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Clinical Procedure Guidelines for Connecticut School Nurses

Clinical Procedure Guidelines for Connecticut School Nurses

7. Specialized Health Care Procedures


Information that addresses the procedures identified in this chapter is intended to be used as a guideline in conjunction with sound theoretical knowledge; medical research and evidence-based clinical references; collaboration with professional peers and expert consultants; and collaboration with students, educators, families, and caregivers.

The procedural guidelines delineate the general steps of physical health care activities and must always be used in conjunction with fundamental principles, standards, and safe practices recognized as vital to working with children with special or complex health care needs. Those principles, standards, and practices are reviewed in chapters 1 and 2, and should form the basis for planning, implementing, and evaluating all specialized health care services for students.

This section addresses the following specialized health care procedures:

  1. Asthma
  2. Allergies
  3. Blood Glucose Monitoring
  4. Catheterization: Clean Intermittent
  5. Catheter: External
  6. Catheter: Indwelling
  7. Catheterization: Reinsertion of Indwelling Urinary Catheter
  8. Central Line Care
  9. Diabetes
  10. Enteral Tube Feeding
  11. Health Assessment
  12. Incontinent Care
  13. Injectables: Intramuscular, Subcutaneous Medication or Vaccination Administration
  14. Insulin Pump Management
  15. Intravenous Therapy
  16. Mechanical Ventilation
  17. Oral Feeding
  18. Oral or Inhaled Medication Administration
  19. Ostomy Management and Care
  20. Oxygen Therapy
  21. Pulse Oximetry
  22. Suctioning (non-tracheostomy)
  23. Tracheostomy Care and Suctioning
  24. Vagus Nerve Stimulator

A. Asthma Management

Definition

A chronic inflammatory disease that results in bronchial hyper-reactivity (bronchospasm), mucous production, and reversible airway obstruction. Successful asthma management is based on the four components of the National Asthma Education and Prevention Program (NAEPP):

  • measures of assessment and monitoring;
  • education for a partnership in asthma care;
  • control of environmental factors and comorbid conditions that affect asthma; and
  • medications.
Purpose

Asthma management and control significantly contributes to school attendance and the general health and wellbeing of students.

Procedure
Metered Dose Inhaler with Spacer

Equipment: metered dose inhaler and holding chamber/spacer. Instructions for the use of a common brand of holding chamber/spacer may be found on the Forest Laboratories Inc. (2011) Web site. Instructions for the use of other brands of holding chamber/spacer may be found on the manufacturer’s Web site.

Nebulizer Administration

Equipment: medication, nebulizer machine (air compressor), facemask, or a mouthpiece held in the mouth.

  1. Set up and plug in the nebulizer machine in a location where the power source is close to a comfortable location for the medication to be administered.
  2. Follow the directions for the specific brand of nebulizer machine and cup.
  3. Most nebulizer cups unscrew from the top.
  4. Most nebulized medication comes packaged in a unit-dose format, requiring the entire contents to be squirted into the bottom half of the nebulizer cup.
  5. Screw the top of the cup back on and attach the tubing from the cup to the nebulizer machine and the cup onto the facemask or mouthpiece.
  6. Place either the facemask on the student or the mouthpiece in his or her mouth and turn on the machine. A mist of medication should rapidly appear.
  7. Instruct the student to take relatively normal slow deep breaths.
  8. The cup may require some tapping on the sides toward the end of the treatment to optimize the completion of the dose.
  9. The treatment is complete when there is no more mist from the cup (usually 10–15 minutes).
Peak Flow Meter (PFM) Administration

The proper use of a PFM can assist in providing an objective measure of one aspect of lung function. The PFM can measure the forced expiratory volume (FEV1) at the first second of a forced exhalation. Accurate use of the PFM is primarily dependent on having a three-zone system that is based on the student’s individual personal best measurement:

  • Green Zone is 80–100 percent of the personal best.
  • Yellow Zone is 50–80 percent of the personal best.
  • Red Zone is less than 50 percent of the personal best.
  1. Stand up (if possible).
  2. Shake down (like a thermometer) to reset.
  3. Take a deep breath.
  4. Seal your lips around the mouthpiece.
  5. Do not stick your tongue in the mouthpiece or cover the end with your fingers.
  6. Blow out as hard and fast as possible.
  7. If you cough or make a mistake, try again.
  8. Do three measurements with good technique. Record the best one.
Delegation Considerations

These procedures may be performed by the school nurse, RN (registered nurse), or LPN (licensed practical nurse). Asthma monitoring may also be delegated to appropriately trained, unlicensed assistive personnel with supervision, evaluation, and feedback and an individualized care plan (IHCP) in place.

Select Nursing Considerations

The school nurse can effectively partner with families and community health providers in assessing asthma control and having a positive impact on a student’s asthma management. Key components of asthma management that are ideal for school nursing include:

  • assessing history of cough (day and night), and exercise or activity intolerance;
  • physical exam findings for complaints of acute symptoms, including response to medications;
  • teaching and reevaluating proper inhaled medication technique;
  • monitoring the frequency of quick-relief medication use and reporting to prescriber as indicated;
  • reviewing the asthma action plan with student and family and making recommendations for follow-up asthma care as indicated; and
  • active participation in the school’s indoor air quality program.

School nurses must ensure that adequate inhaled medication is being administered, all medication administered for as needed (PRN) or acute symptoms is accompanied by the appropriate respiratory assessment before and after medication, and encourage the use of a holding chamber/spacer with all medication administration using a metered-dose inhaler (MDI).

References

American Lung Association.

Center for Disease Control and Prevention. Asthma.

Connecticut Department of Public Health Asthma Program

Connecticut State Department of Education Coordinated School Health Services Cadre of Trainers can provide a professional development session on asthma in schools.

Corjulo, M. (2011). Mastering the metered-dose inhaler: an essential step toward improving asthma control in school. NASN School Nurse 2011 26: 285.

Forest Laboratories, Inc. (2011). Instructions for use: AeroChamber Plus Flow-Vu (aVHC), Retrieved January 20, 2012.

National Heart, Lung, and Blood Institute, National Asthma Education and Prevention Program Expert Panel Report 3.

Resources

Guidelines for the Diagnosis and Management of Asthma 

National Asthma Education and Prevention Program

Asthma public education materials.


B. Allergies

Definition

An allergic reaction occurs when the body releases chemicals in response to a specific protein found in some foods or the venom of an insect. These chemicals can cause a variety of symptoms ranging from relatively mild ones such as hives to severe life-threatening ones such as an inability to breathe, shock, and death (anaphylaxis).

Please refer to the CSDE's Guidelines for Managing Life-Threatening Food Allergies in Connecticut Schools for information on a comprehensive approach to allergy management in schools. This guideline is available on the Health Promotion Services/School Nurse Web site.

Select nursing considerations
  • Active participation in the development and monitoring of the district's allergy plan.
  • Develop the individual student health care plan and emergency care plan through collaboration with student, families, school staff and health care providers.
  • Work with students and staff to minimize the risk of allergy exposure.
Resources

Connecticut State Department of Education, Food Allergies

The Food Allergy and Anaphylaxis Network


C. Blood Glucose Monitoring

Definition

Blood glucose monitoring is the procedure used to determine a student’s blood glucose (sugar) level by the use of a blood glucose monitor (MedlinePlus Encyclopedia, 2010).

Purpose

To evaluate diabetes control; to adjust insulin dosage and nutritional intake.

Equipment

Blood glucose monitor, testing strips, sterile disposable lancet, automatic lancet or lancet pen (many diabetics use the same lancet for a period of time and keep that lancet in their pen), alcohol swab, cotton ball, or Band-Aid, disposal container.

Procedure
  1. Wash hands or clean the child’s fingertip with alcohol swab, by rubbing the area for 5–10 seconds and letting it dry.
  2. Insert the monitor specific test strip into meter.
  3. Using lancing device on the side of student’s fingertip to get a drop of blood (It is best to draw blood from the side of the fingertip).
  4. Gently squeeze or massage finger until a drop of blood forms. (Required sample sizes vary by meter.)
  5. Touch and hold the edge of the test strip to the drop of blood, and wait for the result.
  6. Blood glucose level will appear on the meter’s display.
  7. Wash hands.
  8. Follow health care provider’s orders for snacks, hyper or hypoglycemia, or insulin coverage.
Delegation Considerations

This procedure may be performed by a school nurse, RN, or LPN. Blood glucose monitoring may also be delegated to appropriately trained, unlicensed assistive personnel with supervision, evaluation and feedback, and an individualized health care plan (IHCP) in place.

Select Nursing Considerations

There are many different manufacturers of blood glucose meters. The school nurse needs to be familiar with each particular type he or she handles. Every blood glucose machine works differently, therefore it is important to read and understand the specific instructions that accompany the equipment, as well as having a plan for maintaining the device with quality control checks, cleaning, etc., to ensure the machine stays in proper working condition.

Most monitor companies provide manuals and instructional videos and will provide training, if requested. Hospitals are another resource that will provide training to school nurses for the consistent care and management of their patient’s diabetes.

Students who are capable should be taught to perform this task independently or semi-independently with assistance.

References

Connecticut State Department of Education, Guidelines for Blood Glucose Self-Monitoring in Schools

Connecticut State Department of Education, Learning and Diabetes: A Resource Guide for Connecticut Schools and Families

The American Diabetes Association

MedlinePlus Encyclopedia. (2010). Blood glucose monitoring. Retrieved January 3, 2012.


D. Catheterization: Clean Intermittent

Definition

Clean intermittent catheterization is done with or for students who are either unable to completely empty their bladders or unable to void independently (AUA Foundation, 2011).

Purpose
  1. To allow students to completely empty their bladders on a periodic basis to prevent urinary tract infection or bladder leakage.
  2. To assist students who do not have bladder control to empty their bladders on a periodic basis to prevent leakage.
  3. The ultimate goal is for the student (if able physically and cognitively) to become independent in this procedure.
Equipment

Gloves, clean or sterile straight catheter, disposable wipes or soap and water, urinal or receptacle for urine if procedure is not performed on the toilet, water based lubricant, disposable towel or Chux to place under student if procedure is done on a cot.

