• Medication/Treatment Administration Guidelines

    In this Chapter

    • Medication/Treatment Administration Guidelines
    • Techniques for Administering Medications
      • The 8 Rights of Medication Administration
      • Oral Medication
      • Eardrops
      • Eye Drops or Eye Ointment
      • Nose Drops
      • Topical Medication
      • Inhaled Medications
      • Rectal Medications
    • Medication-Related Emergencies
    • Parent Contact
    • Medication Do's and Don'ts
    • Medication Missed by Parent/Guardian
    • Missed Medication/Treatment at School
    • End of Year - Discarding Medication
    • Medication Administration During Official School Business Off School Property
      • The School Health Aide's Responsibilities
      • The Staff Person's Responsibilities
    • Administration of Emergency Medication During School-Sponsored Events Outside of School Hours
    • Medication Administration Skills Checklist
    • Metered Dose Inhaler 
    • Nebulizers
    • EpiPen® Auto-Injector
    • EpiPen® Injection Procedure
    • EpiPen® Injection Trainer Skills Checklist

    Medication/Treatment Administration Guidelines

    The Sarasota County School Board strives to comply with state law to honor families' private medical decisions while ensuring a learning environment free of disruption.  To accomplish these goals, as a general rule, prescription medication should be administered at home.  Prescription medication should only be administered on District property during school hours when administration cannot reasonably be accomplished outside of school hours.

    A Medication/Treatment Authorization Form (M/TAF) signed by a physician and parent must be provided, and medication must be stored and administered in the manner described below.  Only FDA approved prescriptions and over-the-counter medications are allowed to be administered by school board personnel.  Homeopathic remedies are not FDA approved and will not be administered by school personnel.  Dietary supplements are not approved by the FDA for use as drugs and will not be administered by school personnel.  A dietary supplement is any product taken by mouth that contains a so-called "dietary ingredient" and may include vitamins, minerals, herbs,  and amino acids as well as substances such as *enzymes, organ tissues, metabolites, extracts or concentrates. 

    * Pancreatic enzymes are looked at on an individual basis to determine if they can be given at school per a physician's order.

    Controlled Medications

    Controlled medications including stimulants, depressants, anabolic steroids, some anticonvulsants, and analgesics may be prescribed to students with disabilities or illnesses.  Some frequently prescribed controlled medications taken at the school include Valium, Diastat, Adderall, Concerta, Risperdal, Buspar, Ritalin (metadate), Abilify and Dexedrine.  Before administering a PRN controlled substance, a phone call to a parent/guardian is required to check the time of the previous dose.  Any controlled substance in Schedules 1-5 must be counted monthly by one nursing license and one school staff member and documented on the medication log. 

    Controlled, narcotic medications for severe pain management are not routinely administered in the school setting.  These medications are known to cause decreased coordination and decreased levels of consciousness, thus presenting both impaired learning and safety issues for the student. 

    (Contact your school nurse when controlled medications are prescribed for a student.)

    Medical Marijuana/Low THC Cannabis

    A student's parent/guardian or caregiver may administer the permissable form* (non-smokable/non-inhaled products such as oils, tinctures, edible products that can be administered and fully ingested in a short period of time) of medical marijuana/low THC cannabis to the qualified student on District property in the designated location if all criteria are met.  School Nurses or health care professional or school staff are not allowed to administer, store/hold or transport the medical marijuana/low THC cannabis in any form and it will not be stored on any District property. No student is allowed to store/hold, transport, or self-administer medical marijuana/low THC while on school grounds.  Please see Forms Section - Authorization for Medical Marijuana/Low THC Cannabis Use for Qualified Students at School for criteria and required documentation.

    Other

    When wheelchair, crutches, or other temporary assistive device is needed, it must be supplied by the parent.  The school will need a completed Orthopedic Injury Assistive Device Authorization Form (see Forms Section for forms in English and other languages) signed by the licensed health care provider and parent/guardian.  This form is only valid for the current school year.
         

    Other treatment equipment such as nebulizers and glucometers must be supplied by the parent.  An M/TAF Form signed by the licensed health care provider and the parent/guardian must be on file along with a signed and notarized affidavit.  Both forms are only valid for the current school year.

