Introduction

This chapter is to be used as guidance only and is not a replacement for direct training for each procedure and is based upon standards of practice and best practice. Most importantly, the specific provider authorization/plan should be reviewed by the School Nurse first before implementation. If the school does not employ a School Nurse, the school should follow the provider authorization/plan. If the school employs a School Nurse, the nurse should review the student’s health history, conduct a comprehensive assessment to include student, family, and all educational staff needed to carry out the student’s care needs.

Each local school board should have up-to-date policies and procedures for providing specialized health services to students and should take the following into consideration:

• Parent or guardian to notify the school in writing of the need for such services;
• A signed provider authorization/plan that outlines the type of procedure, time of administration, frequency of administration, and why to administer;
• Require the provider to provide possible adverse reactions or complications and instructions;
• The student’s parent or guardian is responsible for providing all provider orders, medical records, medication, equipment, supplements, oxygen, supplies, and other apparatus necessary for the administration of the specialized health services;
• A statement that the school or school district is usually not required to purchase medical supplies or equipment for an individual student;
• Specialized health services must be authorized annually or when changes occur.

If the school employs a School Nurse, the provider plan and authorization should be reviewed first by the nurse, and then the nurse should write an individualized health care plan, to be reviewed annually.

Recommended Guidelines for Delegation of Specialized Health Services

If the School Nurse is accountable for nursing tasks that are a part of the specialized health services, the school nurse must assess the unlicensed person’s skills and abilities to perform the nursing service. The school nurse must train the unlicensed person to perform the specialized health service, or otherwise see that training is provided to assure that the service is provided properly and safely. Documentation of training must be provided and no unlicensed person should perform that procedure unless the School Nurse delegates and goes through the delegation process for another student.

Complete written instructions, including directions for handling possible complications, must be provided. The School Nurse is to supervise the UAP by initial direction and periodic evaluation of the delegated service. The School Nurse retains accountability for the process of delegation but the UAP is accountable for not following the delegated plan.

For more information on delegation, see Chapter 18 in this manual.

Toileting/Diapering for Students with Specialized Health Services

Toileting/Diapering students may be required due to developmental level or health, or physical or cognitive disabilities of a student; it may require diapering or toileting on a scheduled or on an “as needed” basis. These tasks should be performed with dignity and respect for the student in a private and safe setting.

Due to special education laws and regulations, students cannot be denied entry into or removed from any educational program if they have not mastered this skill. Due to the wide range of disabilities, both physical and cognitive, and the various ages and physical sizes of students who require these services, these procedures should be tailored to each individual student’s specific needs:

• The School Nurse, physical/occupational therapist, teacher, or parent can provide training.
• The student may have special needs requiring specific procedures. This information should be included in the IEP or 504 plan.
• Staff involved in changing diapers or toileting have the potential to spread germs and diseases.
• Follow proper procedures and room set-up to reduce the risk of spreading illnesses.
• All staff involved in toileting and/or diapering must complete the Bloodborne Pathogen Training yearly.
• Parents are usually responsible for supplying diapers, wipes, a change of clothing, and other necessary supplies for their child.
• Schools or districts will supply approved cleaners/wipes for surfaces, gloves, and other protective equipment as needed.
• Consider using a green clean disinfectant or cleaning agent and always EPA approve.
• Staff involved in diapering/toileting should receive the hepatitis B vaccine.
• Staff who prepare or serve food may not change diapers or assist in toilet training.
• Staff should be trained to check each student’s diaper at least once every two hours and change the diaper promptly if it is wet or soiled.
• If the student is sleeping, the diaper must be checked when the student awakes.
• Talk to the student about what you are doing.
• Bring the student to the changing area and wear appropriate Personal Protective Equipment (PPE) – gloves, sleeves, and apron if necessary.
• Prepare the changing area by wiping with a sanitized/disinfectant wipe and/or placing protective paper on the changing surface.
• Transfer student to changing surface and never leave alone on changing surface.

The policy and procedures must be posted in the diaper changing area. It is strongly recommended that two adults always be present when performing these tasks. Also, that the diapering/bathrooming is performed by an adult of the same gender of the child.