Procedure
Male Catheterization
  1. Wash hands.
  2. Grasp sides of penis below the glans.
  3. Clean the tip of the penis and urethra.
  4. Retract foreskin if uncircumcised.
  5. Gently stretch the penis upward.
  6. Generously lubricate the catheter.
  7. Have student take a deep breath.
  8. Slowly insert the catheter until urine begins to flow and then about an inch more.
  9. If you meet resistance before urine flows, have the student take another deep breath and continue with insertion (resistance in male catheterization is normal at about the level of the prostate).
  10. If resistance continues or the student experiences pain, stop insertion, never force the catheter.
  11. When urine flow has stopped, pinch the catheter and remove it slowly when urine flow has stopped.
  12. Measure urine per student’s order.
  13. Discard bodily fluids and catheter per infection control procedures and school district policy.
  14. Wash hands.
  15. (American Academy of Pediatrics, Healthychildren, 2012).
Female Catheterization
  1. Wash hands.
  2. Prepare equipment: Using clean techniques open the urine catheterization package and lubricating jelly.
  3. Place within easy reach.
  4. Prepare the student.
  5. Expose the urethral opening.
  6. Clean the vulva and urethral opening from front to back, starting over the urethral meatus, then each side.
  7. Continue to keep one hand in place exposing the urethral opening.
  8. Generously lubricate catheter.
  9. Separate the labia minora to clearly see the urinary meatus.
  10. Have the student take a deep breath.
  11. Slowly insert the catheter until urine begins to flow, then advance about an inch more.
  12. Pinch the catheter and remove it slowly when urine flow has stopped.
  13. Maintain clean environment.
  14. Wash hands.
  15. (American Academy of Pediatrics, Healthychildren, 2012).
Delegation Considerations

This procedure may be performed by a school nurse, RN, or LPN.

Select Nursing Considerations
  • Assess area for redness, breakdown, swelling, or discharge.
  • Note change in urine color, clarity, or odor, report signs and symptoms of urinary tract infection.
  • Never use non-water-soluble lubricant.
  • Some students will use a new catheter each time, others will need to wash and reuse catheters.
  • Follow health care provider’s orders (such as as frequency; strict measuring of output).
References

AUA Foundation. (2011). Bladder augmentation. Retrieved January 3, 2012.

Centers for Disease Control. (2009). Guideline for Prevention of Catheter-associated Urinary Tract Infections. Retrieved January 14, 2012.

American Academy of Pediatrics. Healthychildren. 2012. Clean Intermittent Catherization.

Resources

Centers for Disease Control. (2009). Guideline for Prevention of Catheter-associated Urinary Tract Infections, 2009. Retrieved January 14, 2012.

Bray, L., and Sanders, C. (2007). Teaching children and young people intermittent self-catheterization. Urologic Nursing, 27, 203-9, 242.

Infectious Disease Association of America, American Hospital Association, Centers for Disease Control, (n.d.). FAQs about catheter associated urinary tract infection. Retrieved January 14, 2012.


E. Catheter: External

Definition

An external catheter is a condom-type urinary collection device, vinyl rolled or with a jock-type supporter (AUA Foundation, 2011).

Purpose

To maintain social continence (clothing dry and/or free from odor).

Equipment

Gloves, washcloth, protective pad; self-adhesive external catheter or double-sided tape and external catheter; drainage bag (or leg bag) and tubing.

Optional depending on individual student: skin-prep adhesive; foam tape (Microfoam); stretch tape (Elastoplast); and clean clothing.

Procedure
  1. Carefully roll off the external catheter and remove tape, if necessary.
  2. Wash and dry penis and scrotum.
  3. Using scissors, cut off any pubic hair that is matted, stuck together, or will be caught in the new condom.
  4. Check the skin around penis and scrotum for skin problems, i.e., sores, redness, a rash, or swelling.
  5. Leave about ½-inch space between the end of the external catheter and the tip of penis. This will help to avoid irritation.
  6. If using tape around the penis, make sure the tape does not overlap on itself. The penis can be damaged if the tape reduces the blood circulation. Read the directions on the catheter package.
  7. If using spray adhesive:
    1. Cut a small hole in the center of a paper towel.
    2. Put the penis through the hole. (This keeps pubic hair from being sprayed with adhesive.)
  8. If using a self-adhesive catheter, move to step “b” below.
    1. Read directions on external catheter package. Unroll the external catheter onto the penis about ½-inch.
    2. Unroll the rest of the external catheter to cover the penis.
  9. Hold the hand around the penis for 30 seconds. This will set the adhesive and help the external catheter stick to the penis.
  10. If you need to use extra tape:
    1. Clip and remove the ring from the external catheter. (If the ring is not removed, the pressure may damage the penis.
    2. Put tape around the penis. Half should be on the external catheter and half should be on the skin. Make sure the tape does not overlap on itself. (The penis can be damaged if the tape reduces the blood circulation.)
  11. If you used spray adhesive, remove paper towel and throw it away.
  12. Hook up the external catheter to the drainage tube or leg bag.
  13. Change into dry clothes, if necessary
  14. (MedlinePlus Health Topic, 2010; National Association for Continence, 2012; Wound Ostomy and Continence Nurses Society, 2008).
Delegation Considerations
  • May be performed by a school nurse, RN, or LPN.
  • May also be delegated to appropriately trained, unlicensed assistive personnel with supervision, evaluation and feedback, and an IHCP in place.
Select Nursing Considerations

This task may be performed on a cot, on the toilet, or in a wheelchair. Skin problems should be reported to the parent or health care provider. Students who are capable should be taught to perform this task independently.

References

AUA Foundation. (2011). Managing bladder dysfunction with products and devices. Retrieved January 3, 2012.

Centers for Disease Control and Prevention. (2010). Catheter-associated urinary tract infections. Retrieved January 14, 2012.

MedlinePlus Health Topic. (2010). External incontinence devices. Retrieved January 3, 2012.

National Association for Continence. (2012). Male external catheters. Retrieved January 3, 2012.

Wound Ostomy and Continence Nurses Society. (2008). External Catheter: Fact Sheet 2008.Retrieved January 3, 2012.


F. Catheter: Indwelling

Definition

An indwelling catheter is inserted into the bladder to provide urinary drainage over a period of time from hours to weeks. It is attached to a closed drainage system that must be emptied periodically (AUA Foundation, 2011).

Purpose

To empty the bladder of urine as it accumulates; to minimize residual urine; to decrease incidence of bladder infection; to control incontinence.

Equipment

Gloves, disposable washcloth and towel, soap and water, graduated drainage container

Procedure

In general, other than emptying the drainage bag into a container and measuring the output, the only care required for an indwelling catheter in school would be if the student were toileted for a bowel movement, the area around the urinary meatus would have to be cleansed if contaminated with feces.

Delegation Considerations

This procedure may be performed by a school nurse, RN, or LPN. With the appropriate training and supervision, monitoring may be performed by unlicensed assistive personnel or certified staff.

Select Nursing Considerations

Most students with an indwelling catheter will not require care of it during the school day, however the school nurse must be notified if there is any evidence of infection; pain; skin breakdown; displacement or obstruction of the catheter; bleeding; or a change in urine consistency, color, or odor.

References

AUA Foundation. (2011). Managing bladder dysfunction with products and devices. Retrieved January 3, 2012.

Centers for Disease Control and Prevention. (2010). Catheter-associated urinary tract infections. Retrieved January 14, 2012.


G. Catherization: Reinsertion of Indwelling Urinary Catheter

Definition

Replacement of a dislodged indwelling urinary catheter. An indwelling urinary catheter is inserted into the bladder to provide urinary drainage over a period from hours to weeks. It is attached to a closed drainage system that must be emptied periodically (AUA Foundation, 2011).

Purpose

To maintain patency of the indwelling urinary catheter and to ensure emptying of the bladder of urine as it accumulates in order to: minimize residual urine; decrease incidence of bladder infection; and to control incontinence.

Equipment

Sterile gloves; sterile Foley catheter; sterile water (10 cc); 10 cc syringe; disposable wipes or soap and water; urinal or receptacle for urine, if procedure is not performed on the toilet; water-based lubricant; towel or disposable blue pads to place under student, if procedure is done on a cot; leg bag or other urinary drainage system.

Procedure
Male Catheterization
  1. Grasp sides of penis below the glans.
  2. Clean the tip of the penis and urethra.
  3. Retract foreskin if uncircumcised.
  4. Gently stretch the penis upward.
  5. Lubricate the catheter.
  6. Have student take a deep breath.
  7. Slowly insert the catheter until urine begins to flow and then about an inch more.
  8. If you meet resistance, have the student take another deep breath and continue with insertion (resistance in male catheterization is normal at about the level of the prostate).
  9. If resistance continues or the student experiences pain, stop insertion. Never force the catheter.
  10. Inflate balloon with appropriate amount of sterile water.
  11. Pull gently on catheter until balloon is snugly against bladder neck.
  12. Attach catheter to leg bag or other drainage system.
  13. Attach catheter to thigh without tension on tubing.
Female Catheterization
  1. Expose the urethral opening.
  2. Clean the vulva and urethral opening.
  3. Lubricate catheter.
  4. Separate the labia minora to clearly see the urinary meatus.
  5. Have the student take a deep breath.
  6. Slowly insert the catheter until urine begins to flow, then advance about an inch more.
  7. Inflate balloon with appropriate amount of sterile water.
  8. Pull gently on catheter until balloon is snugly against bladder neck.
  9. Attach catheter to leg bag or other drainage system.
  10. Attach catheter to thigh without tension on tubing.
Delegation Decisions

According to the Connecticut Board of Examiners for Nursing, this task can only be performed by a school nurse, RN, or LPN (Board of Examiners for Nursing, 2002).

Select Nursing Considerations

In particular circumstances, nursing assessment may indicate that reinsertion of the catheter requires physician evaluation, such as when displacement is traumatic, (i.e., frank bleeding or swelling is present) or when reinsertion is difficult. It is recommended that the same size catheter be reinserted or as close a size as possible. If reinsertion is difficult or the decision is made not to replace the catheter, make sure the student is diapered or protected from soiling himself or herself or his or her clothing. A dry dressing may be used to cover a urinary stoma.

References

AUA Foundation, (2011). Managing bladder dysfunction with products and devices. Retrieved January 3, 2012.

Board of Examiners for Nursing, (2002) Meeting Minutes: January 16, 2002. Retrieved January 17, 2012.


