Sodium Fluoride 4.23% Sodium Saccharin USP 0.04% Flavorings, Cetostearyl Alcohol Known sensitivity to pine nuts.PrecautionsDo not apply varnish on large open carious lesions. Referral to licensed dentist is indicated.Pre-application InstructionsRemind the parent/legal custodian/guardian to provide the child something to eat or drink before receiving the fluoride varnish application. Advise the parent/legal custodian/guardian that the child’s teeth may become temporarily discolored, as some fluoride varnish has an orange-brown tint. Explain the discoloration will be brushed off the following day, yet the protective qualities of the fluoride varnish will remain. Post-application InstructionsThe child may drink water immediately following the varnish application. After the fluoride varnish application, instruct the parent/legal custodian/guardian not to administer other fluoride preparations that day (e.g., gels or foams). The routine use of fluoride tablets and rinses should be interrupted for several days after initial application. The child should eat a soft, non-abrasive diet for the remainder of the day. Avoid sticky foods. Do not brush or floss the child’s teeth for 24 hours after the varnish placement.Side EffectsIt is normal for the teeth to appear to dull and yellow in appearance until the teeth are brushed.Adverse Reactions Edematous swellings have been reported in rare instances, especially after application of extensive surfaces. Dyspnea, although extremely rare, has occurred in asthmatic people. Nausea has been reported when extensive applications have been made. If indicated, varnish film can be removed with a thorough brushing.Caution Store varnish in a safe location at room temperature. Store out of the reach of children.Nutrition, Physical Activity & Weight ManagementExampleEXAMPLE WEIGHT MANAGEMENTHealth Dept Northwest MichiganHealth Department of Northwest MichiganPOLICY/PROCEDUREPROGRAM: Child & Adolescent Health CentersSECTION: Services (10)SUBJECT: Overweight and ObesityPAGE: 1 OF 4EFFECTIVE DATE: September 2, 2011REVISED: September 4, 2013REVIEWED BY:REVISED BY: Lisa Peacock, RN, MSN, WHNP-BC, Advanced Practice ClinicianISSUED BY: Joshua Meyerson, MD, MPH, Medical Director PURPOSE: To assure all Ironmen Health Center (IHC) and Hornet Health Center (HHC) clients receive services according to standards of care based on best practice in scope and frequency as it relates to overweight and obesity. To assure that IHC and HHC staff members are aware of when tests, procedures, and/or screenings need to be performed with all clients. POLICY: The IHC and the HHC staff follow established standards of care for all clients who obtain care at the center. Standards of care are developed, reviewed, and revised based on the Center’s Quality Improvement Program, experiential data, and Health Department of Northwest Michigan (HDNW) and community standards.Overweight is defined as a BMI at or above the 85th percentile and lower than the 95th percentile for children of the same age and sex.Obesity is defined as a BMI at or above the 95th percentile for children of the same age and sex.PROCEDURE:Clients and parents receive regular preventive guidance on general nutrition and exercise recommendations.All clients of the Child and Adolescent Health Center (CAHC) will be encouraged to have at least one appointment with the Nurse Practitioner every year.At a minimum of once per year for all CAHC clients, height, weight, and BMI are entered into the client’s MCIR record. Written consent is obtained through language on the CAHC Parent/Guardian Consent for Services (CAHC-64). If the parent/guardian opts their child out of the Body Mass Index (BMI) module in Michigan Care Improvement Registry (MCIR), they must complete the waiver form, CAHC MCIR BMI Growth Module Consent (CAHC-74).Height and weight are measured, and Body Mass Index (BMI) for sex and age is calculated at each clinical visit or at a minimum of once per month and documented in Insight on the CH-Nursing Tab for all clients age 10 and older. At a minimum of once per year, height, weight, and BMI are entered into the client’s MCIR record.On an annual basis, the Survey for Patients (for appropriate age) is administered. The Survey for Patients is available as one of the MCIR BMI Clinical Support Tools.During the clinical visit when the client’s BMI is entered into MCIR, the Nurse Practitioner reviews BMI and appropriate medical care and guidance is given. Under the Nurse Practitioner’s guidance, the CAHC Public Health Technician “checks” the counseling boxes in MCIR documenting that educational areas were reviewed.Clients with a BMI 85th percentile for age are assessed for the following at least on an annual basis, according to the attached Universal Assessment of Obesity Risk (CAHC-61) using the MCIR BMI Clinical Support Tools. Medical