Protocol for Administration of EpiPens


Anaphylaxis is an acute and potentially lethal multi-system allergic reaction. Unlike common allergy, anaphylaxis onset may be sudden and requires instant action to prevent fatality.

Common Causes of Anaphylaxis:

  • Food
  • Insect sting
  • Medication or immunization

Signs and Symptoms of Anaphylaxis:

  • Throat tightness, difficulty speaking or swallowing
  • Itching, including hives and/or itching of the mouth, throat, or tongue
  • Shortness of breath, wheezing, coughing, chest tightness, blue skin color
  • Swelling of body parts, especially face and mouth
  • Vomiting, diarrhea, abdominal cramps
  • Feeling of apprehension, loss of consciousness

Emergency Response

  • Call 911
  • Retrieve epinephrine Auto-injector (Epipen or Auvi-Q) from the following location _______________________in this building
  • Administer Epinephrine auto-injector at the first sign or symptom of a known or suspected anaphylactic reaction.
  • K, 1st, 2nd grade- use green Epipen Junior or blue Auvi-Q 0.15 mg
  • 3rd grade or older- use yellow Epipen Adult or orange Auvi-Q  0.3 mg
  • May administer oral Benadryl per standing order if victim is alert and breathing normally
  • Notify emergency contact person, school nurse, and administer as soon as possible
  • If reaction continues or worsens, a second dose of epinephrine may be given in 15 minutes.
  • Remain with the victim at all times, note signs, symptoms, and time of epinephrine administration. Send used Epinephrine auto-injector with victim leaving the school.
  • De-brief team response, complete incident report.

Maintenance of Epinephrine Auto-Injector

  • Great Falls Public Schools will provide four (4) epinephrine auto-injectors for each student-occupied school building in the District annually. The elementary buildings will have two (2) pediatric epinephrine auto-injectors and two (2) adult epinephrine auto-injectors, the middle and high schools will have four (4) adult epinephrine auto-injectors
  • The epinephrine auto-injector will be stored in a secure and easily-accessible location chosen by the building administrator and school nurse.
  • The school nurse will be responsible for performing regular checks, on the epinephrine auto-injectors and for requesting replacement auto injectors for those that have been used or expired.

Training of School Personnel

Training in the use of the epinephrine auto-injectors and anaphylaxis protocol will be offered to school staff on an annual basis, or more frequently if the school nurse assesses a need for such. The school nurse will recruit volunteers among school staff who will receive the training.   

The training shall include causes for anaphylaxis, recognition of signs and symptoms of anaphylaxis, indications for administration of epinephrine, administration technique, and the need for immediate access to a certified emergency responder.
Training is to be provided by a school nurse, certified emergency responder, or other health care professional.

_____________________                      _____________________

Physician Signature                                         Date



Protocol for Use of Naloxone (Narcan©)

Protocol for Use of Stock Medications in School - Naloxone (Narcan©)

Naloxone is medication indicated for use in the reversal of opioid overdose in the setting of respiratory depression or unresponsiveness.  In accordance with MT HB 323 and GFPS School Board Policy, schools may implement the use of stock Naloxone.  Naloxone may be administered by a school nurse or other authorized and trained personnel to any student or non-student as needed for an actual or perceived opioid overdose.

What are Opioids? Opioids include illegal drugs such as heroin, as well as prescription medications used to treat pain such as morphine, codeine, methadone, oxycodone, hydrocodone, fentanyl, hydromorphone, and buprenophrine. Opioids work by binding to specific receptors in the brain, spinal cord, and gastrointestinal tract.  In doing so, they minimize the body’s perception of pain.  However, stimulating the opioid receptors or “reward centers” in the brain also can trigger other systems of the body, such as those responsible for regulating mood, breathing, and blood pressure.

Signs and Symptoms of Opioid Overdose

Suspected or confirmed opioid overdose consists of:

  • Respiratory depression evidenced by slow respirations or no breathing (apnea)
  • Unresponsiveness to stimuli (such as calling name, shaking, sternal rub)

Suspicion of opioid overdose can be based on:

  • Presenting symptoms
  • History
  • Report from bystanders
  • School nurse or staff prior knowledge of person
  • Nearby medications, illicit drugs or drug paraphernalia

What it looks like: OPIOID HIGH vs. OPIOID OVERDOSE




Muscles become relaxed

Pale, clammy skin

Speech is slowed/slurred

Infrequent or no breathing

Sleepy looking

Deep snoring or gurgling

Responsive to stimuli

Not responsive to stimuli

Normal heartbeat/pulse

Slow heartbeat/pulse

Normal skin tone/color

Blue lips or fingers

Emergency Response for Known or Suspected Opioid Overdose:

  • Call for help
  • Call 911 and activate school medical response team
  • Check for breathing-administer rescue breaths or start CPR as indicated.
  • Administer Naloxone kit when it arrives to the scene.
  • Remain with person and place in “recovery position” (on left side), and continue to monitor breathing.
  • May repeat dose of Narcan every 2-3 minutes if patient remains unresponsive or repeat dose as needed for loss or decrease in consciousness after response to initial dose.  Alternate nostrils when administering.
  • Notify emergency contact, administrator, and school nurse as soon as possible.
  • Patient should be transported by EMS to hospital for further evaluation
  • Complete Naloxone Administration Report and debrief incident at appropriate time and place with school nurse, administrator, and others as indicated.