H. Central Line Care

Definition

A central line is a catheter most frequently placed through the chest wall into the right atrial chamber of the heart or a large central blood vessel. Central lines are placed internally (implanted), such as portacaths, or externally such as Hickman catheters. In school, central line care should be limited to ensuring that the dressing is occlusive and intact when applicable, intervening in an emergency; or care required to access the line for medication administration or nutrient administration. This procedure may include dressing reinforcement and/or heparin or saline flush.

Purpose

Long-term access to the circulatory system for medications, fluids, and nutrients.

Equipment

Gloves, antiseptic wipes/swabs, heparin or saline if ordered, appropriate size needle and syringe, sterile gauze, tape.

An emergency kit containing wipes, injection cap, heparin flushing supplies, dressing change supplies, and an extra clamp should be available at all times.

Procedure
Flushing or administering medications through a central line
  1. Clean the injection cap for 30 seconds using an appropriate (chlorhexidine, povidone-iodine, alcohol) wipe; allow to air dry.
  2. Using the appropriate flush solution or medication, draw up the solution as ordered.
  3. Inject the flush or medication.
  4. Flush line if ordered following administration of medication (Mannheim, J.K., 2010).
Changing cap on central line
  1. Set up a clean work surface.
  2. Gather all the supplies.
  3. Wash your hands for 15 seconds with liquid antibacterial soap. Dry your hands thoroughly using paper towels.
  4. Make sure that the central venous catheter (CVC) lumens are clamped.
  5. Remove the new cap from its package.
  6. Loosen, but do not remove, the cover on the end of the new cap.
  7. While holding onto the lumen of the CVC with one hand, use the other hand to:
    1. Remove the old cap and set it aside.
    2. Remove the cover from the new cap.
    3. Screw the new cap onto the open end of the lumen. This requires doing a lot with only one hand, but it is important to hold onto the lumen of the CVC to keep it from hanging free and touching anything.
    4. Repeat these steps for each of the lumens.
    5. Follow your routine to change caps in the same order as flushing.
Delegation Considerations

Must be performed by a trained registered nurse.

Select Nursing Considerations

Flushing or administering medications via a central line requires specialized nursing education. Contact an area hospital or other health care groups for training, as necessary. School nurses may need to provide central line care if a student is experiencing symptoms of infection, the catheter is dislodged, or if a student is experiencing shortness of breath or chest pain. Monitoring and ongoing assessments of the central line dressing and site are essential nursing care in a school environment.

Reference

Mannheim, J.K. (2010). Central venous catheter - flushing. Retrieved January 14, 2012.


I. Diabetes

Definition

A chronic disease in which there are high levels of sugar in the blood. There are three major types of diabetes. The causes and risk factors are different for each type:

  1. Type 1 diabetes can occur at any age, but it is most often diagnosed in children, teens, or young adults. In this disease, the body makes little or no insulin. Daily injections of insulin are needed. The exact cause is unknown.
  2. Type 2 diabetes makes up most of diabetes cases. It most often occurs in adulthood, but teens and young adults are now being diagnosed with it because of high obesity rates. Many people with type 2 diabetes do not know they have it.
  3. Gestational diabetes is high blood sugar that develops at any time during pregnancy in a woman who does not have diabetes (PubMed Health: Diabetes, 2012).

The school health team, which includes the school nurse, teachers, the school administrator and other school staff members and parents, plays an important role in helping students manage their diabetes. Effective diabetes management is crucial:

  • for the immediate safety of students with diabetes;
  • for the long-term health of students with diabetes;
  • to ensure that students with diabetes are ready to learn;
  • to participate fully in school activities; and
  • and to minimize the possibility that diabetes-related emergencies will disrupt classroom activities (CSDE, 2005).

Please refer to the CSDE’s Learning and Diabetes a Resource Guide for Connecticut Schools and Families and Guidelines for Blood Glucose Self-Monitoring at School for a comprehensive approach to diabetes management in schools. These guidelines are available on the Health Promotion Services/School Nurse Web site.

References

Connecticut Department of Education. (2005). Learning and Diabetes a Resource Guide for Connecticut Schools and Families.

Connecticut State Department of Education. Guidelines for Blood Glucose Self-Monitoring at School.

PubMed Health. Diabetes. Retrieved on March 30, 2012.


J. Enteral Tube Feedings

Definitions

Delivering a liquid nutrient formula directly to the stomach, duodenum, or jejunum.

  • Enteral Nutrition: Nutrition administered in the gastrointestinal tract.
  • Tube Feedings: Enteral nutrition delivered via a tube, catheter, or stoma.
  • Stoma: A stoma is a surgical bypass of a natural conduit.
  • Gastrostomy: A stoma that bypasses the upper digestive tract and directly enters the stomach.
  • Jejunostomy: Surgical creation of an opening to the middle portion of the small intestine (jejunum), through the abdominal wall.

(American Society for Parenteral and Enteral Nutrition, 2011).

Methods

Bolus feeding is the administration of liquid into a feeding tube using gravity to determine the rate the liquid passes through the tube. The liquid is either poured into a 60 cc syringe or a tube-feeding bag and held (or hung) at a height above the stomach that allows for the most desirable and tolerated rate of administration, typically over 15–30 minutes. Pushing the liquid in with the syringe is sometimes used to augment a bolus feeding (Altman GB, ed., 2003).

Tube feeding pump is a mechanical device that uses a matching tube-feeding bag and tubing. A set rate to administer a set volume over a specific period of time is programmed into the pump. Pumps vary in size and battery power potential. Tube feedings using pumps can be continuous (i.e., 30 cc/hr.) or intermittent (i.e., 240 cc over one hour). The school nurse needs to be competent using the specific type of pump for an individual student.

Types of Feeding Tubes

Feeding tubes use an abbreviation system that indicates the point where it enters the body and the point where it ends (and the liquid is infused).

  1. NGT (Naso Gastric Tube): These can either be inserted for each feeding or remain in place for a set period of time.
  2. GT (Gastrostomy Tube): These are surgically inserted through the stomach wall, leaving one end accessible on the abdomen and the other in the stomach. The most common type used in children is the low-profile brand “Mic-Key” (also referred to as a “button”). An extension tube is connected and locks in place when used for feedings, hydration, or medications. When not in use this device caps off to remain relatively flush with the abdominal wall.
  3. G-JT (Gastro-Jejunostomy Tube): Also surgically inserted through the stomach wall, entering the stomach, passing through the pylorus, and ending in the jejunal segment of the small intestine. These tubes are generally indicated for children who cannot tolerate food in their stomach. They may have a lumen that ends in the stomach and another lumen that ends in the jejunum, so the nurse needs to be clear if one lumen is for medication and the other is for feeding (it is helpful to label the two lumens).
  4. JT (Jejunostomy Tube): Similar to the GT, except it is surgically inserted through the abdominal wall directly into the jejunal section of the small intestine (Rosewell Park Cancer Institute, n.d.).
Purpose

To provide a safe method of feeding a student who cannot tolerate oral feeding or requires supplementation to oral feeding in order to ensure adequate nutritional intake. Also, to provide continuity with the health care plans that students follow at home.

Equipment

Per provider’s order and individual health care plan.

Procedure
Tube Feeding
  • Prepare formula or liquid to be administered (normally room temperature).
  • Ensure feeding tube is intact and in the correct anatomical position.
  • Prime the feeding tube to minimize the amount of excess enteral air.
  • Clamp or pinch-off feeding tube prior to opening to air (to avoid reflux of gastric contents out of tube).
  • Attach syringe and administer fluids.
  • Unclamp feeding tube.
  • Administer feeding as directed.
  • When feeding is complete, flush tube with prescribed amount of water.
  • Cap or disconnect tube as indicated.
Medication Administration
  • Prepare medication as prescribed.
  • If administering a pill or capsule, ensure that solid particles are adequately dissolved or mixed in water.
  • Clamp or pinch-off feeding tube prior to opening to air (to avoid reflux of gastric contents out of tube).
  • Attach syringe and administer medication.
  • Clamp or pinch-off feeding tube prior to disconnecting syringe in order to avoid reflux (and loss) of medication back out of tube.
  • Flush with sufficient water to ensure that no medication is left in tube.
  • If administering medication immediately before tube feeding, tube feeding may be used to flush through the medication.
Delegation Considerations

Initiating tube feeding or tube medication administration: RN, LPN

Monitoring of feeding: RN, LPN, physical therapist, occupational therapist, speech pathologist, teacher, school health aide, other certified personnel.

Select Nursing Considerations
  1. Administration of any tube feeding in school requires a nurse to be present in the building.
  2. Tube feedings in school require a procedure authorization order and plan signed by a prescribing health care provider and parent/guardian, including: the type of formula; amount; infusion type and rate; frequency of administration; and amount of water used to flush the tube.
  3. The most significant risk with tube feedings is aspiration of liquid nutrition into the lungs.
  4. Keys to preventing aspiration include:
    1. Ensuring tube placement is appropriate.
    2. Proper positioning.
    3. Monitoring during feedings:
      1. Stop feeding immediately for gagging, vomiting, coughing, change in skin color, or difficulty breathing. An immediate nursing assessment would then be indicated.
  5. Additional considerations include:
    1. Any specific method for securing a feeding tube.
    2. Storage and preparation of the formula.
    3. Caring for the insertion site:
      1. Rashes tend to occur as a result of leaking around a GT stoma site.
      2. Management may include using a barrier ointment and frequent dry dressing application.
      3. Granulation tissue usually forms as a result of excess friction between the tube and the stoma site.
      4. Daily monitoring of the insertion site to ensure healthy skin integrity at the insertion site is essential.
  6. Mic-Key tube considerations:
    1. Mic-Key tubes should be level with the skin, able to rotate 360 degrees, and use a water-filled balloon in the stomach side of the stoma to maintain it in place.
    2. The balloon is usually filled with 5 cc of sterile or distilled water and should routinely be checked once a week (at home), and more often if it appears loose or leaking (Kimberley Clarke, 2010) .
    3. A balloon that is leaking and unable to hold water is an indication for Mic-Key tube replacement.
    4. A spare Mic-Key should be maintained at school and the nurse needs to be trained in inserting a new one if it falls out:
      1. Prompt reinsertion of a Mic-Key tube is vital to maintain the opening of the stoma site.
      2. If the nurse is unable to reinsert the Mic-Key, prompt medical attention is indicated.
  7. NGT insertion in school is a relatively unique procedure that goes beyond the scope of this manual. Specific procedures and training needs for the school nurse should be obtained on a case-by-case basis. Once an NGT is properly inserted, the procedural steps listed above for feeding and medications can be applied.
  8. Medication and nutrition administered into the jejunum require careful consideration since bypassing the stomach can affect absorption rates and tolerance.
References

Altman GB, ed. Feeding and medicating via a gastrostomy tube. Delmar’s Fundamental and Advanced Nursing Skills. 2nd Ed. Albany, NY: Delmar Thomson Learning; 2003: 742-749. Per Medlineplus.