    School personnel designated by the principal are authorized, under Section 1006.062, Florida Statutes, to assist students in the administration of prescribed medication provided that:

    • The district school board includes in its school health services plan, a procedure for training school health personnel by a registered nurse, a physician, or a physician's assistant.  A yearly skills check is required for all unlicensed school staff who give medications.
    • The district school board adopts policies and procedures for the administration of prescription/over-the-counter medication/s by school health personnel.  (“Prescribed medication” refers only to those products that have been approved by the Food and Drug Administration for use as a drug).
    • The person designated to administer medications/treatments receives the full cooperation from all staff involved to ensure that the physician's orders are followed and the medications and treatments are given at the prescribed times.
    • The M/TAF is completed and signed by the licensed health care provider and the parent/guardian.  This form is only valid for the current school year.  If the parent/guardian has given written permission on the M/TAF, the prescription label may be used for three school days while waiting for the physician’s authorization to be received.  If authorization has not been received after the three days, do not give medication and contact the school nurse.

    The school nurse is to check and verify all medication/treatment orders.

    • The health room aide transcribes the medication/treatment order (unless the order is for liquid medication-see next paragraph) onto the Medication/Treatment Administration Log (M/TAL), using extreme care to accurately transcribe the medication name, strength, dosage and time.  If any of this information is incomplete, or if the information is not on a SCSB Medication Form, contact the school nurse immediately. 
    • Liquid medication is transcribed onto the administration log by a school nurse only.  The health room aide may accept and sign-in liquid medication. Health room aide must immediately notify the school nurse when an order for the administration of liquid medication is received.  If the school nurse cannot be reached, call the School Health Landings office at 927-9000 x 32101 or fax the doctor’s order and prescription bottle label to the Landings at 927-4029, along with a cover letter requesting a nurse to transcribe the order onto the log.
    • The medication is brought to the school by the parent or guardian (not the child).  The principal may make exceptions to this rule in case of hardship (e.g., parent workday begins early).
    • The medication prescribed for the student is labeled with the following information:
      • Student's name
      • Name of the medication
      • Directions concerning dosage (route, dose, frequency)
      • Time of day to be taken
      • Health care provider’s name
      • Date of prescription
      • Pharmacy label must match the physician's order (Medication/Treatment Authorization Form)
      • Expiration date
    • Over-the-counter medication is received unopened, in its original container, and labeled with the student's name, directions for giving, and dosage. (If the licensed health care provided has given the parent sample bottles of medication, the bottle(s) must also be labeled as stated above.) USFDA approved OTC medication for headaches only, will be allowed without a physician's prescription per HB 1537. "A student may possess and use a medication to relieve headaches while on school property or at a school-sponsored event or activity without a physician's note or prescription if the medication is regulated by the United States Food and Drug Administration for over-the-counter use to treat headaches."
      • No over-the-counter (non-prescription) medications such as topical creams/ointments, eye drops, etc. may be given without a completed Medication Authorization for Over-the-Counter Medication Form or a Medication Treatment Authorization Form (M/TAF), whichever one is appropriate. All medications to be administered in a school setting must be USFDA approved.
    • Each prescribed/over-the-counter medication to be administered by school district personnel shall be received, counted, and stored in its original container.  When the medication is not in use, it must be stored in a locked and secure location designated by the principal.  Those medications requiring refrigeration should be kept in a lockbox in the refrigerator (see medication Do’s and Don’ts).
    • All controlled medications schedules 1-5 will be counted monthly by the school nurse and another school district employee or parent.

    OTC medications will be kept in the locked medication cabinet in the health room.  No supply of over-the-counter (OTC) medications will be kept in the health room for distribution to the staff.   

    The signed M/TAF and M/TAL are to be placed in the student’s Cumulative School Health Record when the medication has been completed or changed by the healthcare provider and at the end of the school year.

    Techniques for Administering Medications

    Follow the Eight Rights of Medication Administration to ensure the safety of students requiring medication during school hours.

