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Please consult with your administrator or contact . Your support ID is: 12521609825410606242 Your profile is: Commerce CED.Web-Prod.AppSec Please include the Support ID and Profile if you contact the webmaster. [Go Back] ! Providing Tracheostomy Care Quick Sheet Extended Text Supplies Videos Illustrations Test Checklist Test Results Percentage)Correct:)100%) 1.#How#can#the#nurse#best#minimize#a#patient’s#risk#for#infection#during# tracheostomy#care?# #A.#Adhere#to#sterile#technique#when#appropriate.# B.#Frequently#assess#for#signs#of#local#or#systemic#infection.# C.#Monitor#for#indications#that#tracheostomy#care#is#needed.# D.#Instruct#nursing#assistive#personnel#(NAP)#to#report#any#changes#in# color#or#odor#of#tracheal#drainage.# Rationale:#Adherence#to#sterile#technique#is#the#most#important#factor# in#minimizing#the#patient’s#risk#for#infection#during#tracheostomy#care.# Proper#assessment#is#important#but#will#not#reduce#the#patient’s#risk#for# infection#during#tracheostomy#care.#Monitoring#the#patient#for# indications#that#tracheostomy#care#is#needed#will#not#reduce#the# patient’s#risk#for#infection.#Although#the#NAP#would#be#instructed#to# report#changes#in#tracheal#drainage,#such#notification#will#not#minimize# the#patient’s#risk#for#infection.# 2.#Which#nursing#action#shows#the#most#effective#planning#for#emergency# care#of#a#patient#with#a#tracheostomy?# A.#Having#a#spare#oxygen#mask#at#the#patient’s#bedside# #B.#Keeping#an#obturator#and#a#tracheostomy#tube#at#the#patient’s# bedside# C.#Reviewing#the#agency’s#policy#regarding#tracheostomy#care# 7. Specialized Health Care ProceduresInformation 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:
A. Asthma ManagementDefinitionA 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):
PurposeAsthma management and control significantly contributes to school attendance and the general health and wellbeing of students. ProcedureMetered Dose Inhaler with SpacerEquipment: 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 AdministrationEquipment: medication, nebulizer machine (air compressor), facemask, or a mouthpiece held in the mouth.
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:
Delegation ConsiderationsThese 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 ConsiderationsThe 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:
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). ReferencesAmerican 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. ResourcesGuidelines for the Diagnosis and Management of Asthma National Asthma Education and Prevention Program Asthma public education materials. B. AllergiesDefinitionAn 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
ResourcesConnecticut State Department of Education, Food Allergies The Food Allergy and Anaphylaxis Network C. Blood Glucose MonitoringDefinitionBlood 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). PurposeTo evaluate diabetes control; to adjust insulin dosage and nutritional intake. EquipmentBlood 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
Delegation ConsiderationsThis 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 ConsiderationsThere 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. ReferencesConnecticut 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 IntermittentDefinitionClean 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
EquipmentGloves, 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. ProcedureMale Catheterization
Delegation ConsiderationsThis procedure may be performed by a school nurse, RN, or LPN. Select Nursing Considerations
ReferencesAUA 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. ResourcesCenters 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: ExternalDefinitionAn external catheter is a condom-type urinary collection device, vinyl rolled or with a jock-type supporter (AUA Foundation, 2011). PurposeTo maintain social continence (clothing dry and/or free from odor). EquipmentGloves, 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
Delegation Considerations
Select Nursing ConsiderationsThis 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. ReferencesAUA 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: IndwellingDefinitionAn 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). PurposeTo empty the bladder of urine as it accumulates; to minimize residual urine; to decrease incidence of bladder infection; to control incontinence. EquipmentGloves, disposable washcloth and towel, soap and water, graduated drainage container ProcedureIn 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 ConsiderationsThis 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 ConsiderationsMost 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. ReferencesAUA 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 CatheterDefinitionReplacement 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). PurposeTo 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. EquipmentSterile 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. ProcedureMale Catheterization
Delegation DecisionsAccording 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 ConsiderationsIn 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. ReferencesAUA 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 CareDefinitionA 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. PurposeLong-term access to the circulatory system for medications, fluids, and nutrients. EquipmentGloves, 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. ProcedureFlushing or administering medications through a central line
Delegation ConsiderationsMust be performed by a trained registered nurse. Select Nursing ConsiderationsFlushing 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. ReferenceMannheim, J.K. (2010). Central venous catheter - flushing. Retrieved January 14, 2012. I. DiabetesDefinitionA 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:
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:
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. ReferencesConnecticut 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 FeedingsDefinitionsDelivering a liquid nutrient formula directly to the stomach, duodenum, or jejunum.
