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XV mould clamping force

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									XV.   SPECIAL NEEDS SERVICES
      Performance Standard 1308 (a) (1)
      Performance Standard 1308.4, 1308.4 (7)
      Performance Standard 1308.5
      POLICY
      All components of Head Start/Early Head Start should be involved in the integration of
      children with disabilities and their families into the agency. The Health Content Area
      staff will assist, train and/or ensure arrangement for medical services for children, 0-5
      years with special needs by collaborating with Education, Transition, Special Services
      and Family Advocates.
      Children enrolled in Head Start/Early Head Start program may be enrolled with
      disabilities diagnosed by a diagnostician, physician or health care provider in any of the
      following: mental, hearing, speech/language, visual, emotional, orthopedic, autism,
      traumatic brain injury, and any other impairment. Before entry in the Centers, Special
      Service Specialist will implement procedures (pre-staffing, staffing, trainings, secure
      equipment, supplies, etc.) for all new children which would ensure Head Start is the least
      restrictive environment for the child. The enrollment date will be determined on an
      individual basis for each child. Special Services will make every effort to keep open
      communication with the families involved and other support staff. For returning
      children an IEP will be done after the child has entered into the Center.

      The Special Services Director should be notified of all special needs children. The
      Special Services Director and Health Coordinator must be notified and approve all
      special needs children requiring invasive medical procedures to be performed in
      the Centers prior to assigning an enrollment date (HS and EHS).
      RESPONSIBILITIES
      1)     Medical procedures are often needed for medically challenged children. Often
             these procedures may be temporary.
      2)     These procedures written in this chapter are generic and are designed for all staff
             to perform. The Health Coordinator/ NP and the Special Services Director will
             review the health information for each child who has a need for a procedure to be
             performed in the Center prior to any scheduled meeting. An individual health
             management plan (HMP) may be developed by the Nurse Practitioner or the
             Health Specialist and will use pre-established Health Management Plans
             (written by the Nurse Practitioner) and update accordingly. An individual
             educational plan (IEP) will be developed by the team after the pre-staffing and
             staff can perform efficient demonstration of the procedure.
      3)     The Special Service Specialist will be the case manager for all children requiring
             special procedures. Health Specialist (or a delegated Health Assistant per NP)
             staff will assist with case management when indicated. Attendees to the pre-
             staffing should include the parent, health care provider, teachers, and support
             staff from the different content, Site Manager or Assistant Site Manager. The
             Health Coordinator and/or Special Services Director may attend depending on
             the diagnosis or procedure needed to be performed.
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4) The case manager will evaluate and document the child‟s, parent‟s, and staff„s
   response to the diagnosis, potential problems, adjustments, and plan of action in
   order to assure the quality of services that need to be provided. Everything must be
   in place (trainings, equipment, etc.) prior to a child entering the Center or given
   an enrollment date.