Altman GB, ed. Feeding and medicating via a gastrostomy tube. Delmar’s Fundamental and Advanced Nursing Skills. 2nd Ed. Albany, NY: Delmar Thomson Learning; 2003: 742-749. Per Medlineplus

Americal Society for Parenteral and Enteral Nutrition. (2011). What is enteral nutrition?Retrieved January 17, 2012.

Bowden, V.R., and Greenberg, C.S. (2008). Pediatric Nursing Procedures, 2nd edition. Philadelphia, PA: Lippincott Williams and Wilkins.

Guenter, P. and Silkroski, M. (2001). Tube feeding: practical guidelines and nursing protocols. Gaitherberg, MD: Aspen Publications, Inc.

http://www.mic-key.com/

http://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000165.htm

Kimberley Clarke (2010) MIC-KEY care and usage guide. Retrieved January 19, 2012.

Rosewe Park Cancer Institute. (n.d.). Jejunostomy tube. Retrieved January 17, 2012.

Wilson, D. and Hockenberry, MJ (2007). Wong’s clinical manual of pediatric nursing (7th ed.). Denver, CO: CV Mosby

Resource

Bankhead R., Boullata J., Brantley S., Corkins M., Guenter P., Krenitsky J., Lyman B., Metheny N.A., Mueller C., Robbins S., Wessel J.(2009) Enteral nutrition administration. In: A.S.P.E.N. enteral nutrition practice recommendations. JPEN Journal of Parenteral and Enteral Nutrition; 33, 149-58. Retrieved January 17, 2012.


K. Health Assessment

Definition

Refers to the collection and analysis of information or data about a student’s health situation to determine the student’s state of health; level of wellness; patterns of functioning; and need for health services, counseling, and education. Health assessment by the school nurse includes data collection, data analysis, and nursing diagnosis. It also includes identification of student health needs that require collaborative management with physicians, other health care providers and school team members. The assessment is systematic, goal oriented, directed by a body of knowledge, and related to both the health and educational needs of the student.

Purpose

Identifies student health needs by obtaining appropriate information about a student’s health status, strengths, limitations, and coping mechanisms to manage the student’s health problems in the school setting.

Equipment

Student’s cumulative health record, nursing record, and progress notes; information from physicians, parents, acute care facilities, other related service providers.

Procedure

For any student with actual or potential health care needs, the school nurse, in collaboration with the family, student, health care providers, and other school staff as appropriate, should:

  • Complete the initial health assessment on school entry or reentry.
  • Complete the health assessment component for special education or Section 504 eligibility evaluation, if appropriate.
  • Develop a health care plan to meet the student’s special health needs in school; collaborate with appropriate members of the school team.
  • Evaluate the health care services provided to the student periodically.
  • Revise the health care plan accordingly.
Select Nursing Considerations

School nurses who only meet minimal qualifications under Connecticut General Statutes Section 10-212 School Nurses and School Nurse Practitioners may or may not be competent in the health assessment of children and young people ages 0–21, depending on their educational preparation and experience. School nurses who have had no pediatric experience or those who are new to the educational arena, may need assistance from an experienced school nurse or school nurse supervisor to appropriately perform this activity. Supervision by a qualified school nursing supervisor is desirable and recommended.

Delegation Considerations

Health assessment is the licensed function of physicians and registered nurses and can never be delegated to, or assumed by other school personnel. The school nurse and/or school nurse supervisor will consult with the school medical adviser as appropriate. LPNs and appropriately trained paraprofessionals can contribute to the health assessment by gathering data such as height, weight, and vital signs. The registered nurse is the health professional who has the expertise to present health assessment information at early intervention meetings, PPTs, and 504 meetings.


L. Incontinence Care

Definition

An incontinent student is one who is unable to control the passage of urine or feces (stool).

Purpose

To keep the student as clean and dry as possible; to prevent skin breakdown and subsequent infection; to improve the student’s acceptance by school peers.

Encopresis

Encopresis is one of the more frustrating disorders of middle childhood. It is the passing of stools into the underwear or pajamas far past the time of normal toilet training. Encopresis affects about 1.5 percent of young schoolchildren and can create tremendous anxiety and embarrassment for children and their families.

Encopresis is not a disease but rather a symptom of a complex relationship between the body and psychological/environmental stresses. Boys with encopresis outnumber girls by a ratio of 6 to 1, although the reasons for this greater prevalence among males are not understood. The condition is not related to social class, family size, the child’s position in the family, or the age of the parents.

(American Academy of Pediatrics. Healthychildren: Soiling (Encopresis). Retrieved on April 20, 2011.)

Equipment

Equipment will depend on the age and size of the student. With some students care can be done in a lavatory; with other students it may be necessary to use a cot with incontinence pads, basin, soap and water, disposable wash cloth and towel, plastic bag for disposal and one for soiled clothing, toilet tissue, gloves, diapers if needed, clean clothing.

Procedure
Incontinent care
  1. Remove soiled clothing;
  2. Clean student’s skin with soap and water and pat dry to avoid any irritation to the skin.
  3. Observe the student’s skin for breakdown or skin irritation.
  4. Assist student to put on clean clothing, as needed.
Delegation Considerations

Toileting and care of incontinent students is not a nursing function. Rather, toileting is considered an activity of daily living, including toileting of students with delayed achievement of this developmental task. In most cases, unless there is a specific disability that requires nursing judgment, any related service provider, including paraprofessionals, teacher, or other certified personnel can perform this task. Health aides can also perform the task, although regularly removing a student from the classroom to visit the nurse’s office for this reason may not be in keeping with the student’s educational goals and objectives.

Select Nursing Considerations
  • This procedure should be done minimally twice during the school day or more frequently as determined in the individualized health care plan (IHCP).
  • Clean clothes and personal supplies are provided by the parent.
  • A bowel and bladder training program may be appropriate for this student and should be addressed in an IHCP if needed.
  • Encopresis should be considered for younger students particularly (over age 4), but also in students of any age who are incontinent.

M. Injectables: Intramuscular, Subcutaneous Medication or Vaccination Administration

Definition

Injecting a medication or immunization into a muscle or subcutaneous (SC) tissue.

Purpose

To maintain a medication or immunization regime prescribed by an authorized health care provider.

Equipment

The appropriate size sterile needle, syringe, gloves, and alcohol swab.

Procedure
  1. Follow “The Six Rights of Medication Administration,” (right medication, right dose, right student, right route, right time, and right approach).
  2. Determine the correct size needle and injection site.
  3. Medication authorizations for injectable medications in school should specify the injection site options and any other detail specific to that medication that is necessary to ensure safe administration in school.
  4. For subcutaneous insulin injections, follow the above procedures and see chapter 3 for specific insulin injection considerations.
  5. For intramuscular (IM) injections of epinephrine using an auto-injection device (such as an EpiPen).
Immunization considerations
  1. The list of current vaccines and administration considerations is found on the CDC's Web site. Access the electronic version to ensure that it reflects the most recent updates.
  2. The National Childhood Vaccine Injury Act (NCVIA), enacted in 1986, set forth three basic requirements for all vaccination providers. These apply to school nurses who directly administer a vaccination. When a local health department administers the vaccine at a school, it is responsible for this criteria:
    1. Providers must give the patient (or parent/legal representative of a minor) a copy of the relevant federal “Vaccine Information Statement” (VIS) for the vaccine they are about to receive.
    2. Providers must record certain information about the vaccines administered in the patient’s medical record or a permanent office log, including:
      1. Name of manufacturer
      2. Lot #
      3. Expiration date
    3. Providers must document any adverse event following the vaccination that the patient experiences and that becomes known to the provider, whether or not it is felt to be caused by the vaccine, and submit the report to the Vaccine Adverse Event Reporting System (VAERS).
    4. As of April 2008, NCVIA requirements apply to diphtheria, tetanus, pertussis, measles, mumps, rubella, polio, hepatitis A, hepatitis B, Haemophilus influenzae type b (Hib), varicella, influenza, pneumococcal conjugate, meningococcal, rotavirus, and human papillomavirus (HPV) vaccine.
Select Nursing Considerations

Administration of injectable medications or vaccinations in the school setting by a school nurse needs to carefully consider individual factors related to each student. Some questions to consider include:

  • Is the administration of this medication part of an IHCP that addresses a chronic disease management or is it a short-term health problem?
  • Is the administration of this medication in school necessary for this student to maintain his or her education?
  • Are there other options for administration times that do not include school hours?
  • Is this the safest option to help manage this particular health issue?
Delegation Considerations

Only a school nurse, RN, or LPN can administer IM or SC medications or immunizations.

Exception: If approved by the local or regional board of education, paraprofessionals, in the absence of a school nurse, may only administer medications to a specific student to protect that student from harm or death due to a medically diagnosed allergic condition, including the administration of medications with a cartridge injector, such as an EpiPen (Connecticut General Statutes, Section 20-212a).

References

Bowden, V.R., and Greenberg, C.S. (2008). Pediatric Nursing Procedures, 2nd edition. Philadelphia, PA: Lippincott Williams and Wilkins.

The National Childhood Vaccine Injury Act (NCVIA). 1986.

The Regulations of Connecticut State Agencies. Administration of Medications by School Personnel and Administration of Medication During Before- and After-School Programs and School Readiness Programs.

Resource

State Department of Public Health. Connecticut Immunization Program.


N. Insulin Pump Management

Definition

The insulin pump is a small, battery-operated device, worn on a belt or in a pocket, which delivers a constant infusion of insulin. It is also used to administer a bolus of insulin to provide coverage for the ingestion of carbohydrates. The insulin is infused subcutaneously via a catheter or needle placed in the abdomen, hip, or thigh (National Diabetes Information Clearinghouse, 2009).