Diapering Procedure

A student’s diaper should be changed when wet or soiled and checked prior to bussing/end-of-day pick up. All necessary equipment and supplies should be easily inventoried to ensure availability for each day. Keep accessible all supplies in changing area. Ensure the diapering plan is discussed and agreed upon with the parent prior to diapering the first time. The following steps should take place when assisting a student with toileting:

• Talk to the student about what you are doing.
• Bring the student to the changing area and wear appropriate Personal Protective Equipment (PPE) – gloves, sleeves, and apron if necessary.
• Prepare the changing area by wiping with a sanitized/disinfectant wipe and/or placing protective paper on the changing surface.
• Transfer student to changing surface and never leave alone on changing surface.
• Remove soiled diaper and place in a covered waste receptacle.
• Clean student using wipes or soap and water.
• Dispose of soiled gloves and put on a clean pair of gloves.
• Make sure the student’s clothing is clean and dry. If not, change the student’s clothing and send home soiled clothing in a plastic bag.
• Place the clean diaper on the student.
• Transfer the student from the changing area.
• Remove the changing paper and clean the surface with district-approved cleaner or wipes.
• Use approved hand-washing techniques to clean your hands.
• The soiled/wet diaper container should be cleaned and sanitized daily.
• Cleaning supplies should be kept out of reach of students.

Toileting Procedure

Access to an appropriate toileting environment for each student should be made. It is important for students with special health services needs to consider if an escort to the toileting area is necessary. Ensure the toileting plan is discussed and agreed upon with the parent prior to toileting assistance. If a staff member is required to assist with toileting, two-adult supervision is necessary. The following steps should take place when assisting a student with toileting:

• Escort the student to bathroom.
• Talk to the student about what you are doing.
• Put on PPE – gloves, and protective sleeves or apron if necessary.
• Prepare the toilet by wiping it with a sanitized/disinfectant wipe and/or placing protective paper.
• Assist the student with clothing.
• Transfer and/or assist the student to the toilet.
• If required, stabilize the student on the toilet seat.
• Clean the student when finished.
• Make sure the student’s clothing is clean and dry. If not, change the student’s clothing and send home soiled clothing in a plastic bag.
• Remove the gloves and dispose of the soiled gloves following Universal Precautions procedures.
• Transfer the student from the toilet.
• Supervise children in how to correctly wash their hands after using the bathroom.
• Clean your hands using approved hand-washing techniques.

Blood Glucose Monitoring

Students may have a need to have blood glucose monitored to determine stability of blood sugar level, need for therapeutic intervention such as administration of insulin or food. It is recommended that equipment be provided by the student’s parent/guardian and kept at the school for use.

If this procedure is performed by the student, School Nurse, or other qualified school personnel procedure the following is recommended:

• Wash hands thoroughly with soap and water.
• Assemble equipment on clean work surface in appropriate location.
• Wash student’s hands thoroughly with soap and water.
• Follow manufacturer’s instructions for use of the glucose monitoring kit.
• Dry student’s finger with gauze and discard used stylet into appropriate container. Dispose of gauze, gloves, and any other contaminated material in plastic-lined waste receptacle. Clean work area and wash hands.
• Record glucose level and procedure on student log and sign.
• Proceed with follow-up as specified in the student’s Individualized Health Care Plan. This may include parent notification and administration of food or insulin.

Cardiopulmonary Resuscitation (CPR)

For more information, see Chapter 8.

Cardiopulmonary resuscitation goal is to restore spontaneous circulation using the techniques of chest wall compression and pulmonary ventilation to provide an adequate supply of oxygen to the brain until medical help arrives. This procedure must be performed by school personnel that have been trained in CPR. It is recommended that ALL school personnel working with severely health-impaired or handicapped students receive training and certification in emergency airway management and cardiopulmonary resuscitation procedures. Possible indications for need:

• Airway obstruction.
• Impending airway obstruction and respiratory crisis.
• Cardiopulmonary arrest.
• Anaphylactic reaction.
• Respiratory paralysis.
• Acute head or cervical spinal cord injury.
• Drug overdose.
• Over-oxygenation or other conditions which result in the cessation of normal breathing and/or heart contractions.

Central Venous Line (CVL)

A central venous line (CVL) is a long-term catheter that is surgically inserted into a deep, large vein in the neck or the chest, usually near the heart. Students usually have these lines placed when there is a need for long-term delivery of intravenous food and/or medication. CVLs are used to provide fluids, proteins, carbohydrates, vitamins, or minerals to a student who is unable to get adequate nutrients for growth and development through oral or gastric tube feeding.

Indications

CVLs are indicated for students with health conditions or abnormalities of the intestinal tract that interfere with adequate consumption of calories or absorption of nutrients ingested orally; for students who have recurrent aspiration of stomach contents into the lungs causing frequent pneumonia; or who have acute trauma precluding utilization of other methods of satisfying nutritional needs. It may be used when there is a need to "rest" the bowel, when the intestines are unable to absorb adequate nutrients, or when students are receiving chemotherapy.

