Medication nursing standing orders for emergency care
TEAYS VALLEY LOCAL SCHOOL DISTRICT MEDICATION IN SCHOOL
Scheduling of medication or treatment outside of school hours is encouraged. When that is not possible, a specific policy must be followed. We allow prescribed medication to be taken. However, we must have a written permission from the parent and the physician's signed verification. Medication must be received in the container in which it was dispensed by the physician or pharmacist. It must have proper identification, dosage, and time interval marked. All medications will be kept in a locked cabinet in the school office for the student's use as needed – unless special circumstances justify an exception. Please understand that assistance with medication administration, in the absence of the school nurse, will be rendered by an employee of the district who is not medically trained. For over-the-counter medication, the student should bring the medication to the office in its original container and clearly marked with the student's name. Written permission from the parent will also be required before any non-prescription (over the counter) medication is administered to any student by a school employee. Parents are responsible for the safe delivery of the medication to the school office - it is preferred that the parent bring in the medication to the school office and review with school staff the specific instructions on how and when the medication is to be given. Parents also need to instruct the child as to the medication schedule and when to report to the office. Parents will assume the responsibility of notifying the school if the medication orders have changed. Parents must understand that they are responsible for picking up any left over or expired medication at school and that the medication will be disposed of after the last day of school if not collected by the parent – unless the parent has made specific arrangements with school personnel. Medication forms are available in the school office or may be downloaded from the Teays Valley web site www.tvsd.us The School Physician will serve as a health consultant and will provide written medication standing orders for general and emergency care. In the event that a child needs NON-Prescription medication for minor ailments at school, the school nurse or her designee may dispense any of the following OTC medication under the guidelines of the school physician's standing orders: Ibuprofen (Advil, Motrin), Acetaminophen (Tylenol), Benadryl, Tums, Imodium A-D, Robitussin, or first aid antiseptic/ointment. This would be done with parental signed permission, which would be indicated on the school emergency authorization form that is given to parents annually.
NURSING STANDING ORDERS FOR EMERGENCY CARE TEAYS VALLEY LOCAL SCHOOL DISTRICT 2011 – 2012 TERM School Standing Orders I. PAIN AND OR FEVER OVER 101 degrees, orally
A. Acetaminophen 325 mg. (1 tablet equals 325mg.) (1 tsp. equals 160mg.) to be administered every 4 hours 1)
40 – 60 pounds: 1 tablet every 4 hours or 2 tsp. (320 mg.) every 4 hours
60-100 pounds: 1 ½ tablets every 4 hours or 3 tsp. every 4 hours
Over 100 pounds: 2 tablets (or 500 mg. Caplet) every 4 hours
LOCAL ALLERGIC REACTION Hives, Bee Stings, Poison Ivy, Rashes
A. Administer Diphenhydramine Hydrochloride (12.5 mg.) Allergy Liquid or Capsule
Children up to 50 pounds: 1 tsp. every 4 – 6 hours
Children 50-100 pounds: 2 tsp. every 4 – 6 hours (1capsule)
Children 100 pounds and over: 3 tsp. every 4 - 6 hours (1 –2 capsule)
Apply Hydrocortisone cream 1% - topical antipruritic cream , as directed DO NOT apply more than 3 –4 times per day
MENSTRUAL CRAMPS, MIGRAINE HEADACHES, ORTHODONTIC DISCOMFORT A.
1) Under 40 pounds: 100 mg. every 6 hours 2)
MINOR BURN A.
Apply Polysporin ointment - for minor burns only, as directed DO NOT use more than 3 – 4 times per day
MINOR CUTS/ABRASIONS (Clean the affected area with soap and water) A.
Polysporin Ointment – Active ingredients Polymyxin B Sulfate and Bacitracin Zinc Used as first aid antibiotic as directed – DO NOT use more than 3 times per day
Hydrogen Peroxide –Used as first aid antiseptic as directed
MINOR STOMACH DISCOMFORT WITHOUT FEVER, VOMITING A.
Tums – active ingredient Calcium Carbonate (500 mg.) Used as antacid as directed Chew 2 – 4 tablets as symptoms occur
Imodium A-D – active ingredient Loperamide Hydorchloride (1 mg. per tsp. – 2 mg. per caplet) Used as an antidiarrheal as directed
Children 6 – 8 years (48 – 59 pounds): take 2 tsps. or 1 caplet after the first loose stool and 1 tsp. or ½ caplet after each subsequent loose stool – No More than 4 tsps. or 2 caplets per day
Chidren 9 – 11 years (60 – 95 pounds): take 2 tsps. or 1 caplet after the first loose stool and 1 tsp. or ½ caplet after each subsequent loose stool – No More than 6 tsps. or 3 caplets per day
Children 12 years of age and older: take 4 tsps. or 2 caplets after the first loose stool and 2 tsps. or 1 caplet after each subsequent loose stool – No More than 8 tsps. or 4 caplets per day.