Purpose

Insulin pumps replace the need for periodic injections by delivering rapid acting insulin continuously throughout the day. The use of an insulin pump allows the user to match insulin administration to their lifestyle, rather than adjusting their lifestyle to the administration of insulin. Insulin pumps allow a more “natural” level of insulin in the body.

Equipment

Insulin pump, infusion sets, insulin (ordered by authorized prescriber), adhesive tape or Tegaderm; extra batteries; and gloves (for infusion set change.)

Procedure
  1. Programming insulin pump:
    1. Follow manufacturer’s instructions.
    2. Follow prescriber’s orders for basal rate as well as for bolus infusions:
      1. Make sure instructions are available for types of pumps in use in your schools.
  2. Changing an infusion set:
    1. Check with manufacturer’s instructions for changing infusion sets. There are many different types. Some sets are inserted at an angle, some at 90 degrees. Some sets have separate cannulas and insertion devices; some are an all-in-one device.
Delegation Considerations

Only a school nurse, RN, or LPN may program an insulin pump, administer a bolus or change an infusion set. Unlicensed assistive personnel may be trained to assist a capable student to administer a bolus by checking the student’s calculations and numbers. A student specific IHCP and emergency care plan (ECP) should be in place.

Select Nursing Considerations

There are many different manufacturers of insulin pumps. The school nurse needs to be familiar with each particular type he or she handles. Most insulin pump companies provide manuals for their pumps, instructional videos, and in-person training, if requested. Hospitals are another resource that will provide training to school nurses for the consistent care and management of their patients’ diabetes.

In case of an insulin pump malfunction or failure, an emergency plan must be in place for administration of insulin to the student (such as an insulin pen).

Reference

National Diabetes Information Clearinghouse (2009). Alternative devices for taking insulin. Retrieved January 19, 2012.


O. Intravenous Therapy

Definition

Administration of prescribed fluids via an intravenous route using a pump infusion method.

Purpose
  1. To provide or supplement hydration and nutrition by intravenous route, when other feeding routes are ineffective (oral, g-tube).
  2. To provide IV medication necessary for a student to be in school.
Equipment

Gloves, IV pole, prescribed solutions (including medication if ordered), clamp, alcohol wipes, disposable IV set up, 2 cc syringe, infusion pump.

Procedure
Intravenous Therapy (IVT)
  1. To administer medication through catheter placed in a vein, clean the port with alcohol wipe and administer the medication through the port after expelling all air.
  2. To administer IV fluids, connect the fluids directly to the catheter or through an IV pump after cleaning the port with alcohol wipe and expelling all air. Follow doctor’s orders for the rate of flow. When the ordered amount of fluids has been administered, disconnect the bag from the port and discard appropriately.
Select Nursing Considerations

Performing a venipuncture requires skills and specialized training. Nurses may contact an area hospital or college for a phlebotomy course as necessary.

Delegation Considerations

Only a school nurse, RN, or LPN can administer IV fluids or medications. Appropriately trained, unlicensed assistive personnel can monitor running IV infusions with supervision, evaluation, and feedback with an IHCP in place.


P. Mechanical Ventilation

Definition

An electric or battery-powered machine that delivers positive pressure to the lungs using a variety of different settings based on the student’s individual needs.

Purpose

To aid in maintaining pulmonary gas exchange, acid-base balance, and support the work of breathing either continuously or intermittently based on the student’s individual needs.

Methods

In the school setting, there are a variety of portable mechanical ventilation units that can be used with a student; each one requires a connection with a tracheostomy.

Equipment

There are a variety of portable mechanical ventilation machines from a variety of manufacturers that can be used in the school setting. Since this is an area of frequent technological advances, it is recommended that the nurse obtain specific information from a manufacturer for each mechanical ventilation device as well as the medical provider managing the student’s care.

Procedures
  1. Procedures required for mechanical ventilation in school requires the ability to safely and effectively care for a student with a tracheostomy (see Tracheostomy Care and Suctioning procedure).
  2. Each ventilator requires instructions from the specific manufacturer of the ventilator.
  3. Additional procedural considerations include:
    1. Oxygen administration (see Oxygen Therapy procedure):
      1. Most students’ mechanical ventilation will require some level of supplemental oxygen. This is based on a student’s individual needs.
      2. All students require emergency oxygen. Schools must also have on hand, emergency back-up oxygen.
    2. Pulse Oximetry (see Pulse Oximetry procedure):
      1. Students with mechanical ventilation should have their own pulse oximeter.
      2. A back-up pulse oximeter should be in schools where there is a student with a mechanical ventilator.
    3. Emergency back-up ventilators are generally not indicated in school, however, an emergency back-up source of electricity or a generator is indicated.
Delegation Considerations

The level of continuous skilled assessment required for a student with mechanical ventilation requires a registered nurse, licensed practical nurse (if appropriate), or a respiratory therapist.

Select Nursing Considerations

Each nurse responsible for the care of a student requiring mechanical ventilation must have an understanding of the underlying disease process and reason for requiring a tracheostomy and mechanical ventilation. The nurse must also have a comprehensive understanding of the student’s baseline physical exam, including saturation of peripheral oxygen (Sp02), respiratory effort, breath sounds, pulmonary secretions, and any additional acute or chronic health problem that may affect the student’s respiratory status. Training is also required on the specific brand and type of ventilator the student uses in school.


Q. Oral Feeding

Definition

Provide nutrients and fluids to a student who requires assistance putting food in the mouth and swallowing.

Purpose

To maintain adequate nourishment and hydration. To facilitate developmentally appropriate and safe oral motor skills.

Equipment

Adaptive eating and drinking devices; adaptive seating or positioning equipment; measuring containers; and protective barriers for clothing. Nonlatex disposable gloves and suction equipment, as indicated.

Procedure

Refer to Connecticut State Department of Education’s Guidelines for Feeding and Swallowing Programs in Schools. This document provides comprehensive information that addresses the multiple aspects of oral feeding in school.

Delegation Considerations

This procedure may be performed by licensed, certified, and unlicensed assistive personnel with the appropriate training and supervision.

Select Nursing Considerations
  1. Each school should identify its feeding and swallowing team.
  2. The school nurse is an integral part of the feeding and swallowing team and can provide assessment of students and training to unlicensed assistive personnel for assisting with feeding students.
  3. The feeding and swallowing team responsibilities include:
    1. Working with staff and families to create safe and effective feeding plans for individual students.
    2. Collaborating with medical providers to determine that a medical evaluation (including swallow studies) indicates that the student can swallow safely according to their plan or orders.
    3. Identifying a process to ensure that all staff members who feed a student with an individualized feeding plan know that plan and can demonstrate competency in performing that plan.
  4. Staff working directly with students should report any concerns about a student’s ability to safely feed and swallow to the feeding and swallowing team (CSDE, 2008). Classroom food preparation and cleanup requires careful consideration to maintain sanitary conditions and avoid cross-contamination.
References

Connecticut State Department of Education. (2008). Guidelines for Feeding and Swallowing Programs in Schools.

Connecticut State Department of Education. (2008). Guidelines for Feeding and Swallowing Programs in Schools: New Referrals Algorithm, p. 27.


R. Oral or Inhaled Medication Administration

Definition

Placing medication in a student’s mouth to be swallowed or inhaled.

Purpose

To maintain a medication regime prescribed by an authorized health care provider.

Equipment

Warning: Not all medication is designed to be crushed due to the coating and the pharmacological action of the medication. Serious side effects can occur from administering crushed medication not recommended by the manufacturer.

Based on the medication and the form that the student requires to swallow.

Oral medication
  • Liquid medications require a precise measuring device such as a syringe or plastic dose-marked medication cup.
  • Pills or tablets may require:
  • Crushing utensil (i.e., mortar and pestle, for those that are appropriate for crushing).
  • A student-specific food substance to mix it with (e.g., applesauce).
Inhaled medication

See Asthma and procedures below for specific inhaled medication technique options.

Procedures
  1. The fundamental legal and safe medication administration procedure requires the Six Rights of Medication Administration, which includes the
    1. right medication;
    2. right dose;
    3. right student;
    4. right route;
    5. right time; and
    6. right approach.
  2. All medications administered in school must adhere to the Regulations of Connecticut State Agencies, Administration of Medications by School Personnel and Administration of Medication During Before- and After-School Programs and School Readiness Programs and the district’s policies and procedures, including the specific requirements for controlled substances.
  3. A medication authorization signed by the prescribing provider and parent/guardian is required for each medication.
  4. Prior to administration, each medication, dose, time, and route must be confirmed with the medication authorization.
  5. The person administering the medication should be the same person pouring the medication from a container with the student’s name and prescription label.
  6. An accurate student identification is required.
  7. The person administering the medication needs to ensure that the medication was swallowed.
  8. Assisting a student to take own medication requires all of the above in addition to the medication authorization signed by the prescribing provider and parent authorizing self- administration of that medication.
  9. For inhaled medication, follow the above procedures and see the Asthma section for specific inhaled medication technique options.
Delegation Considerations

Delegation of oral or inhaled medication administration to “qualified personnel” by an RN must be in accordance with the Regulations of Connecticut State Agencies, Administration of Medications by School Personnel and Administration of Medication During Before- and After-School Programs and School Readiness Programs. It is important to note that according to Section 10-212a-9 of these regulations, paraprofessionals, if approved by the local or regional board of education, in the absence of a school nurse, may only administer medications to a specific student in order to protect that student from harm or death due to a medically diagnosed allergic condition.

Medication Administration Training of School Personnel

The school nurse is responsible for teaching, assessing, documenting the competency of, and providing ongoing supervision to staff members medication administration is delegated to.

The Regulations of Connecticut State Agencies, Section 10-212a-3. Administration of Medications by School Personnel and Administration of Medication During Before- and After-School Programs and School Readiness Programs: Training of school personnel.

Select Nursing Considerations

Each nurse should consider the individual school environment and student population regarding establishing and maintaining a safe medication administration system. There are a variety of ways to store and organize daily and PRN medications so that legal criteria are met and safe access is available.