Procedure Principles for Dressing Change of CVL

Dressing changes should routinely be done at home. If a dressing change must be done at school, it should be performed by a school nurse with documented competency-based training in appropriate techniques and problem management. As with all medical conditions, every effort should be made to protect the student's privacy. For a student with a CVL, the following items should receive particular attention:

• The School Nurse should be aware of the student's underlying condition and potential problems associated with the condition or treatment.
• An additional dressing kit including a spare clamp and sterile gloves should be provided by the parent.
• Any fever needs to be investigated.
• Universal precautions should be followed when handling the line.
• No one should touch the tubing or the dressing unless a complication occurs.

Possible Problems

Equipment for emergencies

Foreign-Body Airway Obstruction

For more information, see Chapter 8: New Mexico Emergency Guidelines for Schools.

When a student is presenting with a foreign body airway obstruction it is due to a blocked airway. The goal is to restore adequate air exchange and breathing to prevent respiratory arrest, anoxia, or cardiac arrest.

Foreign body airway obstruction is due to choking with the trachea blocked due to food or other foreign object, so that little or no air is passing in or out of the lungs. The student will be unable to talk or cough effectively, may make a crowing noise during exhalation, and they will show extreme respiratory distress and possible cyanosis.

This procedure is to be performed by qualified school personnel who have been trained in this procedure by the School Nurse or other certified person or agency. It is STRONGLY recommended that all school personnel working with severely handicapped students be trained in this procedure.

Determine need for the procedure by assessing whether there is partial or complete obstruction of the airway. If the student is receiving enough air to allow forceful coughing or speech, do not interfere with the student’s efforts to expel the food or foreign object.

Lifting Techniques for Moving Students

Lifting techniques to pick up, move, raise, support, or transport a student from one place to the other by manual means may be required, if the student is unable to move or transfer independently. Equipment necessary for appropriate and safe will be individualized for each student. It is recommended that the School Nurse, physical therapist, occupational therapist, and adaptive physical education teacher work together to provide school personnel with training needed to lift or transfer students safely. An annual in-service training is suggested for all school personnel at each school site.

There are best practice or principles of lifting and transport for moving students.

Carefully evaluate the size and physical condition of the student before attempting a lifting procedure. It may be necessary for two people to complete the lift. If in doubt, get help.

• Use gravity when possible by sliding student on a hard surface.
• Use smooth, steady motions.
• Keep head and trunk in good alignment and move as one unit. Do not lift or exert force with trunk in a twisted or awkward position.
• Roll turn or pivot student when possible, instead of lifting.
• Use legs to do most of the work, NOT THE BACK! Legs must be in a flexed position to supply the force necessary for lifting.
• Synchronize movements so that the load is distributed over many muscles. Be sure of your footing. Avoid student load shifts.
• To lift student from floor, squat, bending knees, and pull student close to lower abdominal area. Then lift by straightening legs, keeping back straight. To put student on floor, reverse procedure.
• If it is necessary to carry student, keep the student as close to the lower abdominal area as possible. Try to keep student’s arms and legs close to their body so that you will not be pulled off balance.
• Never lift student more than chest high.
• All students should be encouraged to use their muscles as much as possible to help in the procedure, even it takes more time.
• Always use mechanical devices such as wheelchairs, hydraulic lift, handrails, or trapeze to move student if possible.
• Before transferring a student to a diapering table or chair be sure object or equipment is in an accessible, secure position and wheelchair brakes are locked.
• A general recommendation is one person lifting for each 30 to 50 pounds of student weight. (Check local school district policy regarding weight limits.)
• Use proper lifting techniques.
• Wear comfortable shoes with good support.
• Bend with knees and keep back straight. Do not turn or twist to pick up something, and never bend straight over.
• Practice good posture and body mechanics.
• Good exercise program will help build strong and flexible supporting muscles, especially the abdominal muscles. Check with the physical therapist, adaptive physical education instructor or your physician regarding an appropriate exercise program.
• Help relieve unnecessary back strain by keeping weight within the normal range for height and body build.
• See a physician as soon as possible for any persistent back pain.

Nebulizers and Inhalers

Nebulizer and inhalers deliver a fine mist through the mouth/nose to the lungs to improve or prevent impaired breathing and the purpose or goal is to thin secretions which impair breathing by restoring humidity or delivering medication to the airway and improve respiratory function through the administration of humidified bronchodilators, mucolytics, or corticosteroids.

There are many reasons that nebulizers or inhalers would be used to deliver medication, including: chronic lung disease such as bronchopulmonary dysplasia, asthma treatment, or prevention of respiratory distress.

The school will need the following:

• Physician’s order (required annually), including flow rate, method of administration, and specific indications for administration.
• Aerosol facemask or mouthpiece.
• Tubing.
• Nebulizer with chamber for sterile saline and medication.
• Prescribed medication for nebulizer.
• Peak flow meter (if indicated), aero chamber or inspir-ese or metered dose inhaler.