        1.      Right student
        2.      Right medication
        3.      Right dose
        4.      Right time
        5.      Right route
        6.      Right expiration date
        7.      Right documentation
        8.      Right of the student to refuse
       

    • Ask the student to state first and last name (do not prompt).  (Small children will often answer to other names.)  It is important that the student is correctly identified before medication is given.   If necessary, have the teacher send the child to the health room wearing a name-tag or accompanied by an aide.
    • Compare the label on the medication container with the M/TAF for the following information: right student, right medication, right dose, right time, and right route. Always check three times to be sure that the child is receiving the correct medication.  Check the student’s name on the container of medication when it is removed from the shelf, just before the child takes the medication, and before it is returned to the shelf.  Check the expiration date on the medication container to be sure that it has not expired.  Check when the last dose of medication was given.
    • Document the date and time that the medication was given, and sign your initials on the M/TAL for each dose given.  Documentation of medication/treatment must be done immediately after administering.  Document the visit on the computer (if there is no access to the computer, document on the daily service log).
    • A student has the right to refuse any medication.  If a student refuses to take a medication, the school RN and parent/guardian must be notified. If no parent/guardian contact is made, a note must be written to the parent stating what happened (school nurse or principal can assist with content and appropriate documentation of the note).  If a student questions whether the medicine is correct (i.e., appearance, number of tablets, etc.), do not give the dose until the M/TAF has been rechecked.  If there is still a question, contact the parent/guardian.  If parent/guardian information does not coincide with the M/TAF, notify the school nurse for clarification/intervention. 

    Oral Medication:

    • Before giving tablets or capsules, have the student take a few sips of water.  This helps make swallowing medication(s) easier.
    • Give oral medication with the child sitting up.
    • Remove the correct amount of medication (pills) from the bottle.
    • Administer the medication.  Always follow medication with water unless otherwise directed.  Make sure the medication is swallowed - check the child's mouth.
    • Do not crush tablets unless approved by a doctor.

    Liquid Medication:

    • A Child-Specific Medication Administration Skills Checklist is required for each liquid medication. Put a note (sticky) on the MTAF that only the following people can administer this medication. If your name is NOT on this list, call the School RN or School Health Office X32101.  (Exception- Benadryl (Diphenhydramine)- A Medication Administration Skills Checklist is to be completed for each Benadryl (Diphenhydramine) dosage amount. For example- 1 teaspoon- 5mls, 2 teaspoons-10 mls)
    • Always measure liquid medication carefully (liquid medication is often prescribed by the teaspoon).  Measure medication in a disposable plastic calibrated cup or pharmacy provided measuring device. The school nurse will mark the correct dosage line with a marker.
    • Remove the correct amount of medication (liquid) from the bottle.  Shake suspensions before pouring.
    • Administer the medication.  Always follow medication with water unless otherwise directed.  Make sure the medication is swallowed - check the child's mouth.
    • Wipe off any spills on the bottle with a paper towel or clean cotton ball.
    • Mixing of liquid medications shall only be done by persons who are designated in their job description as licensed medical personnel.

    Eardrops:

    • Check M/TAF and the label on the medication container to make sure medication is put into the correct ear.  (See Medical Abbreviations List.)
    • Assist the child to lie down on the side opposite the ear into which drops will be placed.
    • Pull up and back on the ear into which drops will be placed.
    • Put the drops in the ear.
    • Have the child remain on his/her side for a few minutes.
    • Wipe off any medication that runs out of the ear.

    Eyedrops or Eye Ointment:

    • Check M/TAF and the label on the medication container to make sure medication is put into the correct eye.  (See Medical Abbreviations List.)
    • Have the child lie down with his/her neck extended back over a pillow on a cot.
    • Rest your hand on the child's forehead and gently pull down the lower lid.
    • Apply drops or ointment to the inside of the lower lid without touching the container tip to the eye or the skin.
    • Keep the child in the same position for a few minutes.
    • If you contaminate the end of the tube of medicine, squeeze out a small amount onto a sterile gauze pad and start over.

    Nose drops:

    • Assist the child to lie down with the neck extended back over a pillow on a cot.
    • Put drops in the nose.
    • Keep the child in the same position for a few minutes.
    • Observe for choking or vomiting.

    Topical Medications:

    • Apply to clean skin surface.
    • Use cotton-tipped applicator or gauze to apply ointment; never use fingers.
    • Cover the area with gauze or a Band-Aid.
    • If you contaminate the end of the tube of medicine, squeeze out a small amount onto a sterile gauze pad and start over.

