Planning for Care of Students with ADHD
- Identify students diagnosed with ADHD
- Obtain medical authorization to administer medications for students receiving medications at school.
- Establish medication plan for those students receiving medications at school.
- If student is receiving medications from school nurse they may need an IHP.
- Consider nonpharmacological interventions as needed in the classroom.
- Consider evaluation for 504 or IEP.
- Evaluate for any side effects of medication, educate staff as needed.
- Consider referrals for students not diagnosed (refer to school psychologist)
Students with diagnoses learning disabilities (LDs) are eligible for an IEP under IDEA; however, many students with ADHD are not. ADHD students are covered under Section 504 of the Rehabilitation Act, thus making them eligible for an Accommodations Plan. The student suffering from severe ADHD may be eligible under IDEA under “other health impaired.”. The nurse can collaborate with other team members, including but not limited to, the school principal, counselor, and teacher to establish the students eligibility and best suited plan. The school nurse should consider developing and IHP for these students.
Reference: School Nursing, A Comprehensive Text. 2nd edition. Selekman. (20013)
Planning Care for Students with Asthma
- Identify students with asthma
- Obtain proper forms for medications at school. Student may self-carry their inhaler if MT Authorization to Self-Carry Emergency Medication form is signed by medical provider.
- Develop an Emergency Action Plan or Asthma Action Plan for student.
- Consider developing Individualized Healthcare Plan
- Assess student’s ability to self-administer as indicated; teach proper technique if needed
- Assess student’s ability to identify triggers and their self-compliance with medical regimen
- Allow students easy access to inhalers and other equipment (i.e. spacers, peak-flow meter, nebulizers)
- Consider developing school wide protocol for handling asthma episodes.
- Educate staff, parents, and students about asthma
- Collaborate and advocate for students with asthma
- Research your schools air quality policies.
- Assess school for possible triggers (i.e. perfumes, air fresheners, cleaning agents, etc.)
- Communicate with administrator(s), coaches, and other staff re: outdoor air quality concerns.
Refer to respiratory protocols for guidelines in using the following:
- Pulse Oximetry
- Peak Flow Meter
- Nebulizer Treatment
MT Sever Allergy and Medication Authorization Form (insert doc. link)
Asthma Action Plan (insert doc. link)
Example teaching tool for inhaler use (insert doc. link)
See these websites for more resources including educational materials, grant funding, and referral sources regarding asthma.
MTDPHHS Asthma Friendly Schools
Mt Asthma Project-home visiting nurse program
MTDPHHS School Mini-Grant
American Lung Association
CDC Asthma Site: School and Childcare Providers
MCA 20-5-420 allows students to carry and self-administer their rescue inhaler as long as there is a Medication Authorization Form on file.
Type I Diabetes: When the pancreas fails to produce insulin. This diabetes is more common in children and adolescents (formerly referred to as Juvenile Diabetes).
Type II Diabetes: Defined by the American Diabetic Association as, “a type of diabetes that occurs primarily as a result of insulin resistance, characterized by diminished liver, muscle, and adipose tissue sensitivity to insulin…” (2011c)
Diabetic Medical Management Plan (DMMP): Provider orders outlining daily care of diabetic students. DMMP should address blood glucose monitoring, insulin orders (for blood sugar correction and carb coverage) and treatment for high and low blood sugar (see appendix for MT DMMP).
Hyporgylcemia: Low blood glucose, typically less than 300 70mg/dl.
Hypergylcemia: High blood glucose, typically over 300 70mg/dl.
Continuous Glucose Monitor (CGM): A way to measure glucose levels in real-time throughout the day and night. A tiny electrode called a glucose sensor is inserted under the skin to measure glucose levels in tissue fluid. It is connected to a transmitter that sends the information via wireless radio frequency to a monitoring and display device. (www.medtronicdiabetes.com/treatment-and-products/continuous-glucose-monitoring).
Students with Type I Diabetes
Considerations in Planning Care
- The school nurse should work with student’s family and provider to obtain a DMMP for each Diabetic student.
- All diabetic students should have an Emergency Care Plan that addresses actions to take if the student is hyperglycemic or hypoglycemic.
- Diabetic students should have an IHP and be considered for a 504 plan.
- The school nurse needs to assist in establishing meetings for all staff involved with student to review care plans and emergency procedures. School nurse oversees training and possible delegation of diabetes care tasks.
