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Board of Nursing Approval – 5/10/00 Assistance with Medication Information for School Staff (For Field Trips Only) When assisting with medications, it is expected that assistance will be given in a manner which protects the student from harm. It is expected both from a legal and ethical standpoint that you will not knowingly participate in practices which are outside your legally permissible role or which may endanger the well being of the student. Medication is given to the right student, at the right time, in the right amount (dose), and by the right route (such as orally, topically, by inhalation). The following information is developed around these FIVE RIGHTS: • AT THE RIGHT TIME • THE RIGHT STUDENT • THE RIGHT MEDICATION • AT THE RIGHT DOSE • BY THE RIGHT ROUTE • THE RIGHT TIME Routine medications are taken at established times. This helps to insure that the desired levels of medication will be maintained and doses will not be given dangerously close to each other. Medications may be given ½ hour before or after the indicated time except for medications to be given with meals. These may be medications which must be given with food. Some medications should not be given at the same time or in combination with other medications. If two or more practitioners prescribe medications, the person assisting must check medication compatibility with the nurse, pharmacist, or poison control center. • THE RIGHT STUDENT Unlike acute care medical facilities, most schools and other institutions do not require personal identification tags. This presents a problem in assisting with medications as levels of communication and cooperation vary. Even a student may answer to another student's name. Basic rules are: a. Never assist with medication unless you know the student. b. Use the student's name during the assistance process. c. Only deal with one student at a time to prevent other students from interfering with the medication process. d. Pre-fill water cups to avoid distractions; do not ever turn away from the student during the medication process. • THE RIGHT MEDICATION Before leaving on the field trip, check the parent/guardian's permission slip and the prescription bottle to be sure the correct medication was sent. For this reason it would be a good practice to have all medication on the day before the field trip. Pill bottles should contain one drug and one drug only. If a prescription is received which appears strange and unlike what you remember seeing before, check with the school nurse. It may be another drug company's product, a generic drug or a mistake. NEVER mix the contents of an old ∗ A field trip is an "off-campus, school-sponsored activity." Section B - 83 - 6-2005 Board of Nursing Approval – 5/10/00 pill bottle with the contents of a new pill bottle; there may be a change in the brand or dose which will create confusion and error. Read the prescription label and check against the medication log sheet. • THE RIGHT DOSE All medications, including over-the-counter (OTC) products, are given in some measured amount. Common measurement terms and their abbreviations for tablets, pills and capsules are milligrams (mg or mgm), grams (GM) and grains (gr). The prescription will indicate how many pills have to be given so you will not need to figure out the number of milligrams. For example, the prescription may read: "Tegretol 200 mg tablets; give two tablets daily." You would give two tablets. The actual milligram dosage is 400 mg daily but you are not asked to compute this, only to comply with the label. Common measurement terms and their abbreviations for liquids are: ounce (oz), tablespoon (Tbsp.), and teaspoon (tsp.). Some prescriptions may indicate a measurement in milliliters (ml). 5 mls = 1 teaspoon; however, teaspoons can vary in size and should not be used routinely. Liquid medication measuring cups/containers are available and should be used. Ear and eye liquids are usually measured in drops (gtt or gtts) or droppers full. Droppers should be included in the medication package. Prescriptions will state the specific amount of medication to be measured out. If confused about a measurement, DO NOT GIVE until you have checked with the parent/guardian or school nurse or the pharmacist. Follow the practitioner's orders carefully. When assisting with medications, you are legally responsible for making sure that you comply with the requirements that medications be in original containers. • THE RIGHT ROUTE Lay assistants are not to assist with injections. The one exception is in use of the lifesaving medications, where standard emergency procedures prevail in lifesaving circumstances. The teacher, guidance counselor or administrator should be informed about the medication instructions. For your information, the routes appropriate for lay assistance are: a. oral b. topical c. inhalants Generally oral, inhalant, and topical medications will be considered for field trip purposes. a. ORAL: (by mouth) Types of oral medications are: (1) Tablets: Pressed powders which are usually acted upon in the stomach. You may crush between two spoons and unless otherwise indicated, mix with a small amount of food such as pudding if client has difficulty swallowing. You must make sure he/she swallows everything. Capsules/Caplets: Gelatin coated powders or tiny time released beads as