This procedure is to be performed by the School Nurse, the parent, or the student. Medication must be administered according to the medication policy of the local school or school district and should include:

• Refer to the physician’s order for conditions and time of administration.
• If the treatments are to be administered on an as-needed (PRN) basis, ascertain that student has symptoms as described in physician’s order.
• Wash hands.
• Place student in an upright position for maximum chest expansion.
• Fill the nebulizer with sterile saline and/or prescribed medication.
• Attach tubing mask or mouthpiece.
• Place the mask over student’s mouth and nose and tighten strap until held securely in place. If mouthpiece is used, instruct student to hold nebulizer upright, close lips around mouthpiece, and inhale deeply. Hold for several seconds before exhaling. Continue treatment according to physician’s orders.
• Remove equipment, rinse chamber, mask or mouthpiece with warm soapy water, rinse, and air-dry.
• Once a week, the tubing, mask, mouthpiece, and chamber should be washed with vinegar water, rinsed, and air-dried.
• Record procedure on student’s log, date, and sign.

To use a metered-dose inhaler do the following:

• Shake medication container.
• Remove cap from mouthpiece.
• Attach aero chamber or inspir-ese, if ordered.
• Invert inhaler and place mouthpiece near mouth.
• Instruct student to exhale, pushing air from lungs, then hold mouthpiece 2 inches from lips; press mouthpiece and bottle together while inhaling; release and hold breath for 3–5 seconds before exhaling.
• Repeat treatment sequence according to physician’s order. If using an aero chamber or inspir-ese, follow manufacturer’s instructions.
• If using inhaled steroids, have the student rinse mouth with water to prevent thrush.
• Rinse mouthpieces replace cap and return to storage area.
• Record procedure on student’s log, date, and sign.

Ostomy/Stomal Care

An ostomy is a surgically-made opening into the abdominal wall. This may include colostomy (large intestine), ileostomy (small intestine), or ileal conduits (ureters). Its purpose is to provide comfort and security, to protect the skin, to control odor, and to control leakage. For colostomy, ileostomy, or ileal conduits the following will be needed:

• Extra pouch/bag.
• Double faced adhesive and adhesive remover.
• Skin barrier.
• Hypoallergenic tape.
• Gloves (provided for staff by local school district).

All stomal care procedures are to be performed by the student, School Nurse, or other designated qualified school personnel who have been trained by the nurse to perform these procedures under indirect supervision of the nurse.

There are procedural principles to be followed:

• Assemble equipment and accompany student to bathroom or other appropriate private area.
• Position student with stomal area exposed.
• Place absorbent material around stoma to absorb drainage.
• Remove ostomy pouch/bag (note color and odor of drainage) and empty into toilet. Never empty into sink.
• Clean skin gently with wet wipes or washcloth with soap and water, and dry thoroughly.
• Apply skin barrier according to skin condition and type of pouch. Failure to cover all skin surrounding stoma will cause leakage and skin breakdown. Skin barrier should be at least as large as opening of pouch.
• Place clean pouch securely over skin barrier, covering stoma. Apply more adhesive if necessary and trim pouch to fit if necessary (opening should be 1/8 inch larger than stoma).
• Secure pouch according to directions with tape, clip, bands, or belt.
• Discard old pouch if disposable. Save reusable pouch and rinse out with water over toilet. Place in plastic bag and send home with student.
• Clean work area and wash hands.
• Record procedure on student’s log, including date and time, color and odor of drainage, and name of person performing procedure.

Colostomy Maintenance

Ileostomy Maintenance

Urostomy Maintenance

Oxygen Administration

Oxygen may be administered by mask or nasal cannula to prevent hypoxia and symptoms of inadequate oxygenation, either local or generalized. The reasons may be hypoxia resulting from seizures, cardiac problems, chronic lung disease, or other conditions.

Necessary equipment will be:

• Oxygen tank or portable oxygen unit equipped with flow meter and pressure gauge that measures level of oxygen remaining in tank.
• Tubing, mask, or nasal cannula.
• Any other equipment provided and recommended by manufacturer/vendor.
• Physician’s order and parent authorization (required annually).

This procedure is to be performed by the student, the School Nurse, or other school personnel, who have been designated and trained by the nurse to perform this procedure with indirect supervision of the nurse. Students on continuous oxygen will require monitoring to assure that their equipment functions properly during the school day. Tubing needs to be cleaned or changed frequently. Arrangements must be made by parents for routine maintenance of the oxygen tank and equipment. Keep oxygen tank secured in an upright position away from heat and in reasonable proximity to the student. Oxygen supports combustion so there is always danger of fire when oxygen is being used. It is mandatory that there is no smoking or flames, and the area should be kept clear of highly combustible materials. In case of a fire in the building or classroom, evacuate the building immediately. Notify the Fire and Rescue personnel of the location of the oxygen tank.