    Inhaled Medications: 

    • Will be dealt with on an individual basis (refer to “metered dose inhaler” and "Nebulizer" sections in this chapter and "Asthma" in the Medical Conditions/Illness/Injury chapter).

    Injectable Medications:

    • Injectable medication shall only be given by personnel who are designated in their job description as licensed medical personnel. 
    • Emergency Epinephrine is the only injection school health aides or other trained personnel designated by the principal are allowed to administer, and only after documented training by the school nurse.  This epinephrine is only to be given by intramuscular injection and supplied in a single dose, the pre-filled syringe (EpiPen Auto-injector ®) that requires no reconstitution or dose adjustment. The delivery device needs to be such that the recapping of the needle is not required.

    Rectal Medications:

    • Rectal medication shall only be given by personnel who have been trained by the school nurse.

    Medication-Related Emergencies

    (See Chapter on “Life-Threatening Allergies” for complete guidelines.)
         

    An allergic reaction to medication can happen at any time, regardless of how long the child has been taking the medication.  The school must be given instructions about which medical facility to transport the child to in the event of an emergency.

    • Never leave a child alone who is suspected of having an allergic reaction to medication.
    • If a child has an adverse reaction to medication, call the parent/guardian and notify the principal.  Poison Control (1-800-222-1222) or 911 may be contacted regarding adverse effects.
    • If necessary to call 911, call 911 first and then notify the parent/guardian.
    • If a student is taken to the hospital emergency room, send the medication container and a copy of the Health Emergency Information Card with EMS.  The school principal or an appropriate school representative must accompany the child if the parent/guardian is not present.  (See procedures for Emergency Plan of Action in  Emergency Health Needs Chapter.)  
    • Notify the school nurse.

    Reasons for Contacting Parents/Guardians 

    (*You must document every action you take.)

    Parents/Guardians should be contacted for any of the following reasons:

    • Any question regarding the parent's/guardian's instructions.
    • Failure of the child to take the medication/treatment for any reason (i.e., vomiting, refusal, forgot, out of medicine, spilled the last dose).
    • If a variance is made in giving a medication/treatment, the school nurse, principal, and the parent/guardian must be contacted immediately.   The Medication/Treatment Variance Form must be properly documented, according to directions, the same day the variance has occurred or is discovered. The Medication/Treatment Variance form is completed and sent to the School Health office at the Landings.  If no parent/guardian contact is made, a note must be written to the parent stating what happened (school nurse or principal can assist with content and appropriate documentation of the note).  Examples of variances include wrong medication given to the wrong student, wrong dose, wrong route, wrong time or medication not given.  The prescribing physician or Poison Control (1-800-222-1222) or 911 may be contacted regarding adverse effects. 
    • Any change in behavior or physical status that might be attributed to the medication/treatment.
    • Change in the appearance of the medication or expiration date of the medication has passed.

    Medication Do’s and Don’ts

    DO:

    • Make a list of the names of students and times they are to receive medications and maintain the confidentiality of the list.  Do not include the name of medication/procedure or dosage on this list.
    • Wash hands before and after giving medication.
    • Follow directions on the medication label and the M/TAF, including any precautionary notes.
    • Remove medication from the container over a counter, never over a sink or floor.
    • Observe medication for changes in appearance or odor.
    • Replace cap tightly after removing the medication from the container and return the container to the locked storage cabinet.
    • Give the medication within one-hour (60 minutes) before or after the scheduled time it is due.  If the student comes for the medication later than one hour after the scheduled time, notify the school nurse to determine if the medication should be given.  The principal and parent/guardian must be notified and the variance properly documented according to directions on the back of the Medication/Treatment Variance Form.  If no parent/guardian contact is made, a note describing what happened must be sent home to the parent (school nurse or principal can assist with content and appropriate documentation of the note).  Send the completed Medication/Treatment Variance Form to the School Health office at the Landings.
    • Document on the M/TAL the time the child takes the medication.  Document the Medication visit on SIS.
    • Observe child for signs of allergic reaction (rash, itching, swelling, and breathing problems, diarrhea, stomach cramps, or change in skin color).
    • Notify the parent/guardian when a new supply of medication is needed.
    • Call your school nurse for direction if you are unsure of what to do.