in spansules. Caplets are replacing many capsules in over-the-counter products as caplets resist tampering. Caplets have the medication in a very highly compressed form with the outer covering resisting digestion until the intestines are reached. These should not be crushed or mixed with food. Enteric Coated Tablets: These have a hard often colored coat on them (similar to the M&M candies). This is to prevent them from releasing the medication too soon in the GI tract and causing irritation. DO NOT CRUSH. Section B - 84 - 6-2005 Board of Nursing Approval – 5/10/00 Liquids: Pour liquids away from the labeled side to keep the label legible. Two types of oral liquids exist for our purposes: liquids with a short shelf life, and liquids with a long shelf life. (a) Short shelf life: Most prescription antibiotics have a short shelf life and frequently have to be either refrigerated or kept away from heat and out of direct sunlight. They should be used completely and the container discarded. The printed expiration date on these bottles indicates the life of the DRY medication. The pharmacy label gives the date when the mixed solution will expire. DO NOT USE BEYOND THE PHARMACIST'S LABEL OF EXPIRATION DATE. Long shelf life. Most OTC liquids have a long shelf life. The label expiration date should be checked periodically to insure freshness. b. TOPICAL: Medications which are applied to surfaces (skin, eyes, ear canals) Topical skin/hair medications may be creams, liquids, powders, soaps, shampoos, ointments. (a) Wear gloves when assisting with topical medications. Never dip anything (for example a Q-tip) into the medication. Pour (or with a clean spoon) dip out just enough of the medication for one application into a clean container and use from there. Never put unused medication back into its original container. Ointment in a tube can be squeezed onto a sterile gauze pad or a bandage. Avoid splashing facial medications into eyes; they can be very irritating. Do not share tubes of ointment or liquid medications between students to avoid spreading infections. Nasal Inhalants: Follow the directions on the package insert exactly. DO NOT place the tip of the inhaler deeply into the nose, place the inhaler tip just at the opening of the nose. Oral Inhalants such as mist asthma inhalants: Follow the directions on the package insert exactly. Be very aware of discard dates on these medications as they MUST be discarded and replaced promptly. Wash your hands before and after assisting a student. Identify the right student. Read the parent/guardian's request and medication label. STOP and obtain guidance if you have any questions. Follow medication instructions. Record medication assistance to the student on the medication sheet. Report observations. Errors do occur despite training and precautions. For the student's safety, errors should be reported immediately upon discovery. 911, the Poison Control Center, practitioner, parent/guardian or school nurse should be contacted depending upon the nature of the error. All cases of errors reported by the person assisting will be kept on file by the school nurse. RESPONSES TO MEDICATIONS Section B - 85 - 6-2005 Board of Nursing Approval – 5/10/00 For the safety of the student, the first dose of any medication should be given under the supervision of the parent/guardian or school nurse. a. DESIRED: good response, mission accomplished, the medication bringing desired results b. NO RESPONSE: medication does not seem to be working c. ADVERSE REACTIONS: (This is to alert you to potential difficulties, even though no problems have been documented on field trips.) (1) ALLERGY: medication causes rashes (sometimes with itching), hives, fatal shock. An allergy can occur several days after a student has been on a medication or from a medication the client has had many times before. IF THE STUDENT IS HAVING TROUBLE BREATHING, CALL "911"; otherwise, call the healthcare provider and parent/guardian. UNTOWARD REACTION: This means the effect of the medication is the opposite of what is expected and desired. Examples are: giving an antihistamine for a cough but having the student become behaviorally out of control or giving a medication to control nausea but vomiting occurs instead. Treat as you would an illness that develops on a field trip. SIDE EFFECTS: These are undesirable but known reactions to the medication. Report observations to the parent/guardian and school nurse. RESOURCES ON DRUG INFORMATION It is the responsibility of every individual who assists with medication to review possible side effects of the medication being given. Information on medication side effects should be available as part of the medication log. For over-the-counter (OTC) medications, the information concerning how to use the medication and how to properly store it is printed on the package or bottle. Also, any pharmacist can provide answers to questions on use and storage. a. For prescription medications, the following resources are available concerning how to use the medication and how to properly store it: (1) The container label will give directions for use including whether it should be taken with or without food. If a drug must be refrigerated or has to have special handling, the pharmacist indicates that on the container. The pharmacy listed on the container can be called if information is needed concerning use