Appendix C

I. Medications

A. Definition: Substances used to prevent, diagnose, cure, or relieve signs and symptoms of disease.

B. Sources: Plant, animal, mineral, and synthetic.

C. Action

1. Local: Act mainly at site of application.
2. Systemic: Absorbed into the bloodstream and circulated to various parts of the body.
3. Variables that affect actions.

a. Dose.
b. Route of administration.
c. Drug-diet interactions.
d. Drug-drug interactions.
e. Age.
f. Body weight.
g. Sex.
h. Pathological conditions.
i. Psychological considerations.

4. Adverse effects--all medicines are capable of producing undesired responses from rare, mild, and localized, to widespread, severe and life threatening, depending on the medicine and the person receiving it.

D. System of Naming: Classified and grouped according to the effect on a particular body system, therapeutic use and chemical characteristics.

1. Generic: Related to chemical or official name.
2. Brand or trade: designated and patented by the manufacturer.

E. Sources of medication information. 1. Pharmacology textbooks. 2. Drug reference books. 3. Journal articles.

F. Federal and State drug legislation and regulations are designed to ensure the public's safety and regulate the manufacture and sale of drugs.

G. Classification of Drugs

1. Prescription: Medications including controlled substances which require a prescriber's order.
2. Over the Counter (OTC): drugs which may be purchased without a prescription, e.g., first aid cream, analgesics and antacids.
3. Schedules of Controlled Substances: Five schedules of drug and drug products under the jurisdiction of the Controlled Substances Act. Some examples are listed. Listings are subject to change. For a complete list contact the Drug Enforcement Administration or a pharmacist. The drugs are kept in a locked container and the drug amount is documented when received and at administration.

a. Schedule I. Substances that have no accepted medical use in the U.S. and have a high abuse potential (heroin, marihuana, LSD, MDMA, peyote, mescaline).
b. Schedule II. Substances that have a high abuse potential with severe psychic or physical dependence liability. Consist of certain narcotic, stimulant and depressant drugs (opium, codeine, Doriden, Demerol, Percodan, Dexedrine, Ritalin).
c. Schedule III. Substances that have an abuse potential less than those in I and II. Includes compounds with limited quantities of certain narcotic drugs and non-narcotic drugs (hydrocodone, compound or mixture containing secobarbital, anabolic steroids).
d. Schedule IV. Substances with potential for abuse less than those in III (phenobarbital, Placidyl, Librium, Valium, Tranxene, Darvon, Talwin-NX).
e. Schedule V. Substances with an abuse potential less than IV and contain limited quantities of certain narcotic and stimulant drugs generally for anti-tussive, anti-diarrheal and analgesic purposes (buprenorphine).

II. Medication Definitions and Descriptions

A. Policy - A standing plan that provides general guidelines for decision-making.

B. Standing Orders - Written protocol for using a medication applying to the general use of that medication, as opposed to an order for a medication written for a specific individual (e.g., adrenaline in anaphylaxis or ipecac in certain poisonings).

C. Pharmacology - the science of drug properties, reactions and therapeutics.

D. Medication - Prescription and non-prescription substances or preparations

E. Non-prescription Medication - Over-the-counter preparations obtained without a prescription.

F. Legal Prescriber - Physician, dentist podiatrist, physicians assistant, advanced registered nurse health care providers legally authorized to prescribe medication.

G. Dispense - Distribution of a prescription drug by a pharmacist, physician, dentist, podiatrist or other person licensed or registered to distribute prescription medication.

H. Authorization - Medication instructions by the prescriber and/or parent/guardian caretaker to administer medication to an individual student.

l. Administration of Medication - Assisting a student in the ingestion, application, inhalation, injection, insertion or self-management of medication according to the directions of the legal prescriber or parent(s). A licensed health care professional's responsibility for administration of medication is regulated by their respective practice acts and includes, but is not limited to:

a) providing medications for another person according to the five rights
b) recording medication provision
c) observing, monitoring reporting an otherwise -taking appropriate actions regarding desired effects, side effects, interactions, and contraindications associated with the medication.

J. Individual Healthcare Plan - The mechanism to assess, plan, implement, document and evaluate health care delivered to an individual student at school.

K. Delegation - Defined in the Nurse Practice Act as transferring to another individual the authority, responsibility, and accountability for the performance of nursing interventions. The registered nurse is accountable for direction (instruction, monitoring, evaluating student responses) and supervision.