(American Society for Parenteral and Enteral Nutrition, 2011). MethodsBolus 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 TubesFeeding 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).
PurposeTo 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. EquipmentPer provider’s order and individual health care plan. ProcedureTube Feeding
Delegation ConsiderationsInitiating 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
ReferencesAltman 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 ResourceBankhead 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 AssessmentDefinitionRefers 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. PurposeIdentifies 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. EquipmentStudent’s cumulative health record, nursing record, and progress notes; information from physicians, parents, acute care facilities, other related service providers. ProcedureFor 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:
Select Nursing ConsiderationsSchool 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 ConsiderationsHealth 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 CareDefinitionAn incontinent student is one who is unable to control the passage of urine or feces (stool). PurposeTo 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. EncopresisEncopresis 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.) EquipmentEquipment 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. ProcedureIncontinent care
Delegation ConsiderationsToileting 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
M. Injectables: Intramuscular, Subcutaneous Medication or Vaccination AdministrationDefinitionInjecting a medication or immunization into a muscle or subcutaneous (SC) tissue. PurposeTo maintain a medication or immunization regime prescribed by an authorized health care provider. EquipmentThe appropriate size sterile needle, syringe, gloves, and alcohol swab. Procedure
Select Nursing ConsiderationsAdministration 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:
Delegation ConsiderationsOnly 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). ReferencesBowden, 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. ResourceState Department of Public Health. Connecticut Immunization Program. N. Insulin Pump ManagementDefinitionThe 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). PurposeInsulin 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. EquipmentInsulin pump, infusion sets, insulin (ordered by authorized prescriber), adhesive tape or Tegaderm; extra batteries; and gloves (for infusion set change.) Procedure
Delegation ConsiderationsOnly 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 ConsiderationsThere 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). ReferenceNational Diabetes Information Clearinghouse (2009). Alternative devices for taking insulin. Retrieved January 19, 2012. O. Intravenous TherapyDefinitionAdministration of prescribed fluids via an intravenous route using a pump infusion method. Purpose
EquipmentGloves, IV pole, prescribed solutions (including medication if ordered), clamp, alcohol wipes, disposable IV set up, 2 cc syringe, infusion pump. ProcedureIntravenous Therapy (IVT)
Select Nursing ConsiderationsPerforming a venipuncture requires skills and specialized training. Nurses may contact an area hospital or college for a phlebotomy course as necessary. Delegation ConsiderationsOnly 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 VentilationDefinitionAn 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. PurposeTo 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. MethodsIn 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. EquipmentThere 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
Delegation ConsiderationsThe 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 ConsiderationsEach 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 FeedingDefinitionProvide nutrients and fluids to a student who requires assistance putting food in the mouth and swallowing. PurposeTo maintain adequate nourishment and hydration. To facilitate developmentally appropriate and safe oral motor skills. EquipmentAdaptive eating and drinking devices; adaptive seating or positioning equipment; measuring containers; and protective barriers for clothing. Nonlatex disposable gloves and suction equipment, as indicated. ProcedureRefer 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 ConsiderationsThis procedure may be performed by licensed, certified, and unlicensed assistive personnel with the appropriate training and supervision. Select Nursing Considerations
ReferencesConnecticut 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 AdministrationDefinitionPlacing medication in a student’s mouth to be swallowed or inhaled. PurposeTo maintain a medication regime prescribed by an authorized health care provider. EquipmentWarning: 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
See Asthma and procedures below for specific inhaled medication technique options. Procedures
Delegation ConsiderationsDelegation 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 PersonnelThe 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 ConsiderationsEach 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:
ReferencesBowden, 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 CareDefinitionAn 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). PurposeTo 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. EquipmentGloves, scissors; stoma wafer; disposable washcloth; gauze; ostomy bag; skin protectant or barrier ProcedureManagement (emptying bag)
Delegation ConsiderationsManagement 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
ReferenceNational Library of Medicine. (2011). Ostomy. Retrieved January 19, 2012. T. Oxygen TherapyDefinitionsOxygen 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). PurposeOxygen administration in school is indicated to treat either acute or chronic hypoxia as prescribed by a treatment procedure authorization. MethodsNasal 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. EquipmentPer provider’s order and IHCP and ECP. ProcedureHigh pressure tanks (standard metal oxygen tanks)
Delegation Considerations
Select Nursing Considerations
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. ReferenceBowden, V.R., and Greenberg, C.S. (2008). Pediatric Nursing Procedures, 2nd edition. Philadelphia, PA: Lippincott Williams and Wilkins. U. Pulse OximetryDefinitionPulse oximetry provides estimates of arterial oxyhemoglobin saturation (SaO2) by utilizing selected wavelengths of light to noninvasively determine the saturation of oxyhemoglobin (SpO2). PurposePulse 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:
MethodsPulse 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:
EquipmentPulse Oximeter Procedure
An order for continuous pulse oximetry requires an oximeter with an alarm. Delegation ConsiderationPulse oximetry may be performed by a RN, LPN, or RT. Select Nursing Considerations
ReferenceBowden, V.R., and Greenberg, C.S. (2008). Pediatric Nursing Procedures, 2nd edition. Philadelphia, PA: Lippincott Williams and Wilkins. V. Suctioning (non-tracheostomy)DefinitionsUsing a battery or electronic vacuum (suction) device to remove upper airway secretions or fluid that the student cannot expectorate spontaneously. PurposeTo 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. MethodsOropharyngeal 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 EquipmentAn 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. ProcedureOropharyngeal and Nasopharyngeal Suctioning (general procedures)
Delegation ConsiderationOropharyngeal or nasopharyngeal suctioning can only be performed by the RN, LPN, or RT. Select Nursing Considerations
ReferenceBowden, V.R., and Greenberg, C.S. (2008). Pediatric Nursing Procedures, 2nd edition. Philadelphia, PA: Lippincott Williams and Wilkins. W. Tracheostomy Care and SuctioningDefinitionsTracheostomy 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. PurposeThere are two broad medical indications for a tracheostomy:
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. EquipmentThe essential equipment to be kept with the student at all times is as follows: Never use an oil-based lubricant, such as Vaseline.
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. ProceduresStoma and skin care
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”).
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:
Delegation ConsiderationsAll 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 ConsiderationsSee Oral Feeding for guidelines and references associated with orally feeding a student with a tracheostomy.
ReferencesBowden, 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 StimulatorDefinitionVagus 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). PurposeVagus nerve stimulators are used to control partial onset seizures (which originate from only one part of the brain) when other methods have been ineffective. EquipmentVagus nerve stimulator magnet. ProcedureWhen 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 ConsiderationsThe 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 ConsiderationsAs 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. ReferencesEpilepsy 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. What must the nurse do when performing tracheostomy care?Procedure. Introduce self and verify the client's identity using agency protocol. ... . Observe appropriate infection control procedures such as hand hygiene.. Provide for client privacy.. Prepare the client and the equipment. ... . Suction the tracheostomy tube, if necessary. ... . Clean the inner cannula.. What must the nurse do when performing tracheostomy care quizlet?While performing tracheostomy care, the nurse should do the following:. carefully remove the inner cannula and place it into normal saline solution using sterile technique.. suction the outer cannula, if necessary.. rinse the inner cannula with noramle saline after it has been cleaned.. Which situation can be delegated to nursing assistive personnel nap in regard to endotracheal tube care?Endotracheal care may be delegated to NAP only if the patient is on a ventilator.
How can the nurse best minimize the patient's risk for infection during tracheostomy care?Proper care including cleaning of the inner cannula and routine tracheostomy tube changes are important in preventing infections. Hand hygiene should be performed before and after tracheostomy tube care.
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