Medication nursing standing orders for emergency care

TEAYS VALLEY LOCAL SCHOOL DISTRICT
MEDICATION IN SCHOOL
Scheduling of medication or treatment outside of school hours is encouraged.
When that is not possible, a specific policy must be followed.
We allow prescribed medication to be taken. However, we must have a written
permission from the parent and the physician's signed verification.
Medication must be received in the container in which it was dispensed by the
physician or pharmacist. It must have proper identification, dosage, and time
interval marked. All medications will be kept in a locked cabinet in the school office
for the student's use as needed – unless special circumstances justify an exception.
Please understand that assistance with medication administration, in the absence of the
school nurse, will be rendered by an employee of the district who is not medically
trained.
For over-the-counter medication, the student should bring the medication to the office in
its original container and clearly marked with the student's name.
Written permission from the parent will also be required before any non-prescription
(over the counter) medication is administered to any student by a school employee.
Parents are responsible for the safe delivery of the medication to the school office -
it is preferred that the parent bring in the medication to the school office and review
with school staff the specific instructions on how and when the medication is to be given.
Parents also need to instruct the child as to the medication schedule and when to report to
the office. Parents will assume the responsibility of notifying the school if the
medication orders have changed.
Parents must understand that they are responsible for picking up any left over or
expired medication at school and that the medication will be disposed of after the
last day of school if not collected by the parent – unless the parent has made specific
arrangements with school personnel.
Medication forms are available in the school office or may be downloaded from the
Teays Valley web site www.tvsd.us
The School Physician will serve as a health consultant and will provide written
medication standing orders for general and emergency care.
In the event that a child needs NON-Prescription medication for minor ailments at school,
the school nurse or her designee may dispense any of the following OTC medication
under the guidelines of the school physician's standing orders:
Ibuprofen (Advil, Motrin), Acetaminophen (Tylenol), Benadryl, Tums, Imodium A-D,
Robitussin, or first aid antiseptic/ointment.
This would be done with parental signed permission, which would be indicated on
the school emergency authorization form that is given to parents annually.

NURSING STANDING ORDERS FOR EMERGENCY CARE
TEAYS VALLEY LOCAL SCHOOL DISTRICT
2011 – 2012 TERM
School Standing Orders
I.
PAIN AND OR FEVER OVER 101 degrees, orally
A. Acetaminophen 325 mg. (1 tablet equals 325mg.) (1 tsp. equals 160mg.) to be administered every 4 hours 1) 40 – 60 pounds: 1 tablet every 4 hours or 2 tsp. (320 mg.) every 4 hours 60-100 pounds: 1 ½ tablets every 4 hours or 3 tsp. every 4 hours Over 100 pounds: 2 tablets (or 500 mg. Caplet) every 4 hours LOCAL ALLERGIC REACTION
Hives, Bee Stings, Poison Ivy, Rashes
A. Administer Diphenhydramine Hydrochloride (12.5 mg.) Allergy Liquid or Capsule Children up to 50 pounds: 1 tsp. every 4 – 6 hours Children 50-100 pounds: 2 tsp. every 4 – 6 hours (1capsule) Children 100 pounds and over: 3 tsp. every 4 - 6 hours (1 –2 capsule) Apply Hydrocortisone cream 1% - topical antipruritic cream , as directed DO NOT apply more than 3 –4 times per day MENSTRUAL CRAMPS, MIGRAINE HEADACHES, ORTHODONTIC DISCOMFORT
A.
1) Under 40 pounds: 100 mg. every 6 hours 2) MINOR BURN
A.
Apply Polysporin ointment - for minor burns only, as directed DO NOT use more than 3 – 4 times per day MINOR CUTS/ABRASIONS
(Clean the affected area with soap and water)
A.
Polysporin Ointment – Active ingredients Polymyxin B Sulfate and Bacitracin Zinc Used as first aid antibiotic as directed – DO NOT use more than 3 times per day Hydrogen Peroxide –Used as first aid antiseptic as directed MINOR STOMACH DISCOMFORT WITHOUT FEVER, VOMITING
A.
Tums – active ingredient Calcium Carbonate (500 mg.) Used as antacid as directed Chew 2 – 4 tablets as symptoms occur Imodium A-D – active ingredient Loperamide Hydorchloride (1 mg. per tsp. – 2 mg. per caplet) Used as an antidiarrheal as directed Children 6 – 8 years (48 – 59 pounds): take 2 tsps. or 1 caplet after the first loose stool and 1 tsp. or ½ caplet after each subsequent loose stool – No More than 4 tsps. or 2 caplets per day Chidren 9 – 11 years (60 – 95 pounds): take 2 tsps. or 1 caplet after the first loose stool and 1 tsp. or ½ caplet after each subsequent loose stool – No More than 6 tsps. or 3 caplets per day Children 12 years of age and older: take 4 tsps. or 2 caplets after the first loose stool and 2 tsps. or 1 caplet after each subsequent loose stool – No More than 8 tsps. or 4 caplets per day. MILD COUGH
A.
Robitussin – active ingredient Guaifenesin (100 mg.), Dextromethorphan HBr (10mg.) per tsp. Used as cough suppressant / expectorant as directed Children 6 – 12 years: 1 tsp. every 4 hours Children 12 years and older: 2 tsp. every 4 hours
ANY SEVERE OR PERSISTENT SYMPTOMS ARE TO BE REFERRED TO A PHYSICIAN
_______________________________________ Brett Call, D.O. School Physician Teays Valley Local School District NURSING STANDING ORDERS FOR EMERGENCY CARE
TEAYS VALLEY LOCAL SCHOOL DISTRICT
2011-12 TERM

