parapro ppt
TRANSCRIPT
June 2010
Objec&ves Provide information about IDEA, Section 504, and Nurse Practice Act and how they impact the care provided to students with special health care needs by paraprofessionals in schools.
Review the Delegated Nursing Skills Training Manual for Unlicensed Assistive Personnel.
Discuss the roles and responsibilities of the School Nurse/Paraprofessional partnership.
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Documents needed Resource Guide Developing School Policies and Training Programs for Children with Special Health Care Needs (2007 edition).
Delegated Nursing Skills Training Manual for Unlicensed Assistive Personnel: A Reference for School Nurses (2009 edition)
Arkansas State Board of Nursing Roles and Responsibilities School Nurse Guidelines (September 2007 edition)
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Outcomes of Paraprofessional Training
Paraprofessional will:
Provide safe and effective care for the student;
Become competent and confident as a care provider at school; and
Increase family confidence in the provision of services for the student at school.
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Students with Special Health Care Needs Those students who require individualized health care plans to enable participation in the educational process.
Mandated by Federal and State Law: Section 504 of the Rehabilitation Act of 1973; Public Law 108-‐466, the Individuals with Disabilities Education Act (IDEA), 2004; and
Americans with Disabilities Act (ADA).
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Special Services for Students All individuals identified as disabled under IDEA are protected under Section 504 requirements.
All individuals who are identified as disabled under Section 504 are not necessarily disabled under IDEA.
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IDEA & 504 students
504 only students
Regular Education only students
Sec$on 504 of the Rehabilita$on Act of 1973 Prohibits discrimination because of disability and requires any program/public school to make reasonable accommodations for individuals with disabilities.
Protects any student with a physical or mental impairment which substantially limits one or more major life activities such as caring for one’s self, performing tasks, walking, seeing, hearing , speaking, breathing, learning and working.
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Examples A student who requires insulin injection to control diabetes OR medications to avert severe allergic reactions.
A student who uses a wheelchair in their daily routine.
A student who receives supplemental nutrition through a feeding tube.
More examples can be found in the Resource Guide
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Sec&on 504
Statute prohibits discrimination against individuals with disabilities, including students, by public school districts receiving federal financial assistance.
U.S. Office for Civil Rights (OCR) enforces the provisions of Section 504.
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Sec&on 504 Does not have state or federal funding provided to assist districts in complying with implementation.
All costs are the obligation of the local school district.
Section 504 is a law of access, not of benefit.
Section 504 is an existing federal law, and complying with it is NOT an option.
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Sec&on 504 Requires that a school district makes “reasonable accommodations” for a student with disabilities to permit that student an equal opportunity to participate in educational and related activities.
Free and appropriate public education (FAPE).
Often these required accommodations may include providing the student with school health services/health care plan.
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Special Educa&on
“Special Education means specially designed instruction, at no cost to the parents, to meet the unique needs of a child with a disability.” (Individuals with Disabilities Education Act, 2004, 34 CFR 300.26)
Students have conditions that range from mild health conditions to severe, multiple health conditions that have a profound and direct impact on their ability to learn.
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IDEA of 2004
Provides for the inclusion of students with chronic illnesses; with complex health care needs; and/or who are technology dependent through a process of determined eligibility as having a disability.
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IDEA of 2004 For eligible students under the IDEA, the proper forum for a decision regarding appropriate education is through an Individualized Education Program (IEP) meeting. A team knowledgeable about the student’s situation and accommodating alternatives meets to determine what is appropriate for the student.
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Special Educa&on Law
Any questions about Special Education Law or Section 504 can be answered by the Special Education Teacher, Section 504 Coordinator or Special Education Supervisor.
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Roles/Responsibili&es of Team Members In order to provide the necessary services, schools must clarify the roles, responsibilities, and liabilities of the health care team, including various professionals and paraprofessionals, as they work together to meet the health care needs of children.
A health care team may include many different professionals, licensed according to the laws of the state of Arkansas. Licensure delineates the services that each professional may provide.
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Interdisciplinary Team members Parent/Guardian; Administrator/LEA supervisor – A person qualified to supervise and
provide resources to meet the needs of children with disabilities; Regular Education Teacher/Special Education Teacher; Psychologist/Psychological Examiner/School Psychology Specialist; School nurse (RN); Related Services Provider (i.e. OT, PT, Speech); Primary Care Provider; Paraprofessional/Private Duty personnel.
Team members will vary depending on the needs of the student and plan: 504 vs IDEA
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Health Care Services in School RNs, though supervised administratively by a superintendent or principal, are responsible for health services and nursing care administered through the health services program.