Nurses who routinely administer medications to the same students need to consider if their system of medication administration is easily understood by another staff member who may need to fill in when they are not available. Some areas to consider are:

  • medication cabinet labels;
  • medication cabinet key identification;
  • medication pouring organizers;
  • the use of medication cards to identify poured medications;
  • the use of student pictures on the back of medication cards or in the medication book;
  • how students know when to come to the health office for medications or if the medication needs to be administered elsewhere in the school;
  • periodic medication counting for each student; and
  • a refill request system to ensure continuity with medications required at school.
References

Bowden, V.R., and Greenberg, C.S. (2008). Pediatric Nursing Procedures, 2nd edition. Philadelphia, PA: Lippincott Williams and Wilkins.

The Regulations of Connecticut State Agencies. Administration of Medications by School Personnel and Administration of Medication During Before- and After-School Programs and School Readiness Programs.


S. Ostomy Management and Care

Definition

An ostomy is a surgically created opening through the skin to the intestine or urinary tract to provide for elimination of bodily wastes. Urinary stomas and colostomies usually drain into a bag (National Library of Medicine, 2011).

Purpose

To maintain continence; to keep the stoma and the surrounding skin in good condition. To encourage self-care as much as developmentally and physically possible; to facilitate acceptance of the student in school; to replace a bag that is leaking.

Equipment

Gloves, scissors; stoma wafer; disposable washcloth; gauze; ostomy bag; skin protectant or barrier

Procedure
Management (emptying bag)
  1. Empty or assist student to empty contents of bag into toilet.
  2. Inspect skin around stoma for redness, rash, blistering, lesions, or bleeding.
  3. Notify parent if there is any redness, rash, blistering, lesions, or bleeding.
  4. Remind student to wash hands when procedure completed.
Care (changing appliance)
  1. Carefully remove the used bag and skin barrier by pushing the skin away from the bag, instead of pulling the bag off the skin.
  2. Inspect skin for redness, rash, blistering, lesions, or bleeding and notify parent if observed.
  3. Cut skin barrier to fit stoma.
  4. Pat stoma dry with disposable washcloth, cover the stoma with moistened gauze while awaiting placement of bag.
  5. Pat skin dry with disposable washcloth.
  6. Apply skin protectant or barrier to skin around stoma.
  7. Peel off backing from adhesive.
  8. Center the new bag directly over the stoma.
  9. Firmly press the bag to the skin barrier so there are no leaks or wrinkles.
  10. Remind student to wash hands when procedure completed.
Delegation Considerations

Management may be performed by an RN, LPN, OT, PT, teacher, paraprofessional.

Care of stoma or changing appliance may be performed by a RN, LPN, OT, PT, CNA, or trained paraprofessional.

Select Nursing Considerations
  • Health care provider order and parent/guardian authorization is required.
  • Developmental and physical limitations of student.
  • If unfamiliar, training, and consultation for school nurses, RNs and LPNs may be provided by an ostomy-care nurse specialist.
  • Training received by the student and/or family.
  • Irritation at or around the stoma, skin breakdown, increased or decreased ostomy output, vomiting, or pain should be reported for treatment.
Reference

National Library of Medicine. (2011). Ostomy. Retrieved January 19, 2012.


T. Oxygen Therapy

Definitions

Oxygen administration refers to a supplemental source of oxygen above the normal 21 percent oxygen concentration found in room air.

Continuous oxygen: The student has a treatment order to be on a continuous source of supplemental oxygen that needs to be maintained throughout the school day and during transportation to and from school.

Intermittent oxygen: The student has a treatment order to use a prescribed amount of PRN oxygen based on objective clinical assessment date (such as decreased Sa02, increased respiratory rate, or increased respiratory effort).

Emergency oxygen: Requires a standing physician order to administer oxygen to any student under emergency medical situations (such as seizure activity or acute respiratory distress).

Purpose

Oxygen administration in school is indicated to treat either acute or chronic hypoxia as prescribed by a treatment procedure authorization.

Methods

Nasal Cannula: Plastic tube that connects on one end to an oxygen source (tank) with the other end having two short prongs that each fit into the nostrils. Generally indicated as an option for planned use of continuous or intermittent oxygen.

Mask: A plastic facemask with tubing connected to an oxygen source. The two main sizes of oxygen masks are pediatric and adult. They are generally indicated for emergency situations.

Tracheostomy Mask: A plastic mask designed to fit over a tracheostomy cannula and secured by an elastic strap around the neck (over the tracheostomy ties). This may be indicated for planned use of continuous or intermittent oxygen.

Mechanical Ventilation: A variety of portable mechanical ventilation devices may be used for children who attend school. They are attached to the student via a tracheostomy and may or may not involve the routine delivery of supplemental oxygen.

Ambu Bag (Manual Resuscitation): In a case of extreme medical emergency (i.e., severe oxygen desaturation, impending respiratory failure, or respiratory or cardiac arrest), oxygen can be delivered at full flow (> 10 L/min.) with an Ambu Bag using an appropriately sized sealed face mask or fitted directly onto a tracheostomy cannula.

Equipment

Per provider’s order and IHCP and ECP.

Procedure
High pressure tanks (standard metal oxygen tanks)
  1. Require a regulator that has:
    1. A valve to turn the oxygen source on and off.
    2. A flow meter to measure and adjust the flow of oxygen.
    3. A pressure gauge to determine the amount of oxygen remaining in the tank.
  2. Open the tank by turning the valve at the top counterclockwise until the needle on the pressure gauge moves.
  3. Set the flow meter to the prescribed rate (liters/minute) by turning the dial to the number or until the ball rises to the correct level on the scale.
  4. If using a nasal cannula:
    1. Place prongs into nose so they follow the curve of the nostrils.
    2. Secure around back of ears.
    3. Adjust below the chin.
  5. If using a face mask:
    1. Place mask over nose and mouth.
    2. Secure with elastic strap around the head and above the ears.
    3. The mask needs to be comfortably, but firmly against the face:
      1. Any space between the mask and face dilutes the intended concentration of oxygen.
      2. For students unable to tolerate the elastic strap around their head, the mask can be held against the face without the strap (only appropriate for a limited period of time).
  6. If using a tracheostomy mask:
    1. Follow the same procedure as a facemask, except cover the tracheostomy cannula with the mask and secure it around the neck.
  7. If using an Ambu Bag:
    1. Turn oxygen flow rate > 10 L/min.
    2. Administer by either face mask or tracheostomy connection:
      1. Either option requires a tight seal to the airway.
      2. Rate and force of manual resuscitation breaths is determined by CPR certified personnel.
  8. To close the tank:
    1. Disconnect oxygen from the student;
    2. Turn valve clockwise until it cannot go any further. The flow meter should steadily decrease to zero, indicating that no oxygen is flowing (or leaking) from the tank (referred to as “bleeding” the tank off).
    3. Turn the flow meter dial to zero.
  9. Tank needs to be stored in a secured upright position to prevent it from falling or tipping over.
  10. Storage area for oxygen tank must be free of petroleum products.
Liquid oxygen tanks
  1. Portable liquid oxygen tanks can be refilled from a home-based liquid oxygen system.
  2. These tanks are student specific and only indicated as part of an IHCP.
  3. These tanks are used following the same procedural steps listed above and require the same safety considerations.
Delegation Considerations
  1. Initiation of oxygen therapy: registered nurse (RN), practical nurse, (LPN), or respiratory therapist (RT).
  2. Monitoring of oxygen therapy:
    1. Continuous or long-term oxygen use that does not require continuous pulse oximetry (see Pulse Oximetry: RN, LPN, RT, physical therapist, occupational therapist, teacher, or other certified personnel.
    2. Continuous, intermittent, or emergency that requires continuous or frequent assessment of pulse oximetry or respiratory status: RN, LPN, or RT.
Select Nursing Considerations
  1. Oxygen may be drying to the airway mucosa. Humidification systems are often indicated with long-term or continuous use.
  2. Skin assessments around tubing or elastic straps are indicated.
  3. The presence of any source of supplemental oxygen requires strict fire safety guidelines.
  4. “Oxygen in Use” signs should be posted at the entrance of all building sections, classrooms, or nursing offices; on vehicles during transportation of students; and wherever oxygen is stored or potentially used.
  5. Oxygen supply vendor-contact information should be kept readily available.
  6. Any oxygen tank that is heard hissing or noted to be leaking needs to be replaced promptly.
  7. Checking monthly to ensure that they have an adequate supply to use in an emergency situation is a reasonable option.
  8. Emergency (“stock”) high-pressure oxygen tanks should not lose oxygen if they are not being used or if they were turned off properly.
  9. Tanks noted to be less than half-full or expired should be refilled or replaced.
Important Safety Precautions:

Numerous safety precautions that are associated with the storage and maintenance of oxygen in the school setting. School districts should consult with their town’s fire marshal.

Reference

Bowden, V.R., and Greenberg, C.S. (2008). Pediatric Nursing Procedures, 2nd edition. Philadelphia, PA: Lippincott Williams and Wilkins.


U. Pulse Oximetry

Definition

Pulse oximetry provides estimates of arterial oxyhemoglobin saturation (SaO2) by utilizing selected wavelengths of light to noninvasively determine the saturation of oxyhemoglobin (SpO2).

Purpose

Pulse oximetry is used in the school setting as an adjunct to the registered nurse or respiratory therapist’s clinical respiratory assessment. The SpO2 should never be used in isolation to determine the respiratory status of a student. Obtaining an accurate SpO2 is a skilled level of assessment that requires:

  • Demonstrated competency
  • A knowledge of the student’s baseline SpO2 (if known)
  • The ability to interpret the clinical significance of the SpO2 for an individual student and their clinical situation.
Methods

Pulse oximetry in the school setting requires a portable pulse oximeter with a probe that generally attaches to the student’s finger. These devices are either:

  • hand-held with the probe that attaches to the device by a cable; or
  • one-piece integrated fingertip devices
Equipment

Pulse Oximeter

Procedure
  1. Turn on pulse oximeter.
  2. Select a distal extremity (usually a fingertip) that can be held still and is void of nail polish, false nail, moisture, and sweat.
  3. Minimize excessive environmental light.
  4. An accurate SpO2 requires that the pulse oximeter is able to consistently detect the student’s pulse:
    1. all pulse oximeters have some form of light signal or bar graph that correlates with detecting the pulse; and
    2. a consistent high level of detection for at least 20–30 seconds is necessary to determine an accurate reading.
Continuous Pulse Oximetry
  1. If the pulse oximetry is indicated to be continuous, the probe needs to be secured in place per manufacturer’s instructions.
  2. An order for continuous pulse oximetry requires an oximeter with an alarm.
  3. Alarm parameters are to be set per the students IHCP.
  4. If the alarm sounds, the student requires immediate assessment to determine if it is a “false alarm” (commonly due to excessive movement) or a true emergency that reflects a sudden deterioration in the student’s respiratory status.