and storage. The person's practitioner listed on the container can be contacted for information in accordance with school policy. b. Written information references about medications are available upon request from the following sources: (1) The pharmacy: Upon request a package insert from particular medications can be provided. Usually the insert will describe the drug, its intended use, side effects which can occur with use, side effects which warrant immediate medical consultation, warnings about individuals who should not be using the drug, and any special handling or storage directions as appropriate. The insert is available for prescription medications. Similar information can be found on the packaging of over-the-counter medications. MEDICATION STORAGE AND SAFETY Medication storage and safety indicate a two fold obligation: a. Medication must be carried in such a manner as to protect it from being accessed by unauthorized persons – a situation which could lead to misuse/abuse. Medications taken on a Section B - 86 - 6-2005 Board of Nursing Approval – 5/10/00 field trip should be in the personal possession of the person assisting with the medication and secure from unauthorized use. b. Medication must be carried in a manner that protects the product from deterioration or container breakage. (1) Medications which need refrigeration or storage away from light should be appropriately labeled by the pharmacy and stored accordingly. If medication needs to be refrigerated, it should be carried in a cooler. Medications MUST be stored in their original containers. Should an adaptation of a container be needed, it MUST be obtained from a pharmacist and it must bear the appropriate pharmacy label. This includes over the counter medications. No medication may be stored in a container other than the original container. Only a pharmacist or practitioner can generate a container other than that in which the medication was originally distributed from the manufacturer. DISPOSAL OF MEDICATION CONTAINERS Medication containers should be returned to the parent/guardian or the school nurse. MEDICATION RECORDS Records pertaining to medication use include: parent/guardian's written permission, the pharmacy label (original container label), and any other records such as a medication log sheet which are required by your school. The medication log sheet is a record sheet which you initial/sign after each student has received the appropriate medication. (A signature sheet identifying the initials must be included on the sheet.) The log sheet must show the student's name, name of the medication, dose, route of administration, and time received by the student. Example: John Doe – ampicillin 250 mg by mouth at 1:00 p.m. The log should be returned to the school nurse and attached to the regular daily log. For the reader's information: Controlled substances must be counted and accounted for to conform with federal law, state law, and school policy. Ritalin is a controlled substance. Errors in recording medication information should be handled according to school policy. 24 Delaware Code Section 1921 (a) (16) allows for assistance in self administering medication during school field trips upon completion of a training course. The law does not guarantee that one will not be held liable, and thereby protected from litigation. There are no such guarantees despite the fact that parents/guardians must sign a statement that they "… fully and completely waive any claim for liability that may exist against any staff member, resulting from the assistance with medication to my child." Section B - 87 - 6-2005 Board of Nursing Approval – 5/10/00 SCHOOL EMPLOYEE "MEDICATION ON FIELD TRIP"∗ INFORMATION I received, read, and understand the medication information in the "Assistance with Medication Information for School Staff." I will abide by the safe practices and procedures set forth therein. I am aware that any questions regarding this information or the medication should be discussed with the School Nurse. Date Information Printed Name of School Employee Signature of School Employee Received and Read Signature of Staff Instructor: ∗ A field trip is an "off-campus, school-sponsored activity." Section B - 88 - 6-2005 Board of Nursing Approval – 5/10/00 Parent/Guardian Permission to Assist with Medication to Student I give permission for (Student's Name) (Specify field trip) . I understand a staff member will assist my child with (date) medication. Information about the medication that needs to be taken by Name of medication Dose (amount to be taken) Time to be taken How it is taken I understand I must send the medication in the original container. All of the above information is on the label on the container prepared by the pharmacist as prescribed by The following are any allergies or health conditions my child has: Parent/Guardian Signature Please contact your school nurse if you have any questions. Board of Nursing Approval – 5/10/00 Field Trip Medication Record* inhalation, etc. * To be kept in the school nurse's office.



Prof. Francesco Castelli Clinica di Malattie Infettive e Tropicali Centro Interuniversitario Ricerca sulla Malaria (CIRM) Università di Brescia 2° U.O. di Malattie Infettive Azienda Ospedaliera Spedali Civili di Brescia WHO Collaborating Center for TB/HIV co-infection Malaria: nuove prospettive terapeutiche Conflicts of interest