Maintenance of Naloxone:

  • Each school electing to maintain a stock supply of naloxone will work with a school nurse to obtain a standing order for the medication and implement protocol.
  • The Naloxone kit will be stored in a secure and easily-accessible location chosen by the building administrator and school nurse.
  • Naloxone will be available for use during school hours and is not required to be available for use during before or after school activities.
  • The school nurse will be responsible for performing regular checks on stock medication and for requesting replacement kits for those that have been used or expired.  Standing orders will be updated when medication is replaced.

Training and Education: 

Training will be provided by a school nurse, certified emergency responder, or other health care professional.  All trainings will include causes of opioid overdose, recognition of signs and symptoms of opioid overdose, indications for the administration of an opioid antagonist, administration technique of the opioid antagonist carried by the school, and the need for emergent medical follow up.  Each school that maintains stock Naloxone will designate a team of staff members to be trained annually.  A list of trained personnel will be maintained by the building administrator.

References and Resources

  1.  Kentucky Department for Public Health Clinical Protocol for Intranasal Naloxone in the School Setting
  2. Montana HB 323: Emergency use of opioid antagonist in school setting—limit on liability.
  3. Great Falls Public Schools Board Policy 3416
  4. National Association of School Nurses (NASN) Naloxone in Schools Toolkit and Narcan Administration Protocol

Oxygen Therapy Protocol

Tube Feeding Medication

Tube Feeding Protocol

  1. Check for authorization forms/record

  • Medication Administration Form
  • Medical provider
  • Parent/guardian
  1. Check for the Five Rights

  • Right student
  • Correct time
  • The medicine container matches authorization forms and medication administration record
  • The dose on medication container matches authorization form and records
  • The medication is in the correct route as identified on medication container, authorization forms and medication record
  1. Ensure that the medication has not expired

  2. Explain the procedure to the student at his/her level of understanding

  3. Wash hands

  4. Gather equipment and place on clean surface

  5. Position child either sitting or supine with head up at least 30 degrees

  • The most significant risk with giving liquids via a gastrostomy tube is possible aspiration into the lungs, be sure the student is positioned properly with head elevated at least 30 degrees
  1. Put a towel or washcloth under student’s gastrostomy tube

  2. Put on gloves

  3. Observe abdomen for signs of malposition or obstruction of gastrostomy tube such as difference in external tube length compared to baseline measurements or abdominal distention

  • Compare external tube length to tube length measurements obtained after initial placement of the tube, contact parents/guardian and healthcare provider if discrepancy in measurements.
  • If student has abdominal distention do not administer the medication, instead contact parent/guardian and healthcare provider.
  1. Pour prescribed amount of medication into medicine cup

  2. Fill the extension tubing with water using a syringe with at least 5 cc or ml of water

  3. Remove plunger from syringe

  4. Open port on the gastrostomy access port

  5. Attach the extension tube filled with water to the access port

  6. Attach syringe to the medication port on the extension tube

  7. Pour prescribed medication amount into syringe

  8. Elevate the syringe above the level of the stomach

  9. Open clamp on extension tubing and allow medication to slowly flow through extension tubing

  10. Close clamp extension tube

  11. Pour prescribed amount of water into medicine cup

  12. Pour prescribed amount of water into syringe

  13. Open clamp and allow water to allow water to slowly flow through extension tubing

  14. Clamp enteral tube and remove syringe

  15. Snap safety plug in place

  16. Secure medication

  17. Wash syringe and extension tubing with soap and warm water and put in home container

  • Check with your school nurse about the length of time to reuse any of the equipment
  1. Remove gloves

  2. Wash hands

  3. Document medication administration on medication administration record

  4. Follow up with parents/guardian and healthcare provider, as needed

Page last updated: October 5, 2017



Bowden, V. R., & Greenberg, C. S. (2012). Pediatric nursing procedures (Third Edition). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. Connecticut State Department of Education.

Connecticut State Department of Education.  (2012). Clinical Procedure Guidelines for Connecticut School Nurses.  Available at:

Pavia, M.  (2012).  National Institute for Health and Clinical Excellence (NICE). Infection. Prevention and control of healthcare-associated infections in primary and community care. London (UK): National Institute for Health and Clinical Excellence (NICE), 47 p.