Elements of Care Plan for Diabetes
- Where will supplies be kept? Can they keep extra supplies in the classroom or office?
- Blood glucose testing: When/where will student test? Do they need supervision or assistance? If so, who will that person be and who will train them?
- Blood glucose monitoring: What blood sugar range is acceptable? When and how do parents want to be notified.
- What are the student’s typical symptoms of hypo/hyperglycemia? Can they identify when they have high or low blood sugar? Can they communicate this to an adult?
- If the student cannot self-administer insulin, who will be assisting?
- Snacks for the students: who will provide the snacks and where will they be kept?
- Dietary concerns: Type I Diabetics may also have celiac considerations. If the student is eating school lunch will you be able to provide carb counts?
- Recess accommodations: Does the student need to test their blood glucose prior to recess. What training will the recess aids need?
- Fieldtrip accommodations: What supplies will the student need? Do they need a UAP, licensed person, or parent to accompany them?
- Who will be trained to assist student with daily needs and/or administer glucagon.
- Accommodations during classroom parties: Does the student provide their own snack? Can they participate in the party as long as they cover carbs eaten with insulin?
- Physical activity: discuss with family the effects that exercise has on the student’s blood glucose levels. Consider if BG testing should be done prior to or after PE if necessary.
- After school and extracurricular activities: Identify if the student needs support during extracurricular activity time and discuss your role in supporting this process.
Training School Staff
- Review ECP with at least all staff that have daily contact with student. You may want all staff to be familiar with a student if they are a young child in elementary school.
- Some staff may need an overview of Diabetes if they will be assisting with care in any way. See example training record under “Forms”.
- Glucagon: Please refer to MCA 20-5-412, otherwise known as “the Glucagon law.” The nurse may facilitate in teaching staff to use glucagon after they have been designated by the diabetic student’s parents. . Under this law the nurse is not delegating injection of Glucagon, but is identified as teaching the skill. See “Forms” for glucagon related resources.
Students with Type II Diabetes
Students with Type II Diabetes may not require as much daily assistance as students with Type I Diabetes, but it is still recommended that the school nurse have these students identified as students with a chronic condition. It is advisable to discuss their potential needs with the child’s parents and develop an emergency care plan and any other plans deemed appropriate by the school nurse.
Considerations in Planning Care
- Dietary concerns: Does this student have any prescribed dietary plan that requires accommodations in the school day?
- Treatment plan support: If the child’s medical provider has them on a treatment plan discuss with the family if there are ways that you can support this plan at school.
Diabetes Medication Administration
MCA 20-5-412 Definition -- parent-designated adult -- administration of glucagon -- training
- Partial: onset is within one cerebral hemisphere
- Simple partial: Most commonly presents as sensory or motor involvement without impairment to consciousness. Symptoms usually confined to one side of body.
- Complex partial: Sensory and/or motor seizure with alteration in awareness May progress into a secondary generalized tonic-clonic seizure.
- Generalized: seizures involving both cerebral hemispheres simultaneously
- Include absence, atonic, myoclonic, tonic, and tonic-clonic
Reference: Individualized Healthcare Plans for the School Nurse. Arnold, Harrigan, Silkworth, Zaiger. (2005)
- Identify students with Epilepsy/history of seizures
- Speak with family and medical provider as needed to obtain history (is the student on medication? How often do they experience seizures? What type of seizures do they have? What is the typical duration of a seizure?)
- Establish Emergency Care Plan/Seizure Plan
- Establish Individualized Healthcare Plan if needed
- Possible evaluation for 504
- Provide first aid training for staff
- Provide teaching regarding emergency care plan and any procedures specific to the student (i.e. administration of emergency medications or use of Vagus Nerve Stimulator)
Considerations in Planning
- Most seizure ECPs need to include guidelines for seizure first aid and how to keep the student safe during a seizure.
- Assist the student to the floor, provide a safe area
- Do no restrain or put anything in the student’s mouth.
- Turn the child to their side if possible.
- Time the start/stop of the seizure.
- Plan should identify when to call parents and 911.
- Emergency medications:
- Intranasal versed
- **Note: Requests are often made to have unlicensed staff trained in the administration of these medications.
- Use of Vagus Nerve Stimulator (VNS)
- Side effects of seizure medication
- Students may experience learning disability/difficulties related to type of seizures, severity and duration of seizures, medications side effects, or various other reasons related to their diagnosis (could lead to possible IEP or 504 evaluations).