The Arkansas State Board of Nursing Rules and Regulations Chapter Five on Delegation requires that an RN supervise the training and competency validation of paraprofessionals regarding nursing tasks.
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RN supervision Only RNs can determine what “medically necessary” nursing care can be safely delegated to paraprofessionals and under what circumstances.
Paraprofessionals may be accountable to the supervising teacher/LEA supervisor/principal for personnel and school building functions; however they must have RN supervision when assigned delegated nursing tasks.
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General Guidelines for Paraprofessional Training
Training of unlicensed assistive personnel falls under the roles and responsibilities of the school nurse.
The school nurse must be a Registered Nurse in the State of Arkansas.
Training for health care related procedures should be done in a systematic manner.
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Guidelines (cont.)
The RN should provide 1) general training; 2) student-‐specific training; and 3) training for student involvement in self-‐care.
When possible, the student should be encouraged and allowed as much responsibility as can be safely appropriate.
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The School Nurse should:
Know and understand the school district’s policy regarding who is qualified as unlicensed assistive personnel (UAP).
Consider the diversity of each individual and his/her cultural practices and beliefs.
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Delega&on of Procedures
The school RN provides training in student-‐specific procedures for the essential caregivers who will be responsible for providing direct care for the student during the school day.
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Follow-‐up and Training Reviews
Review of training of the UAP occurs at least yearly AND any time there is a change in the student’s status OR when an emergency occurs OR on an as needed basis.
Training and review processes are documented by the RN and records are maintained in the UAP’s file in the RN’s office.
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3 Types of training
General Training;
Student-‐Specific Training; and
Training for student involvement in self-‐care.
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Key Components of general training for all school employees
Description of the health condition and appropriate actions required for the safety of all students;
Example: Interventions for any student having a seizure.
DOES NOT mean giving a copy of the IHP to everyone (violation of confidential information);
Emergency Plan; and
Awareness component.
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Key Components of general training (con’t)
Emergency Plan (Appendix G, page 70-‐71 of the Resource Guide) Standard Precautions; Recognition of emergency situation; Appropriate response; and Designation of people to perform emergency measures and how to reach them (EMS-‐911).
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Key Components of general training (con’t) Awareness component should include:
Acceptance of student with special health care needs; Barriers; Demonstrating cooperation among staff and students by decreasing curiosity with honesty and demonstrating respect of all;
Specific information about medical technology. Such as: student with a working dog, ventilator and wheelchair, relocation between classes.
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FERPA & HIPAA Family Educational Rights and Privacy Act (FERPA) protects the student’s educational record.
Health Insurance Portability and Accountability Act (HIPAA) governs the private health information.
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Protec&ng Confiden&ality NEVER discuss a student with anyone except those directly involved with the student and their care (i.e. nurse, special education teacher, therapist)
Should a discussion need to occur regarding the student and their care MAKE SURE: It occurs in a private area with doors closed and not where others may hear what is discussed.
DISCUSSIONS SHOULD NEVER OCCUR IN PUBLIC PLACES, I.E. GROCERY STORE, CHURCH OR ON A CELL PHONE AFTER SCHOOL HOURS.
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Protec&ng Confiden&ality
If a parent has a question or complaint, always direct them to the nurse and/or special education teacher.
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Standard Precau&ons
Initially, standard precautions were designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection in hospitals.
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Standard Precau&ons Apply to:
Blood; All body fluids, secretions, and excretions except sweat, regardless whether they contain visible blood;
Non-‐intact skin; and Mucous membranes.
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Preven&ng exposure to blood and body fluids Anticipate situations that would place a person in contact with infectious materials.
Hand washing is the most effective procedure to protect staff and other students from the transmission of infectious diseases.
Personal protective equipment provides additional protection.
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REMEMBER HAND WASHING IS THE MOST IMPORTANT PROCEDURE FOR PREVENTING INFECTIOUS DISEASE TRANSMISSION.
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Hand washing requirements Use soap and water; Vigorously rub together all surfaces of lathered hands for at least 10 seconds (Sing Happy Birthday);
Thoroughly rinse under a stream of water; Dry hands with paper towel; Turn off faucet with a DRY paper towel; and Dispose of the paper towel.
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When to wash hands Before and after contact with students;
After touching or cleaning inanimate objects contaminated with secretions, blood or other potentially infectious material EVEN IF GLOVES WERE WORN;
After contamination of the hands by secretions, blood or other potentially infectious material EVEN IF GLOVES WERE WORN;
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When to wash hands (cont) After removal of gloves or other personal protective equipment; and
Before taking breaks and at the end of the workday.