L. Student- Individual age birth to 21 years enrolled in school.

M. Self-administration - Student self-management of medication. Student demonstrates management to appropriate monitoring health personnel.

N. Monitoring - Acceptance of responsibility for observing and taking appropriate action regarding any desired effects, side effects, interactions, and contraindications associated with medication therapy.

O. Supervision - Overseeing delegated tasks through periodic inspection and evaluation, and being available directly or indirectly (through telecommunication) for direction, consultation and collaboration.

P. Registered School Nurse - A registered nurse, licensed to practice nursing in Nebraska and employed in the school setting.

Q. Qualified Designated Personnel - Unlicensed school employees who have successfully demonstrated the minimum competencies required by the Medication Aide Act to provide medication to students at school under direction and monitoring of licensed health care professional or parent/guardian caretaker.

III. School Medication Administration Guidelines
Develop policy and guidelines for prescription and non-prescription medication. The format and content are consistent with other school health policies, medical and health practice and legal statutes. School personnel, prescriber, parent and student work together to assure that the student receives the medication with the least school disruption, while maintaining the optimal benefit of the medication.

A. Parents are routinely notified about-the school medication administration policy for students.

B. Medication is administered to students by a registered nurse or qualified designated school personnel (non-health professional who has successfully completed a school medication administration course with documentation of training, supervision, monitoring, and updates maintained). Competencies of personnel and definitions and descriptions are written. Back-up personnel are designated. Medication administration is part of the student educational program.

C. Registered nurses or qualified school personnel administer medication with:

1. Prescriber's authorization. The legal prescriber's directions on the prescription or non-prescription label specifying the student, medication, administration instructions and date.
2. Parents' written authorization. A parental signed, dated, statement on file at school authorizing medication administration in accord with the prescription or non-prescription medication instructions. The authorization includes a statement that no side effects have been experienced, individual instructions, permission to contact the prescriber as needed and permission to share medication information with appropriate school personnel. The parent provides for the safe delivery of the medication to and from school.
3. Medication labeling. The labeled medicine is in the original container with the original label as dispensed or the manufacturer's label. The parent provides the labeled medication and supplies.
4. Authorization renewal. Medication administration authorizations are renewed annually and updated immediately as changes occur.

D. Establish ongoing communication with the person(s) authorizing administration.

E. Maintain confidentiality of medication information.

F. Record of administration. Document medication administration including student name, medication, dose, date, time, route, signature of the person administering the medication, any unusual circumstances, and reporting.

G. Store medication in a secure area or as authorized. Special security and documentation of controlled substances are required. Narcotics are either double locked or counted daily.

H. Completed medication administration. Advise the parent or guardian at the completion of medication administration to pick up unused portions of medication. Return all unused medication to the parent or guardian for disposal.

I. Student self-administration. An individual health plan may be developed by the registered nurse for student self-administration of medication subject to authorization and student abilities. The plan may include student health counseling and health instruction regarding the principles of self-care.

J. Emergency policies are in place for injections (i.e., allergic reactions).

K. Emergency procedures are in place for medication reactions. An information system for properly monitoring emergencies is established including notification of school nurse, parents, emergency medical personnel and prescriber. The school establishes an ongoing relationship with emergency providers, local hospitals, and/or health facilities, to expedite a student's transfer for needed emergency services. Written incident reports are completed and reviewed at regular intervals. School personnel receive training and rehearsal in the procedures to follow in ease of emergency.

L. Non-prescription medication administered at school may include a standing authorization and specific guidelines of medication and circumstances when the medication may be administered. An example of a policy guideline: Tylenol may be administered with a signed parental consent for the following reasons, minor aches and pains, headache, toothache, dental pain and menstrual cramps. Tylenol will not be given to any student with a temperature of 100 degrees or above. Verbal authorization may be obtained by telephone permission, followed by a written authorization within 24 hours to continue administration.

M.The school district ensures liability insurance coverage for school personnel administering medication.

IV. Examples: Training. Description and Personnel Competencies

A. Medication Administration Training to Qualify School Personnel to Administer Medication at School in Lieu of a Licensed Health Professional (i.e., registered school nurse).

1. Purpose: Provide the course participants with basic knowledge of school medication administration.
2. Goal: Upon completion of the training, the participant will demonstrate safe and accurate administration of medication using school policy and guidelines.