Life Threatening Allergies and Anaphylaxis
Anaphylaxis: An acute and potentially lethal multi system reaction. Unlike common allergy, anaphylaxis onset may be sudden and requires instant action to prevent fatality. Anaphylaxis can be presented as severe symptoms in at least one body system OR it can be presented as a combination of symptoms in two or more body systems.
Epinephrine is the first line choice for treatment of anaphylaxis. ALL student that receive epinephrine should be sent to the emergency department for further evaluation. “It is now recommended that children who normally have epinephrine in the school in case of emergency have at least two doses on hand. Twelve percent of children who needed on dose of epinephrine needed a second dose,” (Selekman2013). A second dose is recommended if symptoms are not resolved within 5-20 minutes (consult student’s provider order).
Dosing Guidelines of Epinephrine
<66 pounds (second grade and lower)
Use junior dose: 0.15mg
>66 pounds (3rd grade and older)
Use adult dose: 0.3mg
“Antihistamines may be administered with epinephrine, but never instead of epinephrine…” (Selekman 2013). Consult student’s physician and guardian to develop protocol for the use of antihistamines, and document in student Emergency Care Plan.
Consider anaphylaxis treatment if any of these signs and symptoms are present and severe:
OR if there are a COMBINATION of symptoms from different body areas:
Lungs: Short of breath, wheeze, repetitive cough
Heart: Pale, blue, faint, weak pulse, dizzy, confused.
THROAT: Tightness, hoarse, trouble breathing/swallowing.
MOUTH: Obstructive swelling (tongue and/or lips)
SKIN: hives over body
SKIN: hives, itchy rashes, swelling (eyes, lips)
GUT: Vomiting, cramping pain, diarrhea
HEENT: Runny nose, sneezing, swollen eyes, phlegmy throat
OTHER: Confusion, agitation, feeling of impending doom.
Guidelines for administering Epinpehrine (taken from the sample protocol developed by the Epinephrine Policies and Procotols Workgroup of the National Association of School Nurses, 12/2014)
Planning Care for Students with Life Threatening Allergies
- Identify students diagnosed with allergies
- Obtain history from parents on their history of anaphylaxis.
- Establish Emergency Care Plan. Consider IHP or 504 for accommodations.
- Obtain orders for student’s medications (epinephrine autoinjector, Benadryl). Students may self-carry emergency medication with MT Self Carry Authorization form filed. (See MT Authorization to Self-Carry)
- Medication: Where will medication be stored? “It is now recommended that children who normally have epinephrine in the school in case of emergency have at least two doses on hand. Twelve percent of children who needed on dose of epinephrine needed a second dose,” (Selekman2013)
- Accommodations: does this student need special diet order? Do they need a “nut free” table? Are their airborne issues with their allergen? What will the child do when there is a class party? Can they have classroom snacks? Are their items in art class or other classrooms that may cause an allergic reaction.
- If your school is going to have a “nut free classroom” or “nut free policy” make sure that all parents are aware. Letters should be sent home. Administrators may choose to have parents sign and return letters.
- Make sure teachers and other team members are familiar with child, their allergies, and their ECP.
- Plan appropriately for field trips and extracurricular activities.
- Train staff in use of epinephrine auto injector.
- Communicate with transportation department if child rides the bus.
- Consider sending letter home to parents. (Sample letter)
Laws and Regulations
20-5-420, MCA Self-administration or possession of asthma, severe allergy, or anaphylaxis medication
27-1-714, MCA Limits on liability for emergency care rendered at scene of accident or emergency
20 USC 1232 Family Education Rights and Privacy Act
According to MCA 20-5-420 Section 2 it is legal for Montana schools to possess a stock supply of epinephrine auto injectors . “Approximately 20-25% of epinephrine administration in schools involve individuals who allergy was unknown at the time of the reaction,” (NASN SCHOOL NURSE. “The Case for stock Epinephrine in Schools. Vol. 27. No 4. July 2012). Stock epinephrine is to be used in the event that an individual (student, staff, visitor, etc) is having an allergic reaction. Many of these incidents will be first time exposures.
Sample MT Stock Epinephrine Policy: See attachment
Free epinephrine auto-injectors are currently available at www.epipens4schools.com
- Montana Authorization to possess or Self-Administer Asthma, Severe Allergy, or Anaphylaxis Medication
- Sample Stock Epinephrine Policy
- Sample Anaphylaxis Emergency Plan