    DON'T:           

    • Don’t take authorization for any medication, prescription or non-prescription, over the telephone.  If a parent/guardian is insistent, refer him/her to the principal.
    • Don’t mix liquid medications.
    • Don’t touch medications with your hands.

    Health room aides: Do not crush pills without a physician’s order.

    Medication Missed by Parent/Guardian

    The school board attorney has indicated that there are limited choices at our disposal if a student was to receive medication in the morning before coming to school, but did not get that dose.

    • The parent/guardian should come to school to give the medication.  
    • If this is not possible, the parent/guardian must call the school health aide to authorize him/her to dispense the medication, in this scenario only.  This can only be done if the prescription bottle at school indicates multiple doses in a day.  If, for instance, it says to give one tablet at 11:30 A.M., an earlier dose may not be given by school personnel.
    • Be careful of administering doses of medication too close together.  If a parent/guardian calls after 8:00 a.m., contact the school nurse who can determine the correct time to administer the next dose.
    • Any action taken which is different from that indicated by the physician on the M/TAF must be properly documented.

    If this is a continuing problem for a particular child, the school will contact the parent/guardian to request that the doctor adjust the times of medication administration to allow school personnel to give both the A.M. and P.M. doses at school.  Notify your school nurse of this situation.
        
    Missed Medication/Treatment at School

    Notify the parent/guardian any time a medication or treatment is not given.  If a variance is made in giving a medication/treatment then the principal, school RN, and parent/guardian must be contacted immediately and the variance properly documented, according to directions on the back of the Medication/Treatment Variance Form.  If no parent contact is made, a note must be sent home to the parent describing the event (school RN or principal can assist with content and appropriate documentation of the note).  The Medication/Treatment Variance Form is completed and sent to the School Health office at the Landings. 

    End of the School Year Medication Disposal

    Health Room Staff Responsibility:

    • Notify parent/guardian at least two weeks before the end of the school year that they must pick up any remaining medication by a specific date (see Medication Pick-up Notice). This includes any medication discontinued or changed during the school year. Explain that if the medication is not picked up by the deadline date, it will be discarded. Also, please include a Medication Treatment Authorization Form for the next school year.

    Over-the-Counter Medications (OTC) that are not picked up by parent/guardian:

    • Make sure that there is no student information on the box or bottle.
    • Separate unopened from opened medication and unexpired from expired medication.
    • Leave unopened and unexpired OTC medication in the original package and deliver to the Landings, School Health Office.
    • Opened or expired medication is bagged or boxed and brought to the Landings.
    • Document on Medication Treatment Administration Log.

    Prescription Medications:

    • Do end of the month count.
    • Document the name, dosage, and amount of leftover medication on the back of each student’s Medication Treatment Administration Log.
    • Mark out student information on the label.
    • Leave all prescription medications: pills and liquid in the original container/bottle. Epi pens and injectables to be placed in Sharps container. Inhalers to be discharged and canisters to be thrown away.
    • Bring to the Landings - School Health Office.

    Stock Epi-Pen: 

    • Unexpired pens remain locked in the Health Room.
    • Expired pens are discarded in the sharps container.

     

    Medication Administration during Official School Business off School Property

    This procedure covers students who require administration of medication during temporary absences from school property for activities such as field trips during the school day.   All medication must be in the original container with the student’s name, dosage, directions for administration, and the current date.

    The staff person accompanying the student will be responsible for the security of the medication and medication administration. Medication cannot be administered by volunteer staff or parent chaperones other than the student’s own parent/guardian.
         

    When a field trip is planned, a student’s medication can be provided by one of the following methods:

    • Request the parent to accompany their child on the field trip to be responsible for administering medication.
    • If the parent is unable to attend, a teacher or other staff person who has been trained in “Field Trip medication administration,” with initial instruction provided by a registered nurse/or annual re-demonstration by a LPN, may administer medication.
    • A teacher or other staff member can be certified to administer the medication on the field trip; however, this does not qualify the teacher or other staff members to administer medication on campus. The teacher or other staff members can only administer medication on field trips.
    • School personnel on campus who have been certified to give medications can be assigned to accompany the class to administer the medication/treatment on the field trip. 