B. Competencies of the Registered School Nurse Responsible for the Administration of Medications in School.

1. Knowledge of disease or disability prognosis.
2. Knowledge of effective use of medications and treatments and their possible side effects.
3. Ability to properly administer and record medication dosage and perform treatments in the school using district policy.
4. Abilities to teach and monitor designated school personnel to administer medication or administer medication treatment.
5. Ability to monitor untoward side effects.
6. Knowledge of proper storage of medication in schools.

C. Medication Tasks Assigned to School Personnel Qualified to Administer Medication at School in Lieu of the Licensed Health Professional (e.g., registered school nurse).

1. Understand role differentiation in medication delivery.
2. Understand the general purpose of the medication.
3. Demonstrate the proper procedures for administration of medication.
4. Demonstrate appropriate and correct record keeping.
5. Demonstrate appropriate actions when unusual circumstances occur.
6. Use resources appropriately.

IVa. Example: Emergency Protocol for Medication-Related Reaction

A. Extreme Allergic Reaction: An extreme sensitivity may cause a reaction. A reaction is rare and an extremely serious situation. The reaction may start rapidly, be brief, and require immediate action.

B. Symptoms may include any change in behavior and are not limited to:

1. Feeling of apprehension, sweating, weakness.
2. Nausea, vomiting, abdominal pain, diarrhea.
3. Low blood pressure with weak, rapid pulse.
4. Flushing, hives, itching.
5. Shallow respiration, difficulty breathing.
6. Nasal congestion, itching, sneezing, wheezing.
7. Seizures, loss of consciousness, shock, coma.
8. Difficulty walking, blue/gray lips or fingernails.

C. Procedure:

1. Get help. Stay with the individual with the reaction. Observe symptoms, note time.
2. Immediate call to emergency service for transportation to health. facility per emergency plan. Example: call 911 in extreme reaction.
3. Immediate adrenalin subcutaneous injection. Per standing orders.
4. Continue observing vital signs (respirations, blood pressure, pulse, level of consciousness). Provide emergency personnel with health information and summary of reaction.
5. Notify school nurse, parent/guardian, and physician.
6. If student is still at school in 15-20 minutes, repeat adrenalin dose.

D. Follow-up:

1. Complete school incident report.
2. Consult with parent/guardian and physician on appropriate individual school emergency health plan.

V. Handwashing
Vigorous, brief rubbing together of all surfaces of lathered hands, followed by rinsing under a stream of water.

A. Purpose
Good hand washing is the single most important procedure to prevent the spread of infection.

B. Objectives

1. To remove disease-causing organisms from the hands.
2. To prevent the spread of micro-organisms to students.
3. To prevent the spread of micro-organisms to personnel.

C. Equipment

1. Soap/or hand sanitizer
2. Running warm water
3. Paper Towels

D. Procedure

1. Wet hands with warm, running water.

2. Apply soap and water.

3. Wash hands, using vigorous, brief (at least 10 seconds) rubbing together of all surfaces of lathered hands.

4. Rinse hands well under running water.

5. Dry thoroughly.

6. Turn off water with towel.

7. Discard towel.

Important Points
Warm water, combined with soap, makes better suds. Hot water removes protective oils.Liquid soap is preferred. The dispenser is replaced or cleaned and filled with fresh soap when empty. Bar soap is kept on a rack allowing drainage of water. Include front and back, between fingers and knuckles, around and under nails, and wrist area. Avoid harsh scrubbing. If hands are visible soiled, more time is required. Soap and running water allow most micro-organisms to be washed off. Leave water running. Dry gently to avoid chapping. Prevent organism transfer from handle.

VI. "Five Rights" of Medication Administration

A.Right Student - Properly identifies the student.

B. Right Time - Administer medication at the prescribed time.

C. Right Medicine - Administer the correct medication.

D. Right Dose - Administer the right amount of medication.

E. Right Route - Use the prescribed method of medication administration

VII. Documentation
Record and report the five rights of medication administration. Include the student name, time, medication, dose, mute, date, person administering and unusual observations and circumstances. Documentation is referred to as the sixth Right.