School Standing Orders
For severe allergic reaction (anaphylaxis)– difficulty breathing, swallowing
EpiPen Auto Syringe, Jr. 0.15 mg. < 100 pounds Administer SQ
EpiPen Auto Syringe, Regular 0.3 mg. > 100 pounds Administer SQ
IMMEDIATELY AFTER USE
*Call 911


____________________________
Brett Call, D.O.
School Physician
Teays Valley Local School District
Teays Valley Local School District
385 Circleville Avenue
Ashville, Ohio 43103

PARENT /GUARDIAN’S REQUEST FOR THE ADMINISTRATION
OF NON-PRESCRIPTION (over the counter) MEDICATION

BY SCHOOL PERSONNEL

*To Be Completed by the Parent/Guardian
Scheduling of medication or treatment outside of school hours is encouraged.
When that is not possible, this form must be completed every school year prior
to school personnel dispensing medication or treatment. The medication and this
form is to be taken to the building principal and kept on file in the school office.
Name of Child _______________________________
Name of Drug _______________________________ Dosage__________
Route __________ At the following time(s)_________________________
As parent/guardian of the above named child, my signature below authorizes the
Principal, Nurse, or other responsible school personnel to administer the medication to
my child. I do assume responsibility for:
1. Safe delivery of the medication in the original drugstore container to the school
2. Instructing my child to present himself/herself and to take the medication at the 3. Understanding the medication will be disposed of the last day of school if not collected by the parent/guardian. 4. Holding the Board of Education, its officials, and its employees harmless from any and all liability for damages or injury resulting directly or indirectly from this
authorization.
Parent/Guardian Signature ________________________
Date________________________
TEAYS VALLEY LOCAL SCHOOL DISTRICT
PRESCRIBED MEDICATION AUTHORIZATION
NAME____________________________
PHONE____________________
ADDRESS_______________________________________________________________
BIRTHDATE__________SCHOOL_______________GRADE/ROOM_______________

To the Parent/Guardian:
THE FOLLOWING INFORMATION IS NECESSARY FOR ANY STUDENT WHO RECEIVES OR
USES PRESCRIBED MEDICATIONS IN SCHOOL: NOTE: BOTH PORTIONS OF THIS FORM
MUST BE COMPLETED.
1.
I am requesting permission for the student named above to receive or use medication according to the doctors’s verification on this form. I have instructed my child to report to the school office to receive the medication at the designated time. I will keep an adequate supply of medication at school. 2. I will assume responsibility for safe delivery of the medication to the school office either by myself or call the principal to I will call the school office and send a written note if my child is taken off this medication. I will retrieve the medication I will bring in a completed prescribed medication form for any dosage/medication/doctor changes. I release and agree to hold the Board of Education, its officials, and its employees, harmless from any and all liability for damages or injury resulting directly or indirectly from this authorization. ____________________________________________________________________ ____________________________ Signature of parent or guardian
Home phone_________________ Work phone_______________ Cell phone_______________ Pager________________
All medication must be in original pharmacy dispensed containers. Labels must match instructions
from physician on this form.

PHYSICAN’S STATEMENT
To the Physician:
The Teays Valley Board of Education urges you to schedule the taking of medication by students at times outside
of school hours. When that is not possible, the receiving or use of medications will be permitted, insofar as
feasible, during school hours. Medication in pill form is preferable to liquids for use in school.
______________________________________________________________ ______________________
Medication
Form of medication/treatment: Tablet/Capsule, Liquid, Inhaler, Nebulizer, Other______________ Diagnosis for which medication is prescribed_____________________________________________________ Medication to be taken at the following time(s)____________________________________________________ Instructions/precautions (including possible side effects)_____________________________________________ Adverse reactions that need to be reported to the physician___________________________________________ Prescription beginning date___________ Prescription expiration date__________________________________ Date form completed________________ Physician Signature________________________________________ Physician printed name___________________________________Phone number_________________________ Physician Address____________________________________________________________________________ *The school will report concerns about medications or disease to the above physician.
A new form must be completed for each dosage/medication/physician change. Each school year a new
form must be completed for each medication.
Rev. 6/11
Teays Valley Local School District
Request For Students Who Carry And Administer
Their Own Inhaled Asthma Medication

Student Name________________________________________Birthdate_________________
Address_______________________________________________________________________
School ____________________________________Grade/Room_________________________
I. Physician’s Section
______________________________ is under my care and should be allowed to carry and administer
Student Name
his/her personal asthma inhaler medication ______________________________________________.
Medication Name