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Personal Protec&ve Equipment Intended to reduce the risk of contact with blood and other potentially infectious materials for the caregiver AND to control the spread of infectious agents from student to student.
Appropriate personal protective equipment MUST be used in a CONSISTENT manner to reduce the risk of exposure.
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Personal Protec&ve Equipment Disposable gloves;
Masks;
Protective eyewear;
A combination of eyewear and mask; and/or
Cover gowns or lab coats.
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Wearing gloves Put on clean gloves just before touching mucous membranes and non-‐intact skin.
Change gloves between tasks.
Change gloves between procedures on the same student after contact with material that may contain a high concentration of microorganisms.
Change gloves if gloves are torn or defective.
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Wearing gloves Remove gloves promptly after use.
Remove gloves promptly before touching non-‐contaminated items and other surfaces.
Remove gloves promptly before going to another student.
Discard gloves after each use and DO NO REUSE THEM.
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REMEMBER HAND WASHING IS THE MOST IMPORTANT PROCEDURE FOR PREVENTING INFECTIOUS DISEASE TRANSMISSION.
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Donning and Removing Gloves Demonstra&on
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Examples of &mes to wear gloves Having contact with blood, other potentially infectious material, mucous membranes and non-‐intact skin.
Changing diapers or assisting the student with cleansing after toileting or catheterization.
Changing dressings/bandages or sanitary napkins/tampons.
Providing mouth, nose, or tracheostomy care.
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Examples of &mes to wear gloves When the UAP has broken skin on the hands or around the fingernails.
Cleaning up spills of secretions, blood or other potentially infectious material.
Touching or cleaning items contaminated with secretions, blood or other potentially infectious material.
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Examples of &mes to wear a mask and eye protec&on
Protecting mucous membranes of the eyes, nose and mouth during procedures and activities that are likely to generate splashes or sprays of blood, body fluids, secretions and excretions (i.e. suctioning, tracheostomy care).
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Examples of &mes to wear a gown
Protecting skin and to prevent soiling of clothing during procedures and activities that are likely to generate splashes or sprays of blood, body fluids, secretions or excretions.
Remove a soiled gown as quickly as possible and WASH HANDS.
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Handling used student equipment Handle used equipment soiled with blood, body fluids, secretions and excretions in a way that prevents skin and mucous membrane contact, contamination of clothing and transfer of microorganisms to other students.
Make sure that reusable equipment is not used for the care of another student until it has been cleaned and reprocessed appropriately.
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REMEMBER Hand washing is the most important procedure for preventing infectious disease transmission
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Cleaning Spills Clean up spills immediately.
Wear gloves during cleaning of spills.
If splashing may occur, wear protective eyewear in combination with a mask and cover gown.
If broken glass or sharp objects are involved, use a brush and dustpan to remove the objects. DO NOT USE YOUR HANDS!
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Cleaning Spills Use a chlorine bleach solution (1 part bleach and 9 parts water) or Cidex. Must be clearly labeled; Must be made daily; and Must keep out of reach of children.
Remove the majority of the spill with disposable paper towels. If splashing may occur, wear a mask and protective eyewear.
Place soiled paper towels in a plastic bag and dispose in plastic lined wastebasket.
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Cleaning spills (cont) Spray chlorine bleach solution onto spill area. Let it set 10 minutes. Wipe with a disposable paper towel. Rinse with water and dry. With a large spill, apply disinfectant directly to the spill, wait 10 minutes and remove with disposable towel.
Decontaminate. Wash hands with soap and water after removing gloves.
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Linen Handle, transport and process used linens soiled with blood, body fluids, secretions and excretions so skin and mucous membrane exposures and contamination of clothing DOES NOT occur.
If used linen is processed on school premises, wash linens separately from other linen using detergent and laundry bleach or bleach substitute.
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Sharps devices NEVER recap used needles or handle them using both hands.
NEVER direct the point of a needle toward any part of the body.
NEVER remove used needles from disposable syringes by hand.
NEVER bend or break used needles.
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Sharps devices
ALWAYS place used disposable needles and syringes and other sharp items in appropriate puncture-‐resistant containers.
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Student-‐Specific Training Is always required even if personnel have provided similar care to another student.
People who are directly responsible for providing health care services to the student need comprehensive training to meet the individual needs of a student.
Provide: an overview; discussion of the procedure(s); and the emergency plan.
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Individualized Healthcare Plans
Ark. Code Ann. § 6-‐18-‐2005 (a)(6)(A) states “students with special health care needs, including the chronically ill, medically fragile, technology-‐dependent and students with other health impairments shall have individualized health care plans.”
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Overview of Student-‐Specific Training Description of health issues and required procedures; Standard Precautions; Psychosocial implications;
Privacy, confidentiality and dignity; Level of student involvement; Attitudes and preferences of student and family;
Information from IHP; and Communication ;
Within school; and Among school, home and health care provider.
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Discussion of the procedure(s) Basic anatomy Body mechanics Name and purpose of the procedure Time(s) to be performed Length of time involved for procedure Teaching methods such as trainer demonstration/return demonstration
Documentation of skills checklist Documentation of procedure
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Discussion of the procedure (con’t) Site where student’s care will take place Hygienic practices, including standard precautions Equipment and supplies required Lifting and positioning of the student Level of student involvement in self-‐care Precautions Signs and symptoms requiring attention Documentation of the procedure Scheduled supervision and follow-‐up
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Example of Documenta&on of Procedure Examples of documentation in the Delegated Nursing Skills manual. Go to pages 17 and 20 for 2 examples of procedures. Notice how they must be individualized for the student’s needs.
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Emergency Plan Signs of possible problems; Recognition of and response to problems and emergency situations;
Individual responsibilities in an emergency situation; Location of the emergency plan; List of people to contact in case of an emergency; and Mock emergency plan drill.
Turn to pages 70-‐71 of the Resource Guide for a template of an emergency plan
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Monitoring and Evalua&on The RN will:
Provide direct care or supervise the student’s care provider;
Update assessment of the student’s health status annually;
Update and evaluate student’s IHP; and Document, review and update skills training.
For students with an IEP, this could be completed at the annual review.
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Delega&on The process for a nurse to direct another person to perform nursing tasks and activities.
NCSBN *– nurse transferring authority ANA **– transfer of responsibility An RN can direct another individual to do something that that person would not normally be allowed to do.
RN retains accountability for the delegation.
*NCSBN-‐National Council of State Boards of Nursing **ANA-‐American Nurses Association
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Delega&on While RNs may delegate skills, they can never assume they are free from the responsibility for the delegated task.
Only the RN can determine “medically necessary” nursing care that can be safely delegated to the unlicensed assistive personnel.
Only the RN is responsible for directing nursing care.
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Delega&on While administrators, teachers and parents may be helpful resources, they may not have the knowledge base to make adequate judgments about delegation of medical or nursing care, nor will they be held legally accountable to the same extent a nurse will be liable for nursing care delivered.
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Delega&on The assumption is made that because a parent has been administering nursing care at home, any school employee can do it.
Family members CAN legally provide nursing care in the home without a nursing license. This is an allowable exception to the Nurse Practice Act (NPA).
When these services are transferred to the public (school), the NPA applies.
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5 Principles of Delega&on Right Task Right Circumstances Right Person Right Direction/Communication Right Supervisor
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Right Task Is the task within the scope of practice?
Is the task appropriate to the job description?
Is the task on a shared tasks list?
What is the desired outcome?
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Right Circumstances Is the setting appropriate?
Are there enough resources available?
Are there any other factors to consider?
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Right Person Is this person currently qualified or can they be qualified to do the task?
Does this fit within his/her job description?
Basically—are you assigning the right person to the right task?
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Right Direc&on/Communica&on
Clear concise description of the task including objective, limits and expectations?
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Right Supervisor Monitoring?
Evaluation?
Intervention?
Feedback?
Hansten, R.I. & Jackson, M. (2004) Clinical delegation skills (3rd ed.) Sudbury, MA: Jones and Bartlett
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Documenta&on A critical component of any procedure.
With each procedure, a section is dedicated to “things to watch for and document”.
Example: page 20 of the Delegated Nursing Skills manual.
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Topics corresponding with School Nurse Guidelines 1.0 Activities of Daily Living 2.0 Urinary Catheterization 3.0 Medical Support Systems 4.0 Medication Administration 5.0 Ostomies 6.0 Respiratory 7.0 Screenings 8.0 Specimen Collecting 9.0 Other Healthcare Procedures 10.0 Developing Protocols
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Ac&vi&es of Daily Living (ASBN 1.0) Tasks performed by individuals everyday which allow the individual to function independently. Elimination Feeding Dressing Hygiene Physical mobility Health care workers play an important role in allowing the individual to maintain or relearn skills to achieve the highest level of functioning.
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Elimina&on Some students may need assistance with toileting, bowel and bladder training, and some will require the use of diapers.
Students with elimination difficulties may require psychosocial and physiological assistance.
Elimination assistance requires compassionate care.
Elimination assistance requires RESPECT.
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Toile&ng (ASBN 1.1)
To decrease the anxiety a student may feel with the exposure while toileting, remember to treat the student with RESPECT and provide as much PRIVACY as possible.
Review KEY POINTS FOR TOILETING, page 15 of the training manual
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Toile&ng Occurrences to watch for and document with toileting are: Foul smelling urine or difficulty urinating; Complaint of pain or discomfort with elimination; and/or
Change in color of the urine.
Notify the RN immediately if any of these occur.
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Diapering To decrease the student’s anxiety and the amount of time the student is exposed, gather all needed supplies before beginning diapering.
Review KEY POINTS FOR TOILETING, page 16 of the training manual
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Diapering Occurrences to watch for and document with toileting are: Foul smelling urine or stool or difficulty expelling urine or stool;
Complaint of pain or discomfort with elimination; Change in color of the urine or color/consistency of stool; and/or
Note any changes in skin such as extreme redness, bleeding or breakage of skin.
Notify the RN immediately if any of these occur.
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Bowel/Bladder Training Programs (ASBN 1.2)
Success of the program is strongly increased when consistency, good nutrition and timing are observed.
A pattern of normal elimination MUST be established.
Observing and documenting the student’s normal elimination pattern over a set period of time.
A student-‐specific plan is developed.
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Bowel/Bladder Training A training program is established to use and enhance the student’s natural urges.
The goal is to form a habit for toileting. Consistency is critical. Coordinate with parent/guardian. Eliminate distractions. Provide positive reinforcement. Document the procedure.
Refer to pages 18-‐20 of training manual.
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Dental and Oral Hygiene (ASBN 1.2 & 1.4) A student usually begins to lose deciduous or “baby” teeth during the early school years.
Proper care of teeth and gums is extremely important since teeth are crucial for chewing food.
Some students may not be able to care for their own teeth.
Document care.
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Dental and Oral Hygiene Report to the RN:
Broken or loose teeth Mouth Sores
Refer to page 21-‐22 of the Training manual
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Altered muscle movement and func&oning Damage to a portion of the brain can result in a break in the transmission of impulses to the muscles.
Muscles may lose ability to contract because of disease or deterioration due to a decrease in number of nerves acting on them.
May lose function due to lack of use.
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Body Mechanics
The coordinated effort of the musculoskeletal and nervous systems to maintain balance, posture and body alignment during lifting, bending, moving and performance of activities of daily living.
Always follow the guidelines for ensuring proper body mechanics.
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Body Mechanics Guidelines Never lift a student who is too heavy. Get help from other staff members.
Explain procedure to student and allow them to help as much as possible.
Maintain lower back in good alignment at all times. Tighten stomach muscles and tuck the pelvis. Place feet at least 12 inches apart broad base of support Bend at knees and keep back straight, helps maintain center of gravity and use strong muscles of the legs to do lifting.
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Body Mechanics Guidelines (cont.) When lifting, keep the weight of the student’s body close to the caregiver’s body. This places weight in the same plane as the lifter and close to the center of gravity for balance.
Maintain an erect trunk and bent knees. Multiple muscle groups work together.
To lift vertically, best height is approximately 2 feet above the ground and close to the lifter’s center of gravity.
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Body Mechanics Guidelines (cont.) When changing directions of movement, pivot feet, turn with short steps and turn the whole body without twisting the upper torso.
When lowering a student, always bend straight down toward the resting place, NEVER twist to lower the student. Reduces risks of twisting sprains and injuries to the back.
Use verbal 1-‐2-‐3 count to coordinate movement with student or other staff. Prevents jerking movements that can lead to strains or injuries.
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Li`ing/Transfers/Posi&oning (ASBN 1.5) Lifting and Transfers 1-‐person
Page 24 of the training manual
Lifting and Transfers 2-‐person Page 24 of the training manual
Positioning Page 24-‐25 of the training manual
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Gastrointes&nal System Breaks down food into nutrients needed by the body.
Protein, vitamins, minerals, water, carbohydrates and fats the body needs for energy, growth and repair.
After food is chewed and swallowed, it goes down the esophagus and enters the stomach where it is broken down by acids.
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Gastrointes&nal System (cont) Then goes into small intestine, broken down more and enters the blood stream.
Excess food the body doesn’t need or cannot digest is turned into waste and is eliminated.
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Feeding (ASBN 1.6) Impaired feeding abilities occur for one or multiple reasons.
May require assistance with oral feedings or feedings through a surgically inserted feeding tube.
Procedure for bolus feedings as well as slow-‐drip is included.
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Gastrostomy Tube (G-‐tube) A surgical opening in the stomach through the abdominal surface.
A flexible catheter held in place by a balloon or a widened flat “mushroom” at the tip of the tube inside the stomach.
Remains in place at all times. Closed between feedings. Causes no discomfort. Can give food and fluids directly into the stomach.
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G-‐tube feedings Bolus feedings
Continuous feedings
Refer to pages 26-‐29 for discussion and pages 34-‐41 of the Delegated Nursing Skills manual for return
demonstration form.
Document procedure
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Possible problems with tube feedings Call RN immediately if Breathing difficulties-‐STOP FEEDING IMMEDIATELY; Nausea and/or cramping; Vomiting; Blocked gastrostomy tube; Bleeding, drainage, redness and/or irritation; and/or Leaking stomach contents.
Page 28 of the Delegated Nursing Skills manual
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If Gastrostomy tube falls out This is not an emergency! Save the tube in clean gauze or container for reinsertion.
May need to be reinserted within 1-‐2 hours. Cover site with bandage or clean dressing. Contact family and school nurse.
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DO NOT DELEGATE Nutritional Assessments (ASBN 1.6.1)
Naso-‐Gastric Feedings (ASBN 1.6.3)
Monitoring N/G Feedings (ASBN 1.6.4)
Jejunostomy Tube Feeding (ASBN 1.6.7)
Total Parenteral Feeding (ASBN 1.6.8)
Monitoring Parenteral Feeding (ASBN 1.6.9)
Naso-‐Gastric Tube Feeding (ASBN 1.6.10)
Naso-‐Gastric Tube Removal (ASBN 1.6.11)
Gastrostomy Tube Reinsertion (ASBN 1.6.12)
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Urinary System Eliminates wastes in the form of urine. Kidneys remove waste from the blood, regulates water in the body, blood pressure, growth, calcium absorption and red blood cell production.
Most water is recycled back to the body. Urine is stored in the bladder until it is discharged through the urethra (the tube from the bladder to the outside of the body).
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Urinary Catheteriza&ons (ASBN 2.0) Some students have urinary problems due to disease or structural issues.
May require clean intermittent catheterization (CIC)
Procedure on page 51-‐52 of Delegated Nursing Skills Manual.
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Clean intermicent catheteriza&on (CIC) Prevents urinary tract infections (URI).
Urine is eliminated before bacteria can multiply to cause an infection.
Prevents wetting caused by overflow incontinence: a condition where urine overflows the bladder and dribbles out of the urethra.
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Clean intermicent catheteriza&on (CIC) Neurogenic bladder: when the nerves that stimulate the bladder do not function well.
Associated with Spina Bifida and other conditions in which nerves from the spinal cord to the bladder are damaged.
Bladder is unable to completely or partially empty.
Performed where the student has privacy.
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CALL RN IMMEDIATELY IF: Bleeding from the urethra;
Inability to pass the catheter;
No urine present when catheterized;
Cloudy urine; and/or
Mucus, foul odor, color changes, or unusual wetting between catheterizations.
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Clean intermicent catheteriza&on (CIC) (ASBN 2.1)
Return demonstration procedure form for Males is on pages 53-‐54.
Return demonstration procedure form for Females is on pages 55-‐56.
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Medical Support Systems (ASBN 3.0) Ventricular Peritoneal Shunt Monitoring (VP shunt)
(ASBN 3.1) Mechanical Ventilator Monitoring (ASBN 3.2.1) Ambu Bag (ASBN 3.2.3) Oxygen therapy (ASBN 3.3)
Intermittent (ASBN 3.3.1) Continuous (ASBN 3.3.1)
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The Brain Hollow spaces in the brain called ventricles produce cerebrospinal fluid (CSF).
Acts as a cushion and supplies nutrients to the brain.
Sometimes there is a backup of the fluid into the ventricle and puts pressure on the brain.
A shunt may be surgically placed. Can be temporary or permanent. May have to be replaced if it is not working properly.
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Key elements to watch for with a VP shunt CALL RN immediately if Headache; Vomiting; Vision difficulties; Confusion; Fever higher than 101.5 orally; Increased redness or discomfort or new or excessive drainage from an incision or would from a recent shunt placement/revision; and
Increased sleepiness.
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Oxygen (O2) Guidelines Considered a medication and must NOT be altered without a doctor’s order.
A sign stating “Oxygen in use” MUST be placed on each entry into the classroom.
Must be stored a minimum of 10 feet from an open flame.
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Oxygen (O2) Guidelines
When in use, O2 cylinders must be kept upright and secured so they do not fall over.
Check the level of the portable oxygen tanks before any event which requires the student to be away from a back-‐up source of oxygen.
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Oxygen Administra&on CALL RN immediately if any of these occur Anxiety, apprehension or behavior change; Increased heart rate; Increased respiratory rate and depth of respirations becomes irregular;
Difficulty breathing; Use of accessory muscles for respirations (nasal flaring, rib retractions);
Dizziness; and/or LATE SIGN Changes in color: student becomes cyanotic (blue or grey lips and/or nailbeds).
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Mechanical Ven&lator Monitoring Ventilators have several alarms that may sound at any time.
STAY CALM.
Notify the RN if an alarm occurs.
A second staff member may need to provide ventilator support with the AMBU bag while one staff member troubleshoots the ventilator.
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DO NOT DELEGATE Adjustment of Ventilator (ASBN 3.2.2)
Central Line Catheter (ASBN 3.4)
Peritoneal Dialysis (ASBN 3.5)
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Medica&on Administra&on Delegation chapter of the ASBN Rules lists medication administration as a task that shall not be delegated to unlicensed persons.
The licensed school nurse is responsible for the administration of medications.
During times when the school nurse is not present, the administration of medications may be delegated to persons identified (Refer to School Nurse Guidelines).
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Medica&on Administra&on (cont.) A Provider order and written permission from the parent/guardian must be on file for all medications.
The licensed nurse is responsible for identifying qualified persons to be trained to administer medications in the nurse’s absence.
After training and documentation of the UAP’s competency, administering medications may be delegated as indicated in the School Nurse Guidelines and following the Delegation Model.
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Medica&on Administra&on Policy Each school district shall have a written policy regarding the administration of medications.
All components of a policy can be found on page 72 of the Delegated Nursing Skills Manual.
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Disposal of Unused Medica&ons Unused controlled substances that cannot be returned to the person for whom they are prescribed are to be sent to Pharmacy Services at the Arkansas Department of Health for destruction.
A surrender form can be obtained from Pharmacy Services at 501-‐661-‐2325.
Large quantities of non-‐controlled substances can also be sent to Pharmacy Services for destruction.
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Disposal of Unused Medica&ons It is NOT recommended that medications be flushed through the sewer system.
There have been multiple studies which show the cleaning and filtration systems are not able to remove all particles of medications.
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Medica&on Administra&on Detailed medication administration procedures can be found on pages 81-‐83 with the documentation example on pages 84-‐87.
Oral medications (ASBN 4.1 and 4.2)
Injections (ASBN 4.3) Do Not Delegate EpiPen (In emergency ONLY)
Inhalation (ASBN 4.5)
Nasal Insulin (ASBN 4.5.3) Do Not Delegate Nasal Controlled Substances (ASBN 4.5.4) Do Not Delegate
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Medica&on Administra&on Rectal Medications (ASBN 4.6) Do Not Delegate Bladder Instillation (ASBN 4.7) Do Not Delegate Eye Drops (ASBN 4.8)
Ear Drops (ASBN 4.8)
Topical (ASBN 4.9)
Per Naso-‐Gastric Tube (ASBN 4.10) Do Not Delegate Per Gastrostomy Tube (ASBN 4.11)
Intravenous (ASBN 4.12) Do Not Delegate
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Ostomies (ASBN 5.0) A surgical procedure where the elimination of stool or urine is re-‐routed from the usual exiting part of the client. Urine or stool exit the body through a surgically created opening called a “stoma”.
The name of the stoma is based on where the stoma is located in the digestive system.
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Types of Ostomies Iliostomy:
diverts contents of the small intestine. Stool is liquid, contains stomach acids and drains freely. Requires a pouch.
Colostomy: diverts contents of the colon (large intestine).
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DO NOT DELEGATE Ostomy Irrigation (ASBN 5.2)
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Respiratory (ASBN 6.0) Postural Drainage and Percussion (ASBN 6.1) Suctioning (ASBN 6.3) Tracheostomy Tube Replacement and Care (ASBN 6.4 &
6.5)
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Postural Drainage and Percussion Postural drainage:
Facilitates drainage of secretions from the airways. Highly dependent on position of the student.