PROCEDURE
The Special Services Director and Health Coordinator must be notified and
approve all special needs children requiring medical procedures to be performed in
the centers (HS and EHS).
For special procedure to be performed in the centers, staff will adhere to the following
steps:
1)     ALL SPECIAL PROCEDURES MUST HAVE A WRITTEN ORDER
       FROM A HEALTH CARE PROVIDER GIVING INSTRUCTIONS TO
       STAFF TO PERFORM THE PROCEDURE IN THE CENTERS.
2)     PARENTS MUST SIGN CONSENT ON THE MEDICATION FORM FOR
       STAFF TO PERFORM THE PROCEDURE IN THE CENTER.
3)     Special Services Specialist will inform the Health Specialist and Health
       Coordinator of the child who needs a procedure to be performed in the Center.
       A pre-staffing meeting will be arranged with the required staff and parent (or the
       child‟s health care provider) to demonstrate the procedure in order to determine
       whether Head Start staff is capable to perform the task. During this meeting
       topics to be discussed/decided are:
       a) A clear understanding of the diagnosis, condition and need of the child
       b) Approval for child to be in the Center
       c) Training needed for staff to become accomplished with the skills to
           perform the procedure
       d) Supplies needed to perform the task
       e) Timeline for staff to become proficient
       f) Projected entry day
3)     Special Services Specialist will secure the Physician‟s orders for the procedure
       and parent‟s permission on the Dispensation of Medication/Special Procedure
       form (HC-26). A copy of the form should be scanned in the Child‟s Health
       Record on the data system. This physician order and parent signature must be
       updated once a year.
4)     The initial training/demonstration for the procedures will be provided by the
       parent (care giver, health care provider, or guardian) of the child. Special
       Services should notify all staff that should attend the meeting and view the
       procedure demonstrated by the parent. At this training the NP will determine if
       Head Start staff will be trained to perform the procedure.
5)     If approved, the NP will recommend 5-6 staff persons who should learn the
       procedure, and a time frame for each staff to become competent with the
       procedure. The NP will schedule dates for training. A written individualized
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              Health Management Plan, which explains “step by step” to those individuals
              performing the procedure, will be written by the NP.
       6)     The NP may delegate to the Health Assistant or Specialist to assist with trainings
              to ensure proper procedures are learned and followed. Once competence is
              established, the staff will be checked off by the NP or Health Staff. This will be
              documented on the Health Management Plan. When checked off, designated
              staff will start performing the procedure without assistance from the Health Staff.
              Depending on the procedure, the time period may take up to 3-6 weeks.
       7)     An HMP (via NP) will be written specifically for the child„s procedure and
              scanned to the child‟s health record on the data system and Special Services
              within 2-3 weeks of completion of the training.
       8)     Staff will sign their initials on the procedure forms (in the classroom) the day the
              procedure is provided to the child. This HMP will be updated when indicated and
              documented on the progress notes of the child‟s health record.
       9)     Health Specialist/Assistant will monitor teacher performance monthly to ensure
              quality of services provided and document on the health record their evaluation
              of the staff performance.
       10)    Special Services will submit a monthly summary report to the Nurse Practitioner
              concerning the staff‟s skill level and the child‟s status.
       11)    Everything must be in-place, prior to a child entering the center.
       12)    At completion of training, a staffing should be done to reassure the parents and
              staff that the needs of the child have been addressed. At the staffing, an
              enrollment date should be given to parents and staff.
       This is the outline to address special procedures that are may occur in Head Start.

CHILDREN WITH CHRONIC ILLNESS REQUIRING A MINOR PROCEDURE TO
BE PERFORMED OR MEDICATION TO BE ADMINSTERED IN THE CENTER.
The Health Service Manager cannot attend ALL HEALTH CARE MEETINGS FOR
CHILDREN. For most cases, the Health Specialist will answer questions and be the case
manager when indicated. The priority for the Health Service Manager will be children with
extensive procedures or rare diagnosis‟s. If the information obtained or discussed seems
complicated or confusing, staff should call and or fax the information to the Health Service
Manager. Another meeting may need to be arranged in order for the Health Service Manager to
attend to clarify the health information to the staff

For those children with a chronic illness such as asthma requiring medication to be administered
in the Center, Epi-pen administration, or seizures, a health management plan (HMP) is
required. The Health Specialists will be trained for these situations and adjustments to the
HMP plan will be made when indicated. For instance:
    1. A child identified during enrollment to have asthma and they need medication every
        day.
    2. That child should be referred to Special Services to see if they qualify for special
        services.
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    3. Health Staff should document their efforts.
    4. Special Service Specialist should send a “Limitation of Function” form to their PCP to
        see if the child is eligible for Special Services.
    5. Information should be obtained from the parent to assess the child‟s ability to participate
        in the Center, such as:
         a) the criteria for administering the medication (what time, amount)
         b) what is the expected reaction, and
         c) what is an unusual reaction (meaning if the child does not respond do we call the
              parent or 911).
While waiting to determine eligibility of a child for Special Services, Health Staff can meet with
the parent and find out the diagnosis for the condition. All this information should be reviewed
by Health Staff (and Health Service Manager when indicated). Once the information is
obtained, Health Staff should ensure all relevant information is shared with the appropriate staff
(teachers, Site Manager, family advocate, etc), document this in the child‟s folder and report
this information on the Nurse Problem List and send to the Health office at the end of the
month.
These are the general steps for ensuring services are being provided with children with acute or
long term medication administration. Review Chapter XV and the Medication Administration
policy.
The health plan should document the following:
1)     The Consent to Release form for past medical information. To make a good assessment,
       the past history, especially the last 12 months is important. This may need to be
       reviewed by the Health Service Manager and Special Services Director.
2)     The Medication Dispensation form signed by the physician and parents
3)     Find out what are the criteria (from parent and doctor) for administering the medication,
       in terms of, when (time) to give the medication, and the amount. What is the expected
       reaction, and what is the abnormal reaction. If this occurs, do we call 911?
4)     Review criteria and procedure for administering the medication with all staff who are
       involved with the child.
5)     Practice with staff to ensure they know when to administer medication and/or know
       when to seek more guidance or help.
6)     Document this training on the parent contact log or progress notes.
       Obtain an updated prescription from the physician every six months.