_________________________________________________________________________________

Dosage, Frequency, and Time of Administration

The student has been instructed and has demonstrated knowledge to the parent and /or
physician of the proper circumstances in which this mediation should be administered,
as well as the proper storage, care and administration of the above indicated medication.
Possible side effects or severe adverse reactions to watch for in the student are:
__________________________________________________________________________________

Procedure to follow in the event that the medication does not produce the expected relief
from the student’s asthma attack:
______________________________________________________________________________________
Prescription beginning date_______________ Prescription expiration date __________________
Date form completed ___________________Physician’s Signature _________________________
Physician Printed Name_______________________________________Phone________________

II. Parent/Guardian Section
I request and give permission for my child to administer his/her own asthma inhaler
medication in keeping with Section I above. Further, I release and agree to hold the
Board of Education, its officials, and its employees, harmless from any and all liability
for damages or injury resulting directly or indirectly from this authorization.
I further agree to submit a revised statement signed by the physician who has prescribed the
medication described above in Section I, in the event that I become aware that any of the
information has changed. I have read and understand the policy of the Teays Valley Local
Schools for the administration of medication and affirm that this request entails special
circumstances justifying an exception from the usual administration of medication by
school personnel.
Signature of Parent/Guardian________________________________________Date___________
Printed Name of Parent/Guardian___________________________________Phone___________
Work Phone_____________________ Cell Phone ______________________ Pager __________________
Rev. 6/11
Teays Valley Local School District
Request That Student Carry and Administer Own Medication

I. Physician’s Section

________________________________________ is under my care and should be allowed to carry
Student Name
and administer his/her personal medication ____________________________________________
Medication Name
Dosage, Frequency, and Time of Administration
The student has been instructed and demonstrates knowledge of the proper circumstances in
which this medication should be administered, as well as the proper care, storage and
administration of the above indicated medication.
Possible side effects or severe adverse reactions to watch for:


Medication starting date_________________________ Expiration date of request___________________
Physician’s Signature______________________________ Physician’s Phone______________________
Date_____________
II.
Parent’s Section
I request and give my permission for by child to self administer his/her medication in keeping with Section I above. Further, I release and agree to hold the Board of Education, its officials, and its employees, harmless from any and all liability for damages or injury resulting directly or indirectly from this authorization. I further agree to submit a revised statement signed by the physician who has prescribed the medication described in Section I, in the event that I become aware that any of the information set forth in that Section has changed. I have read and understand the policy of the Teays Valley Local Schools for the administration of medication and affirm that this request entails special circumstances justifying an exception from the usual administration of medication by school personnel. Student Name_______________________________School_________________Grade_______________ Phone_____________________________ Address ____________________________________________ ______________________________________________________________________________________ Parent/Guardian Signature___________________________________________ Date_________________ Rev. 6/11 TEAYS VALLEY LOCAL SCHOOL DISTRICT
MEDICATION AUTHORIZATION FORM
PHYSICIAN AUTHORIZATION
INJECTABLE MEDICATION
Name of Student______________________________ DOB ______________ Medication ___________________________ Dosage __________________ Route ___________________________ Time ________________________ Special Instructions ______________________________________________ ___ Medical diagnosis of: __________________________________________ ___ STING ALLERGY - Specific insect if known _______________________ ___ FOOD / SUBSTANCE ALLERGY - Child may have an anaphylactic reaction to _______________________________________________________ ________________________________________________________________ Symptoms of anaphylaxis for this student ______________________________ Possible side effects of medication ____________________________________
NOTE: SCHOOL PERSONNEL WILL CALL 911 WHAN AN EPIPEN IS ADMINISTERED
Any additional emergency follow up: __________________________________ Beginning date __________ Expiration date _________ Today's date________ PHYSICIAN SIGNATURE ________________________Phone ____________ Physician address/office stamp _______________________________________ ________________________________________________________________ ________________________________________________________________ TEAYS VALLEY LOCAL SCHOOL DISTRICT
MEDICATION AUTHORIZATION FORM
PHYSICIAN AUTHORIZATION
NEBULIZED MEDICATION
NEBULIZED MEDICATION
Name of student _______________________________ DOB ____________ Medication ________________________Dosage __________ Time_______ Possible side effects to be reported to physician _______________________ ______________________________________________________________ Special Instructions _____________________________________________ Beginning date __________ Expiration date _________ Today's date _____ PHYSICIAN SIGNATURE ____________________ Phone _____________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ Guidelines For Use of a Nebulizer in School When a parent requests that a nebulizer b e kept at school, the following guidelines should be 1. The nebulizer medication authorization form must be completed by the parent and the parent to review the use of that child's nebulizer. 3. The nurse will train the person desig nated to administer medication by nebulizer. The nurse / principal will designate this person according to the guidelines for administration 5. The mask and medication container s hould be rinsed with tap water and allowed to air 6. It is recommended that the mask, medication container and nebulizer tubing be replaced The parent/guardian is responsible for providing and maintaining their personal nebulizer equipment.

Source: https://tvsd.us/nurse/files/MedicationAuthorizationForms.pdf?id=5781