risksBehavior risksAttitudesClients with a BMI 85th percentile for age are counseled for weight maintenance or weight loss according to the attached Universal Assessment of Obesity Risk (CAHC-61) and documented on the MCIR BMI Clinical Support Tools. If the client has a BMI 85th percentile for age, the CAHC Clinician documents results of the routine assessment from the visit on the Weight Management Letter to parents (EMR-WMLTR) which is generated through an EMR note in Insight. The letter is sent to the parent/guardian at least on an annual basis. If the client wishes to participate in the WOW program then the WOW Participation Letter (EMR-CHWOW) is generated in Insight and sent to the parent/guardian. All steps taken are documented in Insight under the CH-Wellness Tab. Following the assessment, the CAHC clinician may consult the student’s primary care physician (using appropriate Overweight/Obesity Letter to Collaborating Physician, (CAHC-71) and recommend laboratory testing, including:For BMI between 85th –94th percentile with no risk factors: fasting lipid profileFor BMI 85th – 94th percentile with risk factors: fasting lipid profile, and if 10 years old, fasting glucose, Aspartate Aminotransferase (AST) and Alanine Aminotransferase (ALT) every two years.For BMI greater than or equal to 95th percentile, regardless of risk factors: fasting lipid profile, and if 10 years old, fasting glucose, Aspartate Aminotransferase (AST) and Alanine Aminotransferase (ALT) every two years.Clients who are unable to obtain above recommended labs through their provider and have a BMI 85th-94th percentile with risk factors and clients with a BMI greater than or equal to 95th percentile, regardless of risk factors, will be offered lab testing in the clinic to include Total cholesterol, HDL, and blood glucose. If blood glucose is out of the normal range and client is not fasting, they will be asked to return for a fasting lab.CAHC staff will follow all cholesterol and glucose testing guidelines in the Cholesterol and Glucose Screening and Referral Policy.Results of labs and recommendations will be communicated to parent/guardian as well as provider if available. Other clients may be screened at the clinician’s discretion if they have no primary care provider and do not know the status of their blood sugar and/or cholesterol.Clients motivated to make changes are offered individual counseling focused on nutrition, physical activity, and limiting screen time in the WOW (Working on Wellness) Program.The Survey for Patients is used to guide individualized counseling.The WOW Program is typically 6 visits long. Frequency and duration of sessions is client driven.The Survey for Patients is administered at the client’s last WOW Program visit.Clients with identified nutritional risk factors are scheduled with the NP for nutritional counseling and assessed for further complications and/or disease. Risk factors may include those listed below and others at clinician discretion:Weight loss is greater than 10% of previous weight at last visitRecurrent dieting is reported when client is not overweightUse of self-induced emesis, laxatives, or starvation to lose weightBody Mass Index is below the fifth percentile for age and genderAll documentation related to weight management is completed in Insight in the CH-Wellness Tab.REFERENCES:National Heart, Lung, Blood Institute GAPS Blood Pressure Value (mm Hg) by Age for Males/FemalesUSDA’s Choose My Plate website: Role of Michigan Schools in Promoting Healthy Weight: schools or emc.cmich.edu/healthyweight, Overweight Children and Adolescents: Recommendations to Screen, Assess, and Manage, CDC Growth Chart Training Modules: HYPERLINK "" of Change Document Expert Committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity: Summary Report: The Appendix that can be found in the attachment on pages S186-S189 gives specific treatment recommendations and timelines.DeVos?Healthy Weight?Center:? of Michigan, MPOWER program:? WISEWOMAN Cholesterol and Glucose Screening and Referral PolicyWOW Program Guidance? BMI Module Forms-Survey for Patients2-5 Year Old6-11 Year Old 12-18 Year Old (example)-Survey for Parents/Caregivers of Children2-5 Year Old6-11 Year Old (example)12-18 Year Old-Clinical Support Tools2-5 Year Old Healthy Weight2-5 Year Old Overweight (example)2-5 Year Old Obese6-11 Year Old Healthy Weight6-11 Year Old Overweight6-11 Year Old Obese12-18 Year Old Healthy Weight12-18 Year Old Overweight12-18 Year Old Obese accessed Feb 4, 2015FORMS: Period for which standing order applies: The standing order applies until it is either replaced by a new order covering the same subject or is cancelled in writing by the issuer. Requirements: Issuer must review the standing order annually and then re-sign and re-date. ................
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