Additional guidelines for safe storage and administration of oxygen administration:

• Turn main valve of oxygen tank on and adjust liter flow according to manufacturer’s directions on tank and physician’s orders.
• Place mask or cannula on student’s face/nose and continue treatment according to physician’s order or until symptoms disappear.
• Turn tank off according to manufacturer’s directions.
• Record procedure on student’s log and sign. Note date and length of administration and any other significant information.
• If a student is on continuous oxygen, monitor the student to assure that oxygen is being delivered according to the physician’s orders, the level of oxygen in the tank is sufficient, the equipment is functioning properly, and safety precautions are being observed. Students may use a standard or portable tank as appropriate or a combination of these during the school day.
• The School Nurse or the parent/guardian should provide appropriate information and training to bus drivers to assure safe transportation of students requiring oxygen.

Oxygen Use Maintenance

Other Potential Problems

NOTE: See Chapter 8 for Guidelines for Oxygen Maintenance/Storage.

Peak Flow Meter Use

DEFINITION: Peak Flow Meter measures peak expiratory flow (PEF), a valuable indicator of lung function.

PURPOSE: Correct use of this instrument will help the medical provider follow the student’s condition closely to provide the most beneficial treatment.

EQUIPMENT: Peak flow meter.

• Inhale as deeply as possible and place your mouth firmly around the mouthpiece, making sure your lips form a tight seal.
• Blow out as hard and fast as you can. This will cause the red indicator to move up the scale. The final position of the red indicator is your peak flow.
• Take three readings and record the highest value along with the date and time in the Daily Record Chart provided with the peak flow meter. (The student’s doctor will show him/her how to record the readings correctly.)
• To repeat the test, slide the red indicator back to the bottom of the scale.

NORMAL PREDICTED AVERAGE PEAK EXPIRATORY FLOW

Peak Flow Readings

• Make sure that records are kept up to date.
• The medical provider can provide a management plan based on peak flow measurements. Contact the provider when changes in readings occur that may indicate worsening of a student’s condition as per the provider’s instructions.
• Taking daily peak flow readings will help the provider make important decisions about asthma treatment.

Postural Drainage

Postural drainage provides relief of lung congestion by placing the student in one or more postural drainage positions to enable secretions to drain from lungs by gravity. For greater effectiveness, this procedure may be combined with percussion. The reason for postural drainage is to enable lung secretions to drain by gravity into the major bronchi or trachea so they can be dislodged by coughing, percussion, vibration, or suction. Indications for students will be with respiratory problems involving thick or excessive lung secretions, ineffective cough, or weak respiratory muscles. EquiPillows, beanbag chair, tumble forms, or similar equipment.

• Tissue.
• Gloves (provided for staff by local school district).
• Paper bag.
• Physician’s order and parent authorization (required annually).

This procedure is to be performed by the School Nurse, occupational therapist, physical therapist, or other school personnel who have been trained by the nurse, OT, or PT to perform this procedure under indirect supervision using the following:

1. Assemble equipment in suitable area, explain procedure to student and wash hands.
   • Omit STEPS 2 THROUGH 4 UNLESS PERCUSSION HAS BEEN ORDERED.
2. Position student seated in front of and with back towards provider, leaning student back about 30 degrees. percuss the shoulder area using two fingers or cupped hands to deliver short, firm blows for approximately 3 to 5 minutes.
3. Lean student forward over small pillow and percuss upper back on each side. Percussion is never done over the spine, sternum or below the rib cage.
4. Position student on their back on a large pillow and percuss the area between the collarbone and the nipple on both sides of chest.
5. Position the student on right side in beanbag chair with head lowered about 15 degrees.
6. Leave in this position approximately 5 to 10 minutes or as ordered. If percussion is used, percuss the area over the left nipple and under arm.
7. Repeat step 5, placing student on left side.
8. Position student on back in beanbag chair with head lowered about 30 degrees. Leave student in this position approximately 5 to 10 minutes or as ordered. If percussion is used, percuss over the lower ribs on both sides of the chest.
9. Repeat step 7, placing student on abdomen.
10. Clear secretions from student’s mouth with tissue. Proceed with suction if ordered.
11. Discard used tissue in paper bag.
12. Clean area and wash hands.
13. Record procedure on student’s log, date and sign.

Suctioning

Suctioning is a method for removing excessive secretions from the airway through the mouth (oral), nose (nasopharyngeal), or tracheal passages to provide an open airway by keeping it clear of excessive mucous and excretions.