    Guidelines for Medication Administration during Field Trips

    Before the field trip, the School Health Aide will:

    • Ensure the staff person responsible for giving the medication has a certificate of training on file in the health room.
    • Notify the school nurse and staff person at least three weeks in advance if medication training needs to take place including child-specific training for students with diabetes, students with injectable medications (EpiPen®) and students with a nebulizer treatment order. 
    • Copy the M/TAF’s and  M/TAL’s for each student on the list (these will be given to the staff person administering the medication/s for documentation purposes). Set aside the medication container/Inhaler/EpiPen® needed by each student. 
    • Count the medication available in the medication bottle along with the staff person responsible for the field trip medication administration.  Document the quantity on the back of the original M/TAL in the # Received field under Quantity of Medication.  Record “field trip” and the date under Date of Transport field and sign under the Signatures field.   Have the staff person sign next to your signature.
    • Enter and circle the time on the front of the original M/TAL under the correct month/day field. On the back of the M/TAL under the Other column, enter the month, day, year and “Field Trip.”

    Upon return from the field trip, the School Health Aide will:

    • Ensure that the medication administration has been recorded on the M/TAL copy by the person who administered the medication.
    • Re-count the medication available in the medication bottle along with the staff person who gave the field trip medication.  Document the quantity returned and date on the back of the M/TAL and sign as shown below:

    * If there are any problems, questions, or concerns with medication administration, the staff person shall call the principal.

    If the medication is not given as ordered, the staff responsible for giving the medication on the field trip will notify the principal, school nurse, and parent/guardian immediately and properly document the variance according to directions on the Medication/Treatment Variance form.  The Medication/Treatment Variance form is completed and sent to the School Health office at the Landings.  If no parent contact is made, a note must be sent home to the parent describing the event (school nurse or principal can assist with content and appropriate documentation of the note). 

    Medication Administration on Overnight Field Trips

    • The staff person responsible for the overnight trip should ask the parent if their child requires medication during the time of the field trip.
    • If a student requires medication administration, the parent must submit a signed Medication/Treatment Authorization Form (unless already on file at the school).
    • Ask the parent to bring the medication to the school health room at least three days before the trip (unless already available in the health room). 

    All further medication guidelines apply as above.

    Administration of Emergency Medications


    During School-Sponsored Events Held Outside Normal School Hours

    To comply with Florida Statutes, 1006.062 Administration of Medication and Provision of Medical Services by District School Board Personnel, school personnel staffing school-sponsored events before and after school must be taught child-specific medication administration procedures for those children who may require emergency medication while under their care.  Emergency medications include, but are not limited to, asthma medications and EpiPens®.  

    For those students who may require emergency medication in these situations, the school RN will include the procedure for emergency medication administration in the student’s Individual Health Plan.  The procedure will be student specific, based on the child’s age and ability to self-manage their illness.

    The school registered nurse/LPN will notify school personnel of the need for child-specific training and will set up a time for that training to take place. 

    All medication must be locked in a safe place at the site of the school-sponsored event according to F.S.1006.062.   

    It is the parent’s responsibility to notify the school nurse that their child is enrolled in a school-sponsored event before or after school and to provide school personnel with the Medication/Treatment Authorization form (signed by parent and physician) and additional prescribed emergency medication.

    Metered Dose Inhaler (MDI):

    Students Using a Metered Dose Inhaler (MDI)

    A metered dose inhaler (MDI) is a device that delivers a mist of medicine that can be breathed directly into the lungs. Medicines are given this way to work faster and with fewer side effects.

    How an MDI works

    The medicine is held under pressure in a canister that fits inside a plastic device. When you press the canister down in its plastic case, the medicine puffs out in a measured dose. The MDI has to be triggered at the exact moment that you start to breathe in through your mouth. It comes out fast.

    (It is highly recommended to attach the inhaler to a chamber which is a valved, anti-static holding device.)

    Medicines that come in MDIs:

    “Bronchodilators (like albuterol): These are reliever medicines that are used only to relieve symptoms of an asthma-like cough, wheeze or difficulty breathing.  They should not be used unless there are symptoms of asthma present.

    Inhaled steroids (like Flovent®, Qvar®, Symbicort ® or Advair®): These are prevention medicines that are used to prevent asthma episodes by decreasing the inflammation and swelling in the airways. They should be taken every day as directed by a doctor.”

    Guidelines for the Care and Delegation of Care for Students with Asthma in Florida Schools, 2013

    See Forms section for Medication by Metered Dose Inhaler Procedure and Skills Checklist.

    NEBULIZERS 

    A nebulizer is a machine used to deliver medicine as a mist that is inhaled directly into the lungs. The nebulizer has a compressor or pump that pushes air through a tube and then through the medicine chamber to change the medicine into very small droplets.  This is the mist that can be seen coming from the nebulizer.

    Usually, it is the student with asthma who will need a nebulized medication.  Several types of medication can be given by nebulizers, such as bronchodilators, anti-inflammatory drugs, or antibiotics.  The medication may be ordered to be administered on a regular schedule each day or only for those times that the student is sick or is having an especially difficult time with breathing.

    Some of the medications given by nebulizer are the same medications that are taken as pills, syrup, or in metered dose inhalers, but may work faster or better when delivered by nebulizer.  When given by nebulizer, the medication is usually ordered as a concentrated solution that will need to be diluted with saline.  The physician's order (Medication/Treatment Authorization Form) will specify the amount of saline as well as the dosage of the solution.  

    Notify the school nurse as soon as a student with a nebulizer treatment order has been identified so unlicensed assistive personnel may receive child-specific training.

    See Forms section for Medication by Nebulizer Procedure and Skills Checklist.

    EpiPen® Auto-Injector Emergency First Aid for Anaphylactic Reaction

    The EpiPen® Auto-Injector is a disposable drug delivery system with a concealed needle that is spring activated.  The active ingredient is epinephrine, the treatment of choice in allergic emergencies (anaphylactic reactions) because it quickly constricts blood vessels, relaxes smooth muscles in the lungs to improve breathing, stimulates the heartbeat and works to reverse hives and swelling around the face and lips.

    The EpiPen® is commonly prescribed for individuals who have had prior severe allergic reactions to certain foods or food additives, to medications, to insect stings or bites or to exercise.  The most common insects that may cause anaphylaxis are the stingers (bees, hornets, yellow jackets and wasps) and the biters (deer flies, black flies, ants, and yellow flies).  

    An emergency may occur anytime a hypersensitive student is exposed to a substance, sting, or bite to which the student is allergic.  Allergic reactions (anaphylaxis, anaphylactic response) can be fatal within minutes.  Hypersensitive students, identified for the school staff by their parents/guardian and physicians, require the availability of emergency medication.  The EpiPen® must be specifically prescribed for the student, just as any other prescription medication.  Be aware of which students are authorized to carry their own EpiPen® as indicated by the physician on the medication Treatment/Authorization Form.

    Initial symptoms of anaphylaxis may represent a potentially fatal outcome and should be treated as a medical emergency, whether the symptoms occur gradually or suddenly.  Even mild symptoms may intensify rapidly, triggering severe and possibly fatal shock.  Usually, symptoms occur immediately following the sting or bite; death may occur within minutes.  Symptoms, which often vary according to individual response, include the following: 

    • A sudden sense of uneasiness/anxiety
    • Flushed skin
    • Widespread hives
    • Itching around the eyes
    • Dry, hacking cough
    • A constricted feeling in throat/chest
    • Wheezing
    • Facial edema or swelling (i.e. lips, tongue, and eyes)
    • Abdominal pain
    • Nausea or vomiting
    • Difficulty breathing
    • Hoarseness or thickened speech
    • Confusion
    • A feeling of impending doom

    These symptoms may escalate swiftly to anaphylactic shock characterized by cyanosis (bluish skin), reduced blood pressure, collapse, incontinence, and unconsciousness.  Epinephrine given after the onset of low blood pressure may not prevent death. 

    If a hypersensitive student (who may experience a possible anaphylactic reaction) has been admitted to the school, immediately notify the school nurse. 

    See Forms section for Epinephrine Auto-Injector Procedure and Skills Checklists.

    References and Resources

    Pasco County School Health Policy
    Washington County School Health Policy
    Hillsborough County School Health Policy
    Johnson, Phillip, (2003) Medications Use in Schools, Florida Edition, Florida Society of Health-System Pharmacists, Inc., Tallahassee, FL.
    Lake County School Health Policy
    Florida School Health Administrative Guidelines (2007)