VIII. Steps In School Medication Administration

A. Follow the school policy for administering medications safely and accurately.

1. Wash hands. Administration of medication is a clean procedure which requires handwashing.
2. Verify the authorization with the label. Seek information for questions and/or dose calculations.
3. Gather necessary items.
4. Prepare and give medications in a well-lighted area free from distractions.
5. Check the label for name, time, medication, dose and route when picking up the container.
6. Prepare the correct dosage of medication without touching medication.
7. Check the label for name, time, medication, dose and route while preparing the correct dose.
8. Check the label for name, time, medication, dose, and route before returning the container to the locked and limited access space.
9. Do not leave medication unattended or within the reach of a student.
10. Identify the student. Ask the student to state his or her name. Non-verbal students may need identifying picture on medication container, or third party identification.
11. Observe the student for any unusual behaviors or conditions prior to medication administration. If unusual behaviors or conditions exist do not give the medication, follow school policy, report immediately and record.
12. Explain the procedure to the student.
13. Position the student properly for medication administration.
14. Provide equipment and supplies as needed.
15. Administer the medication to the correct student.
16. Administer the medication at the correct time.
17. Administer the correct medication.
18. Administer the correct dose.
19. Administer medication by the correct route. Verify the student took the medication.
20. Record as soon as possible after administration according to school procedure. Record student, time, medication, dose, route, person administering and unusual observations.
21. Report unusual reactions immediately following school procedure.
22. Should any questions arise report immediately following school procedure.
23. Clean, return and/or dispose of equipment as necessary.
24. Wash hands.

B. Monitor student self-administration of medication. Student demonstrates competency to self-administer medication. Monitoring of self-administration:

1. Visual observation to ensure proper administration.
2. Reminding student to take medication.
3. Assisting the student to record medication administration.
4. Reporting unusual procedure or circumstances.

C. Errors and omissions in Medication Administration. A medication error is a violation of any of the "Six Rights".

1. Report medication errors Immediately following school procedure (e.g., Notify school nurse, administrator, parents or physician).
2. Complete an incident report and sign the form.
3. Continue to observe the student. Record and report any changes.

D. Recording and Reporting: The school district establishes procedures and forms for recording and reporting.

1. Record immediately after administering medication to limit the chance of error.
2. For each medication administered, record the person administering. If initials are used a signature must appear on the same page.
3. Errors in recording should be red lined and marked error. Then, record the correct information.
4. Record omissions, absence, or refusals immediately, following school procedure.
5. Record only medication you administered.
6. When medications need to be destroyed, they will be destroyed by a nurse or pharmacist according to legal guidelines.

E. Oral Medication
To administer medication use the general administration steps In A. B, C and D along with the following specific information:

1. Oral bottled medication (tablets, capsules, etc.):

a. Remove bottle cap and hold the cap in one hand. and bottle in the other hand.
b. Pour the prescribed dose into the cap.
c. Transfer medication from cap to a clean container (medicine cup) and give cup to the student.
d. Give with a full glass of water unless otherwise indicated. Follow special label instructions (e.g., take with milk, do not take with acidic fruit juices or do not take in combination with other medications).
e. Verify the student swallowed the medication.
f. Recap the bottle and return it to the secure locked place.
g. Refer partial pill dosage to the school nurse.

2. Oral individually wrapped medications:

a. Remove or tear off number needed and place package in a clean medicine cup.
b. Remove from package and transfer into cup when student takes the medication.

3. Oral liquid or powders:

a. Shake medication per label instructions.
b. Pour liquid from side of bottle opposite the label (hold label in palm of hand) into graduated medicine cup.
c. Pour medication at eye level and directly in front of eyes.
d. Measure the dosage at the bottom of the disc (meniscus).
e. Wipe off any medication on the outside of the container.
f. Use calibrated medicine dropper or syringe to measure small amounts of liquid.
g. Hold medicine dropper at right angle to cup to measure drops.
h. Pour liquid medications into separate containers unless otherwise ordered.
i. Give cough syrup undiluted and do not follow with water.

4. Problems with oral medication administration:

a. Refusal of Medication - Report immediately.
b. Vomiting Medication - Report: the student's name and age, medication and dosage, time lapse since administration and if medication was intact.
c. Suggestions for students with difficulty swallowing medicines

1) Position student for medication administration.
2) Give one medicine at a time with adequate fluids.
3) Place medicine on back of tongue.
4) Give liquid medications slowly.
5) Watch for choking. Call for help if the student has coughing spasms and skin begins to darken, or if the student develops breathing problems.
6) Verify that the student swallowed the medication.
7) Give medications with other food or crushed, only if directed (some medications lose effectiveness if crushed).