An order for continuous pulse oximetry requires an oximeter with an alarm.

Delegation Consideration

Pulse oximetry may be performed by a RN, LPN, or RT.

Select Nursing Considerations
  1. Continuous pulse oximetry requires the rotation of probe sites, per IHCP.
  2. Pulse oximetry should be available for students who have a tracheostomy, require oxygen supplementation and/or mechanical ventilation, or frequent airway suctioning.
  3. The use of pulse oximetry for other common health problems, such as asthma, is generally not indicated.
Reference

Bowden, V.R., and Greenberg, C.S. (2008). Pediatric Nursing Procedures, 2nd edition. Philadelphia, PA: Lippincott Williams and Wilkins.


V. Suctioning (non-tracheostomy)

Definitions

Using a battery or electronic vacuum (suction) device to remove upper airway secretions or fluid that the student cannot expectorate spontaneously.

Purpose

To remove secretions or fluid that may contribute to upper airway obstruction, increased respiratory effort, the potential for respiratory distress, aspiration, or increased risk of infection.

Methods

Oropharyngeal Suctioning: Removing secretions or fluid from the mouth and pharynx (anatomic area from the soft palate to the upper most aspect of the esophagus)

Nasopharyngeal Suctioning: Removal of secretions or fluids from either nostril to the pharynx

Equipment

An electric or battery /rechargeable operated portable suction machine with pressure gauge; flexible extension suction tubing; suction catheter sizes per IHCP (8 Fr to 14 Fr are most common); Yankauer catheters may be an option for clearing oral secretions; towel or disposable pad or cloth.

Procedure
Oropharyngeal and Nasopharyngeal Suctioning (general procedures)
  1. As with all invasive procedures, carefully consider an appropriate and safe location based on degree of urgency and physical design of the school/class/health office.
  2. Using appropriate personal protective equipment.
  3. Confirm that respiratory assessment requires suctioning procedure.
  4. Ensure that suction machine has the appropriate level of subatmospheric pressure:
    1. Standard maximal pressure for children ranges from 80–120 mm Hg.
    2. Maximal pressure can be determined by turning on suction and occluding extension tubing by folding it in half. Pressure reading on gauge when tubing is completely occluded is the maximal suction pressure.
  5. The option of using a sterile catheter should be determined per treatment procedure authorization and IHCP. (See procedures specific to oropharyngeal and nasopharyngeal suctioning below.)
  6. Positioning of the student is based on the clinical situation:
    1. Students in wheelchairs or other supportive seating devices can remain sitting upright or reclined up to, but not exceeding, semi-fowlers or 45 degrees.
    2. Students who are lying either on the floor or health office couch should be turned on their side. This position may be commonly associated with a student experiencing a seizure who may require supplemental oxygen and/or suctioning.
  7. Respiratory assessment should be an ongoing process to determine:
    1. How well the student is tolerating the procedure.
    2. The amount of time and suction attempts that are clinically indicated.
Oropharyngeal Suctioning
  1. Using appropriate personal protective equipment.
  2. Attach the specified suction catheter to the suction extension tubing.
  3. Start by gently suctioning visible secretions from the oral cavity.
  4. Proceed to the pharynx, as clinically indicated, using caution to minimize gagging, which may increase the risk of vomiting.
Nasopharyngeal Suctioning
  1. Using appropriate personal protective equipment.
  2. Aseptic technique using a sterile catheter is the standard for this procedure.
  3. Approximate the insertion length of the catheter by measuring the catheter from the nose to the ear, and use the thumb and forefinger of your nondominant hand to mark the catheter at that point of maximal insertion.
  4. Dip the catheter tip in sterile water-soluble lubricant to minimize trauma to the nasal mucosa.
  5. Without applying suction gently introduce the catheter into the nostril and slowly proceed along the floor of the nasal cavity.
  6. If unable to continue inserting downward toward the pharynx, remove catheter while applying suction and attempt insertion in the other nostril.
  7. If able to insert to the pharynx, up to the maximal insertion point, apply suction while rotating and withdrawing catheter.
  8. Duration of suction should not exceed 15 seconds.
  9. If additional suction passes are required:
    1. wait at least 30 seconds while performing appropriate aspects of the respiratory assessment and determining the student’s toleration of the procedure;
    2. cleanse the catheter with sterile water; and
    3. re-lubricate as indicated.
Delegation Consideration

Oropharyngeal or nasopharyngeal suctioning can only be performed by the RN, LPN, or RT.

Select Nursing Considerations
  1. Nasopharyngeal suctioning is not commonly performed in school. Students requiring this procedure may have a 1 to 1 (1:1) nurse assigned to them based on nursing assessment.
  2. Consider activating EMS/911 for students who experience apnea, unresolved cyanosis, or respiratory/cardiac distress despite appropriate suctioning attempts.
  3. Bradycardia may occur as a result of vagal stimulation at the posterior oropharynx with vigorous suctioning.
  4. The use of pulse oximetry is an optional component of the respiratory assessment and should be determined in collaboration with the family, authorizing prescriber, and district medical adviser, as indicated.
  5. Some children learn to suction their own mouths at home. This practice in the school setting would require very thoughtful consideration and assessment by the school nurse, with authorization from the health care provider and parents.
Reference

Bowden, V.R., and Greenberg, C.S. (2008). Pediatric Nursing Procedures, 2nd edition. Philadelphia, PA: Lippincott Williams and Wilkins.


W. Tracheostomy Care and Suctioning

Definitions

Tracheostomy is a surgical opening creating a stoma through the neck into the trachea where a tracheostomy tube can be inserted.

Tracheostomy (“trach”) Tube is a plastic (most common) or metal tube inserted through the tracheostomy stoma that provides a fixed airway to accommodate breathing while bypassing the upper airway. This tube can be used with or without mechanical ventilation or supplemental oxygen, but generally requires at least some means of humidification. There are a variety of tracheostomy tube brands; the most common are Shiley and Bivona. Most pediatric trach tubes consist of a single cannula. If the tube has two cannulas, the inner cannula can be removed for cleaning while the outer cannula stays in place.

Obturator is a small plastic device used as a guide during the insertion of the tracheostomy tube.

Ambu-bag (manual ventilation bag) is a device used to manually instill air into the airway. A universal 15 mm adaptor allows it to fit directly onto the trach tube so that each “squeeze” of the bag correlates with a “breath.” A facemask can also be fitted onto the bag to instill air via the mouth in the event that the tracheostomy tube is occluded or not functioning.

Decannulization is the intentional or accidental removal of the trach tube out of the trachea

Passy-Muir Valve is a one-way valve that fits directly onto a trach tube, allowing air to be inspired through the trach tube, and forcing the exhaled air through the vocal cords and out of the mouth to facilitate vocalization and speech.

Purpose

There are two broad medical indications for a tracheostomy:

  1. An acquired or congenital anatomic defect in the upper airway.
  2. An inability to maintain adequate respiratory function due to chronic intrapulmonary or extrapulmonary (neuromuscular or metabolic) disease.

Caregivers responsible for the student need to be CPR-certified and specifically trained in routine and emergency tracheostomy care and procedures for each individual student.

Nurses must understand the underlying etiology of the need for each student who has a tracheostomy. A student with a tracheostomy is at risk for life-threatening complications that can be avoided with accurate physical assessment and diligent care of the airway. Proper care of a tracheostomy includes adequate skin care around the stoma and ensures the maintenance of the student’s airway.

Equipment

The essential equipment to be kept with the student at all times is as follows:

Never use an oil-based lubricant, such as Vaseline.

  • gloves;
  • portable oxygen with appropriate sized Ambu-bag;
  • Appropriate size Ambu-bag facemask (for emergencies when unable to reinsert a new tracheostomy tube;
  • portable suction machine that can operate with battery or electricity;
  • sterile suction catheters;
  • sterile saline vials;
  • water-based lubricant;
  • two spare tracheostomy tubes — one the size the student currently uses and one that is a size smaller in the event that the tube needs to be changed and there is difficulty passing it through the stoma;
  • spare tracheostomy ties;
  • blunt scissors;
  • personal protective equipment — to be used for all tracheostomy procedures;
  • emergency phone numbers; and
  • pulse oximeter — may be optional if student is not on oxygen or mechanical ventilation.

It is recommended that this equipment be stored together in an “emergency travel bag” that is easily transported with the student during transportation and the entire school day. Additional equipment may be indicated per the IHCP.

Procedures
Stoma and skin care
  1. The frequency of stoma care and the care of the surrounding skin is based on the individual student’s current skin condition and associated factors, such as the amount of secretions and the degree of skin folds around the neck.
  2. Ensure all essential equipment or travel bag is within reach prior to initiating stoma and skin care.
  3. Use gauze sponges and cotton-tipped swabs with water or a diluted peroxide solution per IHCP:
    1. Cleanse outer portion of tracheostomy tube and surrounding skin going from using wet to dry sponges or swabs.
    2. Minimize direct moisture to the tracheostomy ties.
    3. Drying the skin is vital to maintaining skin integrity.
Changing tracheostomy ties
  1. The two most common forms of tracheostomy ties are a soft padded tie with Velcro tabs (most common) or a simple thin cloth or twill tie that requires tying to secure.
  2. Changing tracheostomy ties in the school setting is usually not done on a routine basis, rather it is an, as-needed (PRN) procedure based on the integrity of the ties, the skin, or as part of an emergency tracheostomy change;
  3. Two people should be present during the procedure in the event of accidental decannulization.
  4. A shoulder roll is recommended to assist with the visualization and access to the tracheostomy site.
  5. Remove the old ties while holding the tracheostomy tube in place:
    1. Use caution not to occlude the tracheostomy tube.
    2. Removal of cloth ties requires the use of a blunt scissor.
    3. Removal of Velcro tab ties is done by detaching each end of the tie.
  6. Skin care is performed as indicated.
  7. Maintaining the tracheostomy tube in place is always the priority:
    1. Insert one end of the tie through the slit opening on the side of the tracheostomy tube.
    2. Bring the other end of the tie around the back of the neck.
    3. Repeat with the other end of the tie through the slit opening on the other side of the tracheostomy tube.
    4. Velcro tabs are fastened back on themselves.
    5. Cloth ties are secured using a single square knot on the side or back of the neck.
    6. The ties should allow enough space for fingers between it and the neck.
  8. If a split gauze is used around the stoma, replace it now with a clean one.
  9. Re-assess the student’s respiratory status to ensure that the tracheostomy tube remained in place and patent during the procedure.
Cleaning an Inner Cannula
  1. Remove the inner cannula as indicated per manufacturer’s instructions.
  2. The inner cannula is generally cleansed with a half-strength hydrogen peroxide solution using pipe cleaners to remove any dried secretions from inside the cannula.
  3. Thoroughly rinse the cannula with sterile water and dry.
  4. Reinsert the inner cannula by turning it 90 degrees from its usual position, introduce the tip into the outer cannula, slowly rotating it back 90 degrees to its final position.
  5. Lock the cannula in place per manufacturer’s instructions.
Tracheostomy Tube Suctioning

Suctioning is performed based on clinical assessment with consideration of individual student factors and considerations. Many students can cough out their secretions through their tracheostomy tubes without the need for suctioning (this maneuver is synonymous with “blowing their nose”).