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Suc&oning Oral suctioning (ASBN 6.3.1)
Procedure found in Delegated Nursing Skills manual, pages 93-‐95
Tracheostomy suctioning (ASBN 6.3.2)
Procedure found in Delegated Nursing Skills manual, pages 93-‐95
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Screenings (ASBN 7.0) Growth (ASBN 7.1) Do Not Delegate Hearing (ASBN 7.3) Do Not Delegate Vision (ASBN 7.4) Do Not Delegate Scoliosis (ASBN 7.5) Do Not Delegate
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Vital Signs (ASBN 7.2) May be delegated. UAP may ONLY obtain values and report them to the RN.
RN MUST be the one to determine further indications for treatment.
Documentation found in Delegated Nursing Skills Manual, page 102
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Heart Rate (demonstra&on)
Have student sit in a chair or lie on the health bed. Place index finger on the radial pulse. Count the number of beats for one minute. Record the number. NOTIFY RN OF FINDINGS.
Procedure on page 102 in Delegated Nursing Skills manual
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Respiratory Rate (demonstra&on)
Have student sit in a chair or lie on the health bed. Place hand in the center of the chest and feel for the rise and fall with each breath.
It may be necessary to watch the rise and fall of the chest while you keep your fingers on the radial pulse, so the student is not aware of the observation of the respiratory rate.
Count the number of times the chest rises for one minute. NOTIFY RN OF FINDINGS. Procedure on page 102 in Delegated Nursing Skills manual
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Blood Pressure (demonstra&on) Determine the appropriate size cuff to use. Wrap the cuff around the student’s middle upper arm and make sure the arrow points to the brachial artery.
Place the Sthethoscope on the brachial artery. Close the circuit on the bulb and pump until the needle reaches ______mmHg.
Slowly release the air out of the cuff while listening for the first audible beat.
Remember the number.
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Blood Pressure (demonstra&on) con&nued Listen for the last audible beat. Remember the number. Release all the air from the cuff. Document the blood pressure with the first number on top and the second number on bottom (###/##)
NOTIFY RN OF FINDINGS.
Procedure on page 102 in Delegated Nursing Skills manual
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Specimen Collec&ng/Tes&ng (ASBN 8.0) Blood Glucose (ASBN 8.1)
Follow the student-‐specific Health Care Plan Procedure in Delegated Nursing Skills, page 103
Urine Glucose (ASBN 8.2) Follow the student-‐specific Health Care Plan
Procedure in Delegated Nursing Skills, page 104
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Seizures (ASBN 9.1) Partial Seizures
May or may not have loss of consciousness; Muscle twitching, repetitive motions, and “daydreams”; and/or
May become generalized. Generalized Seizures
Loss of Consciousness; and/or Blank stares, sudden jerking movements.
Absence Seizures (petit mal) Most common, blank stare.
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Key points during seizure Remain calm. Help the child to the floor. Move objects away from the child. DO NOT put anything into the child’s mouth. Once the jerking movements have stopped turn the child on his/her side.
Follow IHP for length of seizure activity before medication administration.
Stay with student until he/she is fully alert.
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Document seizure episode Time of onset; Length of episode; Loss of consciousness; Loss of bowel/bladder continence; and Did the student return to pre-‐episode state of alertness?
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Pressure Ulcers (ASBN 9.2) A localized area of tissue destruction that develops when soft tissue is compressed between a bony prominence and an external surface, for a prolonged period of time. (Butler, 2006 & NPUAP)
When the blood supply to the skin is lessened for a time, tissue death begins to occur and an ulcer begins to form.
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Forma&on of ulcers Four factors contributing to ulcer formation:
Friction; Prolonged pressure on one area; Shearing; and/or Moisture contact with the skin for extended periods of time.
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Dressing Changes Dressing Changes – Sterile (ASBN 9.3)
Dressing Changes – Non-‐Sterile (ASBN 9.4)
Documentation found in the Delegated Nursing Skills on page 113.
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Protocols Do Not Delegate Healthcare Procedures (ASBN 10.1) Emergency Protocols (ASBN 10.2) Individualized Healthcare Plans (ASBN 10.3)
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Func&onal Living Skills Functional living skills will be addressed individually with each student.
These skills will be incorporated into the student’s IHP.
These plans will be developed by the appropriate therapist for that student. The person may be a physical therapist, speech therapist, occupational therapist or other therapist.
Training for the paraprofessional and any others necessary will be coordinated by the school nurse and the therapist.
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Func&onal Living Skills Exercise Program Feeding Program Functional Walking Program Lifting Orthotic Program Positioning Program Sensory Program Standing Program Wheelchair Use
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THANK YOU Thank you for your participation in this Paraprofessional Training. Your input and evaluation is valuable to the development of future modules.
Thank you in advance from the students you will care for each day. Your assistance is vital to their educational success.
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