F. Skin Medications

1. Gather necessary equipment: tongue blade, gauze, tape, cleansing material and cotton-tipped applicator. For broken skin or open lesions use gloves.
2. Note condition of affected area. If unusual, report before applying medication.
3. Cleanse the skin, remove previously applied medication, apply medication in a thin layer or as ordered.
4. Record any changes seen in skin area treated. Notify school nurse of any change.
5. Cover as ordered.

G. Eye Drops. Use preparations labeled for ophthalmic use.

1. Gather necessary equipment: cotton balls, tissue.
2. Observe affected eye for any unusual condition and report before medication administration.
3. Cleanse eye with clean cotton ball wiping once from inside to outside. Use clean cotton ball for each eye.
4. Position student with head tilted back and eyes looking up.
5. Open eye to expose the conjunctival sac (lower inside eyelid).
6. Approach the eye from outside the field of vision. Avoid touching the dropper tip to anything.
7. Drop the medication gently into the sac, not on the eyeball with the drop not falling more than 1" to eye. Wait 1-5 minutes between installations if more than one drop is ordered.
8. Gently close eye. Ask student to keep eye closed for a few minutes.
9. Blot the excess medication with a new clean cotton ball or tissue.

H. Eye Ointment

1. Gather necessary equipment: cotton balls and tissue.
2. Observe affected eye(s) for any unusual condition. Report to the school nurse.
3. Cleanse eye with clean cotton ball. Wipe once from inside to outside. Use a clean cotton ball for each eye.
4. Position student with head tilted back and eyes looking up.
5. Open eye to expose the conjunctival sac.
6. Approach the eye from outside the field of vision. Avoid touching anything.
7. Apply in a thin layer along the inside lower lid or as ordered.
8. Hold lid open a few seconds.
9. Close eye gently. Ask the student to keep eyes closed for a few minutes.
10. Blot the excess medication with a new clean cotton ball or tissue.

L. Ear Drops

1. Gather necessary equipment: cotton balls and tissue.
2. Position the student.

a. If lying flat on a cot, turn face to opposite side.
b. If sitting in chair, tilt head sideways until ear is horizontal.
3. Cleanse entry to car canal with a clean cotton ball as needed.
4. Observe affected area for any unusual condition, report to the school nurse.
5. Straighten the ear canal, pull outer ear gently down and back (ages 3 and under) or up and back (older children).
6. Drop the medication on the side of the canal. Avoid the dropper touching anything.
7. Instruct the student to maintain the required position for 1 minute. Gently rub the skin in front of the ear to assist the medication to flow to the inside of the ear.
8. If the other ear is to be treated repeat procedure after the 1 minute wait.
9. Loosely place a cotton ball in the ear as ordered.

J. Medication inhaler
Follow individual student plan which may include device prescribed to asthmatics to measure the peak expiratory flow rate (peak flow meter), device used in conjunction with inhalers to improve delivery of drug to airway (spacer), self-management, self-administration and immediate availability with student carrying the medication. Observations when monitoring student self-administration of medication include:

1. Attach mouthpiece to inhaler which contains the medicine.
2. Stand up, feet slightly apart.
3. Shake inhaler for approximately two seconds.
4. Position inhaler with canister upside down above mouthpiece.
5. Holding mouthpiece 1-2 inched from lips (or as instructed), open mouth wide. If a spacer is used, place mouthpiece in mouth.
6. Breathe out naturally.
7. Open mouth wide and begin to inhale a deep breath slowly. If using a spacer, seal mouth around mouthpiece and inhale a deep breath.
8. After the beginning of deep breath, squeeze canister down on mouthpiece and breathe as slowly and deeply as possible.
9. Hold breath as long as possible - up to 10 seconds - to allow medication to settle as deeply as possible into and onto air passages.
10. Wait approximately 1-2 minutes, repeat the process. This technique should allow delivery of medicine into air passages opened by first whiff. See reference, Brannin.

K. Auto-injector medication. A disposable injection with a spring-activated, concealed needle used for emergency administration in individuals sensitive to potentially fatal reactions. Follow individualized student plan.

1. Pull off safety cap.
2. Place tip on thigh.
3. Press auto-injector against thigh until mechanism activates, and hold in place several seconds. May be injected through clothing.
4. Follow the emergency procedure. See reference, EpiPen.