MILD COUGH A.
Robitussin – active ingredient Guaifenesin (100 mg.), Dextromethorphan HBr (10mg.) per tsp. Used as cough suppressant / expectorant as directed
Children 6 – 12 years: 1 tsp. every 4 hours
Children 12 years and older: 2 tsp. every 4 hours
ANY SEVERE OR PERSISTENT SYMPTOMS ARE TO BE REFERRED TO A PHYSICIAN
_______________________________________ Brett Call, D.O. School Physician Teays Valley Local School District
NURSING STANDING ORDERS FOR EMERGENCY CARE TEAYS VALLEY LOCAL SCHOOL DISTRICT 2011-12 TERM
School Standing Orders For severe allergic reaction (anaphylaxis)– difficulty breathing, swallowing EpiPen Auto Syringe, Jr. 0.15 mg. < 100 pounds Administer SQ EpiPen Auto Syringe, Regular 0.3 mg. > 100 pounds Administer SQ IMMEDIATELY AFTER USE *Call 911
____________________________ Brett Call, D.O. School Physician Teays Valley Local School District Teays Valley Local School District 385 Circleville Avenue Ashville, Ohio 43103 PARENT /GUARDIAN’S REQUEST FOR THE ADMINISTRATION OF NON-PRESCRIPTION (over the counter) MEDICATION
BY SCHOOL PERSONNEL *To Be Completed by the Parent/Guardian Scheduling of medication or treatment outside of school hours is encouraged. When that is not possible, this form must be completed every school year prior to school personnel dispensing medication or treatment. The medication and this form is to be taken to the building principal and kept on file in the school office. Name of Child _______________________________ Name of Drug _______________________________ Dosage__________ Route __________ At the following time(s)_________________________ As parent/guardian of the above named child, my signature below authorizes the Principal, Nurse, or other responsible school personnel to administer the medication to my child. I do assume responsibility for: 1. Safe delivery of the medication in the original drugstore container to the school
2. Instructing my child to present himself/herself and to take the medication at the
3. Understanding the medication will be disposed of the last day of school if not collected by the parent/guardian. 4. Holding the Board of Education, its officials, and its employees harmless from
any and all liability for damages or injury resulting directly or indirectly from this authorization. Parent/Guardian Signature ________________________ Date________________________ TEAYS VALLEY LOCAL SCHOOL DISTRICT PRESCRIBED MEDICATION AUTHORIZATION NAME____________________________ PHONE____________________ ADDRESS_______________________________________________________________ BIRTHDATE__________SCHOOL_______________GRADE/ROOM_______________ To the Parent/Guardian: THE FOLLOWING INFORMATION IS NECESSARY FOR ANY STUDENT WHO RECEIVES OR USES PRESCRIBED MEDICATIONS IN SCHOOL: NOTE: BOTH PORTIONS OF THIS FORM MUST BE COMPLETED. 1.
I am requesting permission for the student named above to receive or use medication according to the doctors’s verification on this form. I have instructed my child to report to the school office to receive the medication at the designated time.
I will keep an adequate supply of medication at school. 2.
I will assume responsibility for safe delivery of the medication to the school office either by myself or call the principal to
I will call the school office and send a written note if my child is taken off this medication. I will retrieve the medication
I will bring in a completed prescribed medication form for any dosage/medication/doctor changes.
I release and agree to hold the Board of Education, its officials, and its employees, harmless from any and all liability for
damages or injury resulting directly or indirectly from this authorization.
____________________________________________________________________ ____________________________ Signature of parent or guardian
Home phone_________________ Work phone_______________ Cell phone_______________ Pager________________ All medication must be in original pharmacy dispensed containers. Labels must match instructions from physician on this form.