  1. As with all invasive procedures, carefully consider an appropriate and safe location based on degree of urgency and physical design of the school, student’s classroom, and the health office.
  2. Confirm that respiratory assessment requires the suctioning procedure.
  3. Emergency travel bag (essential equipment listed above) must be present before suctioning.
  4. Ensure the suction machine has the appropriate level of subatmospheric pressure:
    1. standard maximal pressure for children ranges from 80–100 mm Hg; and
    2. maximal pressure may be determined by turning on suction and occluding extension tubing by folding it in half. Pressure reading on the gauge when the tubing is completely occluded is the maximal suction pressure.
  5. The option of using a sterile catheter should be determined per treatment procedure authorization and IHCP.
  6. Positioning of the student is based on the clinical situation:
    1. students in wheelchairs or other supportive seating devices can remain sitting upright or reclined up to, but not exceeding, semi-fowlers or 45 degrees; and
    2. students who are lying either on the floor or health office couch should be turned on their side (this position may be commonly associated with a student experiencing a seizure who may require supplemental oxygen and/or suctioning).
  7. The respiratory assessment should be an ongoing process to determine:
    1. how well the student is tolerating the procedure; and
    2. the amount of time and suction attempts that are clinically indicated.
  8. Determine the length of catheter insertion:
    1. it should be limited to just beyond the distal end of the tracheostomy tube; and
    2. “deep suctioning” up to or beyond the tracheal carina (point of bronchial bifurcation and tissue resistance) should not be indicated in a school setting, as it may cause epithelial damage.
  9. Hold the suction catheter at the point of maximal insertion length.
  10. Lubricate the catheter with normal saline.
  11. The use of normal saline to lavage the tracheostomy tube needs is based on the IHCP and, if indicated, to assist with the removal of thick secretions, needs to be used judiciously.
  12. Remove tracheostomy mask or ventilator connection and promptly insert catheter while gently rotating within the cannula. Do not apply suction during catheter insertion.
  13. At point of maximal insertion, apply suction while gently rotating the catheter out of the cannula:
    1. tracheal suctioning should not exceed five seconds; and
    2. if secretions are visible at the onset of suctioning, an initial shallow pass may be appropriate before proceeding further down the cannula.
  14. Rinse the catheter and repeat as indicated based on the clinical assessment and treatment order.
  15. Provide hyperventilation with Ambu-bag, if indicated.
  16. Rinse suction catheter and extension tubing
  17. (Ireton, J., 2007; Cincinnati Children’s Hospital, 2009).
Tracheostomy Tube Change

The changing of a tracheostomy tube in the school setting should be considered an emergency situation based on clinical assessment and the student’s history. Any concern that the situation is potentially life-threatening requires the activation of the EMS/911 system while the procedure is being performed. If there are complications during the procedure, the nurse must have an understanding of the student’s underlying need for the tracheostomy and ability to breathe without one. The nurse must be prepared to take control of the situation by acting swiftly, calmly, and clearly. The two most common emergency scenarios are:

  • accidental decannulization; and
  • tracheostomy tube obstruction unrelieved by reasonable suction attempts. Obstruction can be caused by thick secretions/mucous plugging, foreign body, or airway granuloma tissue. Airway granuloma tissue can persist to obstruct a new tracheostomy tube, resulting in the highest degree of medical emergency.
  1. Ensure the emergency travel bag is present.
  2. Ensure the presence of another responsible adult, preferably another nurse if available.
  3. If not already done, attach Ambu-bag to oxygen with gauge set at > 10 L/min.
  4. If able, position the student supine on the floor with a shoulder roll to gently hyperextend the neck.
  5. Open the new tracheostomy tube that is the same size as is currently in the student. Have the size smaller new tracheostomy tube readily available if needed.
  6. Taking care to not touch the curved part of the tracheostomy tube:
    1. be sure the obturator is in the tube;
    2. attach one end of the tracheostomy tie to a slot on the side of the tracheostomy tube;
    3. lubricate the distal end of the new tracheostomy tube with water-based lubricant; and
    4. return it to the clean package that it was sealed in.
  7. Remove or cut old tracheostomy ties.
  8. If possible, have assistant hold old tracheostomy tube in place:
    1. most students will not have cuffed tracheostomy tubes (with a balloon); and
    2. if this student does, deflate the cuff at this time per manufacturer’s instructions.
  9. With one hand remove the old tracheostomy tube and set it out of the way.
  10. Gently and quickly insert the new tracheostomy tube, pushing back and then down, in an arching motion:
    1. if unable to insert the new tracheostomy tube, attempt the same procedure using the new tracheostomy that is one size smaller; and
    2. if still unable to insert a new tracheostomy tube, use the Ambu-bag with facemask as indicated to maintain a stable airway while awaiting the emergency medical system (EMS).
  11. Once inserted, immediately remove the obturator (if used).
  12. Have assistant continue to hold new tracheostomy in place.
  13. Since this procedure done in school would most likely be an emergency situation, provide the student with manual breaths using the Ambu Bag and oxygen while auscultating the lungs to confirm adequate and symmetrical air movement.
  14. Continue the respiratory assessment, using pulse oximetry if available to confirm a return to the student’s baseline status.
  15. Secure the new tracheostomy tube in place by fastening the tracheostomy ties:
  16. If this is a cuffed tracheostomy tube, inflate at this time per manufacturer’s instructions.
  17. Position the student comfortably and observe to ensure he or she remains stable on their baseline level of supplemental or ventilator support (if any).
  18. If EMS was activated, the RN in charge can determine, in collaboration with the family and health care provider if necessary, if transportation to the local emergency room is still indicated.
  19. Regardless of outcome, notify family and medical provider that student required a tracheostomy change procedure.
  20. (Cincinnati Children’s Hospital, 2011)
Delegation Considerations

All students with a tracheostomy require a level of skilled nursing assessment by a RN. Care and management of the student’s tracheostomy may be assigned to an LPN during transportation and throughout the school day.

Select Nursing Considerations

See Oral Feeding for guidelines and references associated with orally feeding a student with a tracheostomy.

  • Maintaining adequate hydration is essential to minimize thick and crusting secretions.
  • Do not permit the use of powders, aerosols, or any small airborne particles around the student, especially if the tracheostomy tube is not covered with a ventilator, filter, or Passy-Muir valve.
  • If foreign material is aspirated into the tracheostomy tube, attempt to suction prior to giving breaths with an Ambu-bag.
  • Potential complications related to suctioning are bronchospasm and bleeding, which generally occur as a result of excessive suctioning or insertion of catheter past the distal end of the tracheostomy tube.
  • Comprehensive oral hygiene is required for a student with a tracheostomy
  • Water activities must be carefully considered and supervised.
  • The emergency travel bag should be inspected daily to ensure all used essential supplies have been replaced and are present.
  • Gauze used around the tracheostomy tube should be pre-split, not cut, to prevent threads from entering the airway.
References

Bowden, V.R., and Greenberg, C.S. (2008). Pediatric Nursing Procedures, 2nd edition. Philadelphia, PA: Lippincott Williams and Wilkins.

Ireton, J. (2007). Tracheostomy suction: A protocol for practice. Paediatric nursing, 19(10), 14-8.

Cincinnati Children’s Hospital. (2009). Suctioning. Retrieved January 19, 2012.

Cincinnati Children’s Hospital. (2011). Basic Pediatric Tracheostomy Care. Retrieved January 19, 2012.


X. Vagus Nerve Stimulator

Definition

Vagus nerve stimulation (VNS) is a type of treatment in which short bursts of electrical energy are directed into the brain via the vagus nerve, a large nerve in the neck. A battery about the size of a silver dollar is implanted under the skin in the chest. Electrical leads are threaded under the skin and attached to the vagus nerve during the same procedure. The device is programmed to deliver electrical stimulation that can help reduce the frequency of a child’s seizures. (Epilepsy Therapy Project [2006]; National Institute of Mental Health, 2009).

Purpose

Vagus nerve stimulators are used to control partial onset seizures (which originate from only one part of the brain) when other methods have been ineffective.

Equipment

Vagus nerve stimulator magnet.

Procedure

When the student has an aura, the magnet is passed over the implanted stimulator to cause an immediate stimulation of the vagus nerve. The stimulator may also be used for students who are having a seizure.

Delegation Considerations

The school nurse, RN, or LPN may use the Vagus nerve stimulator. Appropriately trained, unlicensed assistive personnel may also use the magnet when the student is having a seizure with supervision, evaluation, and feedback and an IHCP in place.

Select Nursing Considerations

As with other medical equipment refer to the manufacturer’s instructions for operation. In addition, contact the manufacturer’s representative if you need education regarding the unit.

References

Epilepsy Therapy Project. (2006). Vagus nerve stimulation. Retrieved January 19, 2012.

Epilepsy Foundation.

National Institute of Mental Health. (2009). Brain stimulation therapies. Retrieved January 19, 2012.

Gilette Children’s Specialty Healthcare. 2012. Vagus Nerve Stimulator. Retrieved on January 23, 2012.