The reason is to help students who are unable to clear their airway sufficiently and exhibit respiratory difficulty because of an airway blocked with secretions and the following will be needed:

• Suction machine.
• Suction catheter with vent.
• Connecting tube.
• Collection jar.
• Large jar or container of water.
• Tissues.
• Disposable gloves (provided for staff by local school district).
• Physician’s order and parent authorization (required annually).

This procedure is to be performed by the School Nurse or other school personnel who have been designated and trained by the nurse to perform this procedure with indirect supervision of the nurse:

• Assemble equipment, wash hands, and explain procedure to student.
• Turn on suction machine and regulate pressure.
• Attach catheter to suction tubing and place tip in container of water to draw water through catheter to lubricate and check suctioning capability.
• Insert catheter into area to be suctioned. Place thumb over catheter vent and slowly withdraw catheter while rotating it between thumb and finger. If catheter “grabs” remove thumb to decrease suction.
• Dip catheter tip into container of water to clean.
• Repeat process as necessary, suctioning no longer than 10 seconds at a time. Prolonged suctioning may produce laryngo-spasm, slow heartbeat, and/or arrhythmia from vagus nerve stimulation and loss of oxygen.
• Turn off suction machine when suctioning is complete. Respirations should be quiet and occur with less effort.
• Discard secretions and unused water into toilet. Clean equipment, discarding solution in toilet.
• Clean work area. Wash hands and never discard secretions into sink.
• Record procedure on student’s log. Record any significant findings, such as amount, color, and consistency of secretions. Sign and date.

Tracheostomy Care

A tracheostomy is a surgically made opening in the neck (trachea) to allow for breathing when the normal pathways are impaired. The opening is held open by means of a metal or plastic tube that is tied in place. The equipment needed:

Possible Problems Require Immediate Attention

*DO NOT LEAVE STUDENT ALONE*

The student shows any of the following signs of respiratory distress:

Other Potential Problems

Procedure for Tracheostomy Suctioning

This procedure is to be performed by the School Nurse or other school personnel who have been designated and trained by the nurse to perform this procedure with indirect supervision of the nurse.

Possible Problems During Suctioning

*IF ANY PROBLEMS OCCUR, DO NOT LEAVE STUDENT ALONE.*

Procedure for Cleaning Inner Cannula if Indicated

Occasionally the inner cannula of the tracheal tube may need to be removed and cleaned prior to suctioning. Normally the inner cannula will be cleaned at home. Cleaning at school will only be done by the School Nurse.

• Unlock and remove inner cannula, holding outer cannula in place.
• Clean as directed by physician. If no orders, place cannula in paper cup filled with enough hydrogen peroxide to completely cover cannula. Clean opening with brush or pipe cleaner. Rinse in another cup filled with saline or water. Shake out moisture and re-insert.
• Reinsert and lock cannula into tracheal tube, or replace with a new inner cannula and send used cannula home with student.

Procedure for Changing a Traceal Tube

Normally it should not be necessary to change a tracheal tube at school. However, should the tube become plugged or blocked and cannot be cleared with suctioning, it must be changed AT ONCE or the student will suffer anoxia and respiratory arrest.

EQUIPMENT (parent responsibility):

• Trach tube with ties.
• Sterile gloves (provided for staff by local school district).
• Small scissors.

This procedure is to be performed by the School Nurse or other school personnel who have been designated and trained by the nurse to perform this procedure with indirect supervision of the nurse.

• Assemble equipment and explain procedure to student.
• Wash hands (unless extreme emergency) and put glove on dominant hand.
• Cut old trach ties, being careful of student’s neck, and gently pull trach tube out.
• Using gloved hand, take a new trach tube and insert gently into opening. Secure tube with ties. Tie tightly enough to maintain position without cutting into student’s neck. Tie knot toward SIDE of neck. Cut off loose ends of ties.
• Clean work area and wash hands.
• Record procedure on student’s log, date and sign.

If the student does not breathe normally when new tube is in place, administer rescue breathing and have someone activate EMS. If unable to get the new tube in place, hold the ostomy open with your fingers until help arrives. Try to remain calm and reassure the student.

Procedure to Change a Tracheostomy Tube in an Emergency

Potential Problems

The trach tube comes out: NEVER LEAVE STUDENT ALONE. CALL FOR ASSISTANCE.

Problems Requiring Immediate Attention

Procedure for Tracheostomy Collar

The collar is one means of delivering oxygen or humidified air to the tracheostomy. The tracheostomy collar may be used with a humidifying device and tubing to prevent dry and/or thick secretions from plugging the trach, and to administer oxygen to the student.

Tube Feeding (Gastrostomy)

Tube feedings are to provide adequate fluids, nutrition, or medication through the abdominal wall for a student who is unable to accomplish this orally.

Physically or health impaired students who are unable to orally consume adequate fluids or solids to satisfy nutritional needs, students who may have anomalies of the intestinal tract, students prone to reflux of gastric contents, or aspiration of food and fluids into the lungs, and/or students with severe oral feeding difficulties. The equipment needed:

• Physician’s order and parent authorization (required annually).
• Syringe with catheter tip.
• Container of prescribed supplement, formula medication, or liquid at room temperature.
• Container of water.
• Clamp for tube.
• Continuous feeding pump (if indicated).

The maintenance of an adequately functioning and properly placed gastrostomy tube is the responsibility of the parent/guardian and physician. Replacement or reinsertion of a gastrostomy tube will be the responsibility of the parent.

This procedure is to be performed by the School Nurse or other school personnel who have been designated and trained by the nurse to perform this procedure with indirect supervision of the nurse. If medication is ordered, it will be administered by the nurse.

1. Assemble equipment, explain procedure to student and wash hands.
2. Position student with head elevated to a minimum of 30 degrees.
3. Positioning may vary; consult physician. Supine position creates a greater danger of reflux and aspiration.
4. Perform feeding as specified. Methods of tube feeding may vary, e.g., bolus, gravity flow, or continuous feed. Consult physician for details
5. Allow student to remain elevated for time prescribed by physician and observe for signs of reflux or aspiration.
6. Clean equipment and work surface. Wash hands.
7. Record procedure on student’s log, including date and time of feeding, type and amount of fluid given, amount of water given, any adverse reactions and name of person performing the procedure

Feeding Difficulties and Precautions

• If student starts to gag, discontinue feeding and let tube hang down unclamped. Gagging may be caused by allowing the fluid to flow in too rapidly or causing distension of the stomach by allowing air to enter.
• If the student vomits, clamp the tube and discontinue feeding.
• If formula will not go in, consult parent or physician.
• If this procedure is being performed by designated school personnel, the School Nurse must be notified of any adverse reactions or complications. The School Nurse should perform this procedure if the student routinely exhibits complications during feeding.

Possible Problems Requiring Immediate Attention

Possible Problems that are Not Emergencies

Tube Feeding (Nasogastric)

Tube feeding is to provide adequate fluids, nutrition, or medication via a nasogastric tube.

Students who are unable to orally consume adequate fluids or solids to satisfy nutritional needs. Necessary equipment are:

• Physician’s order and parent authorization (required annually).
• Syringe with catheter tip.
• Container of prescribed supplement, formula, medication, or liquid at room temperature.
• Container of water.
• Clamp or plug for tube.
• Continuous feeding pump (if indicated).

The maintenance of an adequately functioning and properly placed nasogastric tube is the responsibility of the parent/guardian.

This procedure is to be performed by the School Nurse or other school personnel who have been designated and trained by the nurse to perform this procedure with indirect supervision of the nurse. If medication is ordered, it will be administered by the nurse:

1. Assemble equipment, explain procedure to student and wash hands.
2. Position student as specified with head elevated to a minimum of 30 degrees. Positioning may vary; consult physician.
3. Check the placement of the tube. Some readjustment of the nasogastric tube may be performed prior to feeding.
4. Perform feeding as specified. Methods of tube feeding may vary, e.g., gravity, syringe, pump. Consult physician for details.
5. Clamp the tube.
6. Allow student to remain elevated for time prescribed by physician and observe for signs of discomfort.
7. Clean work area and wash hands.
8. Record procedure on student’s log, date and sign.

Possible Problems Requiring Immediate Attention

Urinary Catheterization

Urinary catheterization is the insertion of a sterile catheter into the bladder using sterile techniques. Clean catheterization is the insertion of a clean catheter into the bladder using clean techniques. Intermittent catheterization is the insertion of a clean or sterile catheter into the bladder at periodic intervals. Self-catheterization is the insertion of a catheter into the bladder by the student. Clean, intermittent self-catheterization is the ultimate goal of all students who require catheterization during the school day.

Students should be instructed in this procedure as soon as they are ready. The School Nurse, in cooperation with the family and physician, will assist with providing this instruction. Many adaptations may be needed to accommodate each individual student. Students should be encouraged to participate in any steps of the process as they wish, no matter how minimal.

To empty the bladder of urine at appropriate intervals or instill prescribed medication, to prevent bladder distention and constant urine leakage, to reduce chances of a bladder infection, to remove residual urine, and to reduce chances of urinary reflux into the kidneys and secondary kidney damage. Equipment needed:

• Physician’s order and parent authorization (required annually).
• Clean or sterile catheter of appropriate size.
• Lubricant (especially for males).
• Drainage or collection receptacle.
• Wet wipes or equivalent.
• Sterile gloves (only if ordered), clean gloves.
• Antiseptic solution (only if ordered by physician).

This procedure is to be performed by the student, the School Nurse or other school personnel who have been designated and trained by the nurse to perform this procedure with indirect supervision of the nurse.

Procedure for Clean Intermittent Catheterization – Male:

Procedure for Clean Intermittent Catheterization – Female:

Possible Problems

Ventilators/Mechanical Respiratory Support

DEFINITION: A mechanism for stimulating breathing and total exchange of gasses, including the administration of oxygen, in the lungs by the use of mechanical pressure to accomplish the inspiration and expiration which is usually provided by the diaphragm and thoracic cage. The ventilator is attached through a tracheostomy tube.

Some students who would otherwise require long term dependence on a ventilator may receive assistance breathing with a Phrenic Nerve Pacemaker, which is an electrode surgically implanted next to one or both phrenic nerves and attached to a transmitter which is worn outside the body. This stimulates the diaphragm in a manner similar to the ventilator. The student may also be on oxygen. This technique allows greater mobility of the student.

INDICATIONS: Students who need help breathing because of central nervous system dysfunction, neuromuscular disease, musculoskeletal diseases or injury, cardiac conditions, chronic obstructive pulmonary disease, or other chronic respiratory distress syndrome.

Ventilator Features

Standard ventilator features that should be checked at least daily and on arrival at school.

Ventilator Parameters

Procedure Principles

• See procedures regarding tracheostomy care, suctioning, oxygen administration, and CPR in this manual.
• All ventilators have manuals that should be read prior to assuming care of the student.
• The ventilator must be continually monitored to assure that it is working properly. All machines have alarms that are triggered if a malfunction occurs. If an alarm goes off always check the student first! If the student is okay, then check the ventilator.
• The SDE-licensed School Nurse should monitor respiratory status and suction the student as indicated or ordered by the primary care provider.
• Nutritional status needs to be monitored to ensure student is receiving adequate nutrients and fluid.
• Respiratory tract infection can be decreased by using good hand washing technique and classroom sanitation. Aseptic technique and gloves should be used for suctioning.
• Students who require ventilator assistance, and who are attending a school-based program, must provide a written physician’s statement and recommendations for management in the school setting. Health management must include access to a SDE-licensed School Nurse who is present on campus during the school day. The student may also require a student-specific educational assistant to monitor them at all times during the school day and facilitate placement in the least restrictive environment.
• The SDE-licensed School Nurse will maintain close communication with the student’s primary care provider and provide emotional support to the student, family, classmates, and staff as needed.

Possible Problems

NOTE: Most home ventilators run on electric current with battery back-up. If the power is interrupted and all DC backup systems fail, activate EMS and ventilate the student with an AMBU bag until help arrives. The power source for a phrenic pacemaker is a battery pack. The spare battery pack and an AMBU bag should be carried by the student at all times.

Ventriculo-Peritoneal (V-P) Shunt

A V-P shunt or tube is a with a one-way valve is inserted surgically into the ventricle of the brain to drain excess cerebrospinal fluid from the brain into the peritoneal cavity to prevent the development of ever-increasing head size when hydrocephalus is present. There may be complications that occur frequently and may need shunt revision frequently occurs because of occlusion, infection or malfunction of the shunt. Occasionally revision is necessary because of the growth of the student; however, coiled tubing normally allows for adequate growth. Shunt-dependent students will manifest symptoms of increased intracranial pressure if the shunt does not function properly.

Signs of Shunt Malfunction

• Nausea and vomiting.
• Increased systolic blood pressure.
• Lethargy.
• Headaches.
• Irritability.
• Fever.
• Swelling, redness, or tenderness along the shunt tract.
• Seizures.

Guidelines

• Obtaining a complete health history.
• Obtaining medical reports providing the physicians recommendations for care in the school setting.
• Completing nursing assessment and development of an Individualized Healthcare Plan.
• Observing for signs of shunt malfunction and increased intracranial pressure. If observed, notify the School Nurse and parent/guardian.
• Generally, few restrictions need to be placed on the student’s daily activities. The student’s head should, however, be protected from trauma.
• The School Nurse should monitor the student’s head circumference and blood pressure on a regular basis. Any symptoms or unusual findings should be reported to the parent/guardian and/or physician immediately.
• Students who require hospitalization for surgical revision of their shunt may experience significant interruption of their educational program. Occasionally previously learned skills are lost. These students may require temporary home-based services.