To the Physician: The Teays Valley Board of Education urges you to schedule the taking of medication by students at times outside of school hours. When that is not possible, the receiving or use of medications will be permitted, insofar as feasible, during school hours. Medication in pill form is preferable to liquids for use in school. ______________________________________________________________ ______________________ Medication
Form of medication/treatment: Tablet/Capsule, Liquid, Inhaler, Nebulizer, Other______________
Diagnosis for which medication is prescribed_____________________________________________________ Medication to be taken at the following time(s)____________________________________________________ Instructions/precautions (including possible side effects)_____________________________________________ Adverse reactions that need to be reported to the physician___________________________________________ Prescription beginning date___________ Prescription expiration date__________________________________ Date form completed________________ Physician Signature________________________________________ Physician printed name___________________________________Phone number_________________________ Physician Address____________________________________________________________________________
*The school will report concerns about medications or disease to the above physician. A new form must be completed for each dosage/medication/physician change. Each school year a new form must be completed for each medication. Rev. 6/11 Teays Valley Local School District Request For Students Who Carry And Administer Their Own Inhaled Asthma Medication Student Name________________________________________Birthdate_________________ Address_______________________________________________________________________ School ____________________________________Grade/Room_________________________ I. Physician’s Section
______________________________ is under my care and should be allowed to carry and administer Student Name his/her personal asthma inhaler medication ______________________________________________. Medication Name
Dosage, Frequency, and Time of Administration The student has been instructed and has demonstrated knowledge to the parent and /or physician of the proper circumstances in which this mediation should be administered, as well as the proper storage, care and administration of the above indicated medication. Possible side effects or severe adverse reactions to watch for in the student are: __________________________________________________________________________________ Procedure to follow in the event that the medication does not produce the expected relief from the student’s asthma attack: ______________________________________________________________________________________ Prescription beginning date_______________ Prescription expiration date __________________ Date form completed ___________________Physician’s Signature _________________________ Physician Printed Name_______________________________________Phone________________ II. Parent/Guardian Section I request and give permission for my child to administer his/her own asthma inhaler medication in keeping with Section I above. Further, I release and agree to hold the Board of Education, its officials, and its employees, harmless from any and all liability for damages or injury resulting directly or indirectly from this authorization. I further agree to submit a revised statement signed by the physician who has prescribed the medication described above in Section I, in the event that I become aware that any of the information has changed. I have read and understand the policy of the Teays Valley Local Schools for the administration of medication and affirm that this request entails special circumstances justifying an exception from the usual administration of medication by school personnel. Signature of Parent/Guardian________________________________________Date___________ Printed Name of Parent/Guardian___________________________________Phone___________
Work Phone_____________________ Cell Phone ______________________ Pager __________________ Rev. 6/11 Teays Valley Local School District Request That Student Carry and Administer Own Medication I. Physician’s Section
________________________________________ is under my care and should be allowed to carry Student Name and administer his/her personal medication ____________________________________________ Medication Name Dosage, Frequency, and Time of Administration
The student has been instructed and demonstrates knowledge of the proper circumstances in which this medication should be administered, as well as the proper care, storage and administration of the above indicated medication. Possible side effects or severe adverse reactions to watch for:
Medication starting date_________________________ Expiration date of request___________________ Physician’s Signature______________________________ Physician’s Phone______________________ Date_____________ II. Parent’s Section
I request and give my permission for by child to self administer his/her medication in keeping with Section I above. Further, I release and agree to hold the Board of Education, its officials, and its employees, harmless from any and all liability for damages or injury resulting directly or indirectly from this authorization. I further agree to submit a revised statement signed by the physician who has prescribed the medication described in Section I, in the event that I become aware that any of the information set forth in that Section has changed. I have read and understand the policy of the Teays Valley Local Schools for the administration of medication and affirm that this request entails special circumstances justifying an exception from the usual administration of medication by school personnel. Student Name_______________________________School_________________Grade_______________ Phone_____________________________ Address ____________________________________________ ______________________________________________________________________________________ Parent/Guardian Signature___________________________________________ Date_________________ Rev. 6/11
TEAYS VALLEY LOCAL SCHOOL DISTRICT MEDICATION AUTHORIZATION FORM PHYSICIAN AUTHORIZATION INJECTABLE MEDICATION
Name of Student______________________________ DOB ______________
Medication ___________________________ Dosage __________________
Route ___________________________ Time ________________________
Special Instructions ______________________________________________
___ Medical diagnosis of: __________________________________________
___ STING ALLERGY - Specific insect if known _______________________
___ FOOD / SUBSTANCE ALLERGY - Child may have an anaphylactic
reaction to _______________________________________________________
Symptoms of anaphylaxis for this student ______________________________
Possible side effects of medication ____________________________________
NOTE: SCHOOL PERSONNEL WILL CALL 911 WHAN AN EPIPEN IS ADMINISTERED
Any additional emergency follow up: __________________________________
Beginning date __________ Expiration date _________ Today's date________
PHYSICIAN SIGNATURE ________________________Phone ____________
Physician address/office stamp _______________________________________
TEAYS VALLEY LOCAL SCHOOL DISTRICT MEDICATION AUTHORIZATION FORM PHYSICIAN AUTHORIZATION NEBULIZED MEDICATION NEBULIZED MEDICATION
Name of student _______________________________ DOB ____________
Medication ________________________Dosage __________ Time_______
Possible side effects to be reported to physician _______________________
Special Instructions _____________________________________________
Beginning date __________ Expiration date _________ Today's date _____
PHYSICIAN SIGNATURE ____________________ Phone _____________
Guidelines For Use of a Nebulizer in School
When a parent requests that a nebulizer b
e kept at school, the following guidelines should be
1. The nebulizer medication authorization form must be completed by the parent and the
parent to review the use of that child's nebulizer.
3. The nurse will train the person desig
nated to administer medication by nebulizer. The
nurse / principal will designate this person according to the guidelines for administration
5. The mask and medication container s hould be rinsed with tap water and allowed to air
6. It is recommended that the mask, medication container and nebulizer tubing be replaced
The parent/guardian is responsible for providing and maintaining their personal nebulizer equipment.
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