CHILDREN WITH CHRONIC ILLNESS WITHOUT MEDICATION
ADMINISTRATION JUST NEED CLOSE MONITORING

If there is no intervention required by the agency, then the Special Services Specialist and
Health Staff will provide educational information to those staff involved with the child. If the
diagnosis seems complicated or confusing, send the information to the Health Coordinator.
Another meeting may need to be arranged in order for the Health Coordinator to attend to
clarify the health information to the staff.
For these children (syndromes, conditions, etc.), a health management plan may or may not be
written for children. This will be decided on an individual basis by the Health Service Manager.



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If the child is in Special Services they are the case manager. If the child is not in Special
Services, the Health Staff is the case manager.
GENERAL GUIDELINES FOR CHILDREN WITH HEALTH PROBLEMS
A)     GUIDELINES FOR ASTHMA
       Asthma is a chronic inflammatory disease of the lungs causing episodes of difficult
       breathing. The airways are super-sensitive to many different things or "triggers."
       THE MAIN SIGNS AND SYMPTOMS INCLUDE:
          Coughing
          Wheezing
          Shortness of breath
          Chest tightness
       TRIGGERS:
          Allergens - Pollens, mold, dust mites, animal dander, cockroach allergen
          Irritants - Smog (ozone), smoke (tobacco, wood), chemical odors and sprays
          Infections - Colds and upper respiratory tract infections
          Exercise and sleep-related airway changes
          Abrupt weather changes
          Gastro esophageal reflux - upset stomach, spitting up
          Strong emotions - laughing, crying, playing
       Bronchospasm is when an asthma attack occurs, the muscles surrounding the airways
       will spasm and tighten. The lining of the airways become inflamed and swollen. This is
       known as airway inflammation. Excess mucus is produced, and the airways become
       plugged with mucus.
       Asthma episodes are prevented and controlled by appropriate medications and an asthma
       action plan. An asthma action plan is prepared by the doctor to help guide decisions
       about the type and dose of medication needed day to day. The plan is based on the
       severity of signs and symptoms of asthma and daily peak flow readings (if applicable).
       MEDICATION INFORMATION
       Bronchodilators - Albuterol (Proventil, Ventolin), Serevent, Tornalate, Maxair,
       Terbutaline, Atrovent (Ipratropium Bromide) is another type of bronchodilator that
       works well with Albuterol.
        Work by relaxing the smooth muscles surrounding the airways of the lungs.
        Available in syrup, tablets, metered dose inhalers, or nebulizer solution.
        Side effects include rapid heartbeat, tremor, anxiety and nausea.
        May be used regularly in small doses and as needed for breakthrough symptoms.
       CORTICOSTEROIDS
       Aerobid, Azmacort, Beclovent, Flovent, Pulmocort, Vanceril
        Reduce and prevent swelling of the airways by reducing hypersensitivity of the
          airways to "triggers."
        Are available in pills, metered dose inhalers, nebulizer solution and shots.

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        Side effects vary depending on the route taken. Pill forms have the most side effects,
         which is why your doctor will most likely prescribe the inhaled form for long-term
         use. The inhaled form side effects include yeast infection in the mouth and cough,
         but using a spacer and rinsing the mouth after each use can reduce these.
     OTHER ANTI-INFLAMATORIES
     Cromolyn sodium (Intal), Nedocromil (Tilade), Accolate, Singulair, Zyflo
     Intal and Tilade work to stabilize the mast cells preventing the release of histamines and
     other chemical mediators of inflammation. They can work to prevent exercise induced
     bronchspasm, or on a daily basis to control asthma symptoms. They work as a good
     starting point for children under age five.
        Accolate, Zyflo, and Singulair are the latest pill form drugs for asthma treatment.
         They also are involved in blocking the cycle of inflammation and may help control
         mild persistent asthma.
     Many primary care doctors are more than capable to manage asthma and prescribe the
     appropriate medications and devices to take the medications. If he or she is not able to
     get the patient's asthma under good control, or is not sure how to treat or manage
     asthma, the doctor will refer the patient to a specialist. Many children with asthma also
     are seen by an allergist to determine what "triggers" the child's asthma. If the child is an
     appropriate candidate, he or she may be put on allergy shots. Allergy shots must be
     given under medical supervision and are given for a period of two to five years.
     Allergy relief from allergy shots does not occur for about one year. Patients with
     allergies usually require medication by mouth and/or nose spray to get relief for allergy
     symptoms. Allergies also can cause asthma to act up, so many times the allergy
     medications prescribed also play a role in keeping the allergic asthmatic's asthma under
     good control.
B)   GUIDELINES FOR HYDROCEPHALUS
     Hydrocephalus is an excessive accumulation of cerebrospinal fluid (CSF) in the brain
     ventricles (cavities), which causes increased pressure within the brain. Hydrocephalus
     usually is treatable with surgery .The most common surgery is insertion of a narrow tube
     (shunt) into a ventricle to divert fluid away from the brain. The tube is passed under the
     skin and attached to a tube in the abdominal cavity (or occasionally the heart). The shunt
     is permanent and will require periodic surgeries to replace, usually when it stops
     functioning or needs to be adjusted for the child's growth.
     Hydrocephalus is a chronic condition, not a disease. Early identification and intervention
     may help compensate for known deficiencies and stimulate development of the child's
     abilities. Many children with hydrocephalus have normal intelligence and physical
     development. However, they are at risk for delays in cognitive, motor and sensory
     development, such as hand-eye coordination and walking skills.
     Signs and Symptoms frequently seen with untreated hydrocephalus and shunt
     malfunctions
      Abnormal enlargement of the child's head
      Bulging or tense soft spot (fontanel), dilated scalp veins.
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      Vomiting and nausea
      Feeding difficulties (poor oral-motor coordination)
      Irritability
     Signs and Symptoms frequently seen with untreated hydrocephalus and shunt
     malfunctions

        Sleepiness, lethargy
        Downward deviation of the eyes
        Seizures
        Change in academic performance
        Complaints of headache, coordination problems and/or vision changes
     CAUSES
     Hydrocephalus may be acquired or congenital. Acquired hydrocephalus may be caused
     by head injury, meningitis, and intraventricular hemorrhage or brain tumor. Congenital
     hydrocephalus is caused by genetic factors during pregnancy and frequently is seen in
     children with spina bifida.
     SPECIFIC PROCEDURES
     In case of emergency, obtain parent/caregiver. When a medical crisis occurs,
     immediately contact the Site Manager, parent/caregiver, health specialist and special
     services specialist.
C)   GUIDELINES FOR SICKLE CELL DISEASE & BETA THALASSEMIA
     PROBLEM
     Malformation of red blood cells is caused by a genetic factor. This results in an almost
     constant anemia. The red blood cells tend to form into sickle shapes and break down
     rapidly. The most common complication is pain, which may be severe enough to
     require hospitalization.
     MEDICATION
     The usual treatment for painful episodes is pain medication. Teachers and Site
     Managers must make themselves aware of the types on medication being used and how
     each medication is given.
     NOTE: Site Managers and/or Teachers may give pain medication to a sickle cell child
     based on written instructions from the child’s physician.
     PERSON RESPONSIBLE: SPECIAL SERVICE SPECIALIST
     SPECIFIC PROCEDURE
     Contact the Site Manager, parent, health specialist and special services specialist
     immediately. When a painful episode occurs, begin pain medication, encourage fluids
     and rest. Never leave the child alone and keep the child as comfortable as possible.



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SICKLE CELL DISEASE
In sickle cell disease, the red blood cells contain abnormal hemoglobin called
hemoglobin S. In sickle cell anemia, the individual inherits a sickle cell gene from each
parent. In other forms of sickle cell disease, the individual inherits the sickle cell gene
from one parent and abnormal hemoglobin from the other parent. The condition
must be distinguished from sickle cell trait, in which the individual inherits only one
sickle cell gene from one parent and a normal hemoglobin gene from the other parent.
With sickle cell trait, the individual‟s health usually is not impaired.
Hemoglobin S causes the red blood cells to become deformed in shape or “sickle.” The
abnormal shaped cells do not flow smoothly through the capillaries, or smaller blood
vessels. They may clog the vessels and prevent blood form reaching the tissues. This
blockage causes anoxia, or lack of oxygen, which makes the sickling worse. This can
lead to sickle cell pain. How often do painful episodes occur? Hemolysis or premature
destruction of red blood cells also occurs. This leads to chronic anemia.
Sickle cell trait and sickle cell disease occur predominately in people of African descent
and in individuals from parts of Italy, Greece, Arabia and India. About one in every 10
black Americans has sickle cell trait and one in every 1,000 black Americans has sickle
cell disease.
What are the signs and symptoms?
An individual with sickle cell disease may have symptoms of anemia, such as being
more easily fatigued and having less stamina and endurance. Fever is a sign that may
indicate that infection is present. Jaundice (yellowish eye color) is associated with the
rapid breakdown of the red blood cells. The child‟s growth may be delayed.
What are the risks?
There is virtually no risk from sickle cell trait, but a man and a woman who both have
sickle cell trait may produce a child with sickle cell disease.
What is treatment?
Acute pain is the most common problem. This is treated with pain medications, extra
fluids and rest. It is extremely important that the individual do everything to maintain
good health, and obtain prompt treatment for fever. Also, the individual should see a
physician regularly who is familiar with the disease. Special precautions may be
necessary before any surgery.
BETA THALASSEMIA
Beta thalassemia is a blood disorder affecting the formation of the red blood cells. The
majority of the red blood cells produced in this condition are destroyed constantly within
the circulation. These red blood cells are smaller in size. Due to the small size and the
constant destruction of the red blood cells, anemia is one of the features of the disorder.
Other features include changes in the facial bones and delayed growth.

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     Beta thalassemia occurs primarily in people of Mediterranean and Asian origin. It is
     also presents in people of African, Southeast Asian and Middle Eastern ancestry.
     The most severe form of the disorder is thalassemia major. Thelassemia major occurs if
     an individual inherits the beta thalassemia gene from both parents. If the beta
     thalassemia gene is inherited from only one parent, the individual will have beta
     thalassemia trait, which rarely causes symptoms.
     The treatment of thalassemia major includes regular blood transfusions.
D)   GUIDELINES FOR HEMOPHILIA (FREE BLEEDER)
     Hemophilia is a genetic disorder in which one of the clotting proteins in the blood is
     decreased or absent, resulting in excessive bleeding. Hemophilia A is a deficiency of
     the factor VIII clotting protein and hemophilia B is a deficiency of factor IX.
     Bleeding most commonly occurs in the skin, muscles and joints. Life – threatening
     bleeds may involve the head, abdomen or neck. Any trauma to the head, neck or
     abdomen should be evaluated immediately.
     Signs and symptoms of bleeding episodes may include:
      A bubbling or tingling sensation into a joint.
      Warmth, pain, stiffness and/or swelling.
      Refusal to bear weight or favoring a joint or limb.
     MEDICATION
     Bleeding episodes are promptly treated with factor concentrates, which are administered
     intravenously. These infusions replace the clotting protein that is deficient or absent.
     Some children receive infusions of factor concentrates on a regular basis (i.e. 3 times a
     week) to prevent bleeding episodes whereas others receive treatment for the bleeds as
     they occur. Prompt treatment of bleeding episodes is essential. Parents or an authorized
     health care professional should administer the medication.
     PERSONS RESPONSIBLE: SITE MANAGER AND TEACHER
     GENERAL PROCEDURE
        If a medical crisis occurs, get the child to a doctor immediately.
        Contact the Site Manager, parent, Health Specialist and Special Services Specialist
         immediately.
        Keep the child quiet and resting until medical assistance has been obtained.
     A child with hemophilia should have periodic check ups with a pediatric hematologist,
     which is a specialist in children’s blood disorders.
E)   CHILDREN WITH HIV/AIDS
     POLICY
     Because of the seriousness of children with Human Immunodeficiency Virus
     (HIV)/Acquired Immunodeficiency Disease Syndrome (AIDS) this is written as a
     guideline for Head Start of Greater Dallas.


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Children tested positive for HIV or children diagnosed with AIDS will be permitted to
enroll into the Head Start centers. Appropriate services will be provided based on the
medical practitioner‟s recommendations. Head Start Centers will provide the least
restrictive environment for all children enrolled. Special Services Specialist will provide
rules and guidelines of IFSP/IEP implementation.
Head Start will adhere to the Communicable Disease Chart for Schools and Child
Centers recommended by the Texas Department of Health for admittance and exclusions
with acute illnesses. Centers will not need to take any special precautions to protect
other children beyond their routine procedures for cleaning up body fluids
(UNIVERSAL PRECAUTIONS) after a HIV child has an accident. These provisions
generally allow for the attendance of a child with HIV/AIDS with the following
exceptions:
 Children who are biting
 Incontinence
 Communicable diseases
 Have open sores
 Behavioral problems (scratching)
 Etc.
If a HIV child exhibits the exceptions described (above), the child will be excluded
immediately. A case management meeting should be held, lead by the Special Services
Specialist. Site Managers and all involved staff (Teachers, Health, etc.) will discuss a
plan of action for intervention. The parent will be informed of the agency‟s plan and
conditions for re-admittance of the child (if possible). Once accommodations or changes
have been met, the child will be allowed to return to the center.
Children with HIV/AIDS will need protection if there is an outbreak (communicable) of
measles or chicken pox since the child is unable to fight off or be protected by vaccines
against such diseases. Those children with HIV will be exempt from school during this
time for their protection.
PROCEDURE
1)     All children diagnosed with disabilities must be pre-staffed by the Special
       Service Specialist.
2)     Staffing committee will discuss the child‟s status and determine placement
       before a child is enrolled into a Head Start center.
3)     The committee will consist of the parent (and medical provider if possible or
       paper work), Special Services Specialist, Site Manager/Coordinator, Nurse
       Practitioner, Health Specialist, and Family Advocate Specialist.
4)     If there is a risk of transmission of HIV or other communicable disease (per
       staffing and medical doctor), that child will not be permitted to enroll or will be
       removed from the classroom until one of the following occurs:
       a) An appropriate program adjustment, alternative or special education program
          can be established.
       b) The physician/health authority determines the risk has abated and the child
          can return to the classroom.
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A decision to remove a child from the classroom for his/her own protection
(communicable diseases, etc.) shall be made in accordance with the Texas Department
of Health guidelines; however, only a staffing committee can change the status in order
to allow the child to re-enter the Center. The staffing committee and/or a group of
professionals who are knowledgeable about the child‟s condition shall make any
decisions regarding restriction, participation, and hygiene. This committee may need to
consult the local health authority, parent and physician when making such decisions.
All health information will be kept separate from the child‟s standard file in the Special
Services office.
GENERAL QUESTIONS AND ANSWERS RELATED TO HIV/AIDS
What is HIV?
HIV is the acronym for human immunodeficiency virus. This is a retrovirus that causes
AIDS.
What is AIDS?
AIDS is the acronym for acquired immunodeficiency disease syndrome. AIDS is a
disease that has a long incubation period manifested by various opportunistic infections.
How can it be transmitted?
HIV is a virus that is spread by:
 Blood-to-blood contact (blood transfusions, open wound contact with
   another person‟s blood or indirect transfusion).
 Intimate sexual contact with persons infected with the virus
 IV drug use with an HIV infected needle/syringe
 HIV mother to the unborn child
 To date, HIV is NOT spread by casual contact (shaking hands, hugging, etc.)
Can my child catch HIV from adults or other children?
Children, like adults, can only catch this disease from intimate sexual contact or blood-
to-blood contact with a person who has AIDS virus infection. The children who are
known to have the disease received the infection from exposure to their mother‟s blood
during pregnancy or in the course of childbirth, from a blood transfusion, or from blood
products used in treating hemophilia.
Are there certain precautions that will be taken if a child with HIV is present in the
school?
Schools will not need any special precaution to protect other children beyond their
routine procedures for cleaning up body fluids after any child has an accident or injury.
The child with AIDS/HIV will need protection if there is an outbreak of measles or
chickenpox, since the child is unable to fight off or be protected by vaccines against
such disease.
Will teachers be informed of a child with HIV in their class? Do teachers have a right
not to accept them in their class?
The classroom teacher(s) will be informed if a child with HIV has been enrolled in their
class. The child would be enrolled after a Staffing to determine the child‟s status.
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     Therefore, the child would pose no undue medical threat to others and could not be
     refused classroom entry. Such refusal would violate the child‟s civil rights.
     Isn’t there the possibility that the AIDS/HIV child can cut him/herself and not inform
     anyone? After all, a four-year-old cannot understand how serious the implication of
     this could be. What if the child bleeds in the bathroom and doesn’t tell anyone?
     There is no risk of spread of infection from the blood of a child with HIV/AIDS unless
     the blood is inoculated into another person throughout a cut that is open to their
     bloodstream. Teachers monitor activities on the playground and children are taught to
     report any accident that may occur. Children will often seek care if they are injured,
     even for minor cuts.
     What about spit/saliva? Are you 100% positive that this can’t transmit HIV?
     From everything that has been studied, there has been no documentation of transmittal
     of the disease by saliva even in the intimacy of the family setting.
     With all the cold germs that children carry, wouldn’t it be a risk to the HIV child to be
     exposed to these germs?
     Most children with HIV/AIDS are under medical treatment to protect them as much as is
     possible from common germs. It is not considered appropriate to deprive any child with
     an immune deficiency of normal socialization with other children. Those who are too ill
     to tolerate childhood infections will not be sent to school.
F)   DIAPER RASH
     POLICY
     Diaper rash is any rash, redness or inflammation in the diaper area caused by an irritant.
     Most diaper rashes are caused by prolonged contact with moisture, bacteria or ammonia.
     The skin irritants are made by the action of bacteria from bowel movements on certain
     chemicals in the urine. Bouts of diarrhea may also cause diaper rashes in many children.
     Diaper rashes occur equally with cloth and disposable diapers.
     DIAPERING
     Diapering will take place in a designated area and will occur in a safe, sanitary and
     respectful manner. If a diaper rash is diagnosed, then implement the following steps:
        Change diapers frequently. The key to successful treatment is keeping the area dry
         and clean so it can heal itself. Check the diaper about every hour, and if it is wet or
         soiled, change it immediately. Make sure that the baby‟s bottom is completely dry
         before closing up the fresh diaper.
        Wash skin with plain water with every diaper change. Washing the skin with soap
         after every diaper change will damage the skin. Use a mild soap or baby wash after
         a bowel movement. The soap will remove the film of bacteria left on the skin. After
         using the soap, rinse skin and hands well.
        Air dry for fifteen minutes, four times a day. Leave the baby‟s bottom exposed to
         the air as much as possible. Practical times are during naps and after each bowel

                                                                                              295
           movement. When the diaper is on, fasten it loosely so air can circulate between it
           and the skin. Avoid airtight diapers, punch holes in them to let air in.
          Discontinue all lotions and powders. Most babies do not need any diaper creams or
           powders.
          Petroleum Jelly - A barrier ointment is often necessary to protect the skin. Apply a
           modest amount of petroleum jelly to the diaper area after a through cleansing with
           plain water. This should be done after every diaper change.
     PROCEDURE
     1)       Staff will inform parents of any changes with the skin when they are identified.
     2)       Staff will have parents sign the consent form when petroleum jelly is used on a
              regularly basis (once or more in a day). This form will be filed in Section 10
              behind the progress form.
     3)       For occasional use (once week/month), staff will verbally inform parents that the
              petroleum jelly was applied.
     4)       Staff will wash hands prior to putting on gloves.
     5)       Diaper should be removed and properly discard.
     6)       Skin will be properly cleaned.
     7)       Staff will use a tongue depressor to remove a modest amount of petroleum jelly
              and place on the gloved hand.
     8)       Tongue depressor should be discarded after each use.
     9)       Staff will apply the petroleum jelly gently and apply a clean diaper.
     10)      Gloves should be removed and hands washed.
     REFERRAL PROCEDURE
     Refer the baby for evaluation to their PCP or Nurse Practitioners if any of the following
     symptoms are apparent:
      The skin (diaper) area becomes red and swollen.
      Blisters discharge or odor develops.
      The rash spreads.
      The baby runs a fever.
G)   DIAPERING PROCEDURE
     Minimum Standard 746.3501
     Minimum Standard 746. 3503
     Minimum Standard 746.3505
     Head Start and Early Head Start staff will frequently (every hour or more often) check
     and change the diapers of the children enrolled in the agency. The changing of the
     diapers will be done in a designated area in each classroom not easily visible for others
     to watch. Staff will ensure that sanitation and hygiene procedures are followed during
     diapering. Staff will ensure the safety and protection of the child served. The following
     procedure will be implemented.




                                                                                                296
       PROCEDURE
       1)     The changing table or surface cover should be smooth, non-absorbent and easy to
              clean.
       2)     Gather all needed supplies and place near (not on) the changing table before
              beginning to diaper.
       3)     If petroleum jelly is to be used, please remove a modest amount using a tongue
              depressor and place with the other supplies.
       4)     A diapering table above the floor must have a safety mechanism that prevents the
              child from falling and must be used at all times when a child is on the surface.
       5)     Wash hands and apply gloves.
       6)     Ensure that the surface is clean and covered with examination paper.
       7)     If the surface is not cleaned, clean surface, remove gloves, wash hands, replace
              with clean gloves and proceed.
       8)     Place the child on the table using proper and safe lifting procedures.
       9)     Never leave the child unattended.
       10)    Remove the diaper being careful not to contaminate other objects and surfaces.
              Clean the child‟s bottom with a moist disposable wipe. Wipe from front to back
              using the towelette only once. Repeat with fresh wipes until the child is
              completely clean. Pay attention to skin folds. Apply Petroleum Jelly when
              indicated.
       11)    Remove soiled clothes and place in individual sealed bags.
       12)    Put disposable wipe into diaper and fold inward, reseal the tapes and place into a
              proper receptacle. Receptacle should be near table.
       13)    Ensure the child is dry before placing a new diaper on the child.
       14)    Diaper and dress the child. Wash child‟s hands and remove child from the
              changing table.
       15)    Tear off and discard used paper from the roll of paper on the table‟s surface.
       16)    Clean surface with the sanitizing bleach and dry with a paper towel.
       17)    Discard gloves and paper towel into the trash can.
       18)    Wash hands thoroughly with soap and water for 10 seconds or more. Dry hands,
              turn off faucets with a paper towel and discard into the trash can.

SPECIAL NOTE: Caregivers with open wounds and/or injury that inhibit hand washing,
such as casts, bandages, or braces, must not change diapers.
If a diaper rash is present see the policy for care. Do not apply powders, creams, ointments,
or lotion without the parent’s written permission (HC-86). If the parent supplies these items
label all containers with the child’s name.


SPECIALIZED HEALTH CARE PROCEDURE AND GUIDELINES
These guidelines are adapted from the Guidelines & Procedures for Meeting the Specialized
Physical Health Care Needs of Students and Techniques for preventing the Spread of Infectious
Disease, (1989) California State Department of Education. These guidelines and procedures
address the needs of school districts to establish an acceptable standard of care and to ensure
appropriate educational programs for all children.


                                                                                            297
These guidelines will be used and modified by the Health Coordinator/Nurse Practitioner for the
specific and unique needs of the children enrolled in Head Start of Greater Dallas, Inc.




1)     CATHETERIZATION
       DEFINITION
       The introduction of a catheter into a body cavity or organ to inject or remove a fluid.
       The most common procedure is the insertion of a catheter into the bladder through the
       urethra for the relief of urinary retention and for emptying the bladder.
       POLICY
       Clean intermittent catheterization may be provided upon receipt of physician‟s standing
       order and parental request indicating that catheterization is necessary for school
       attendance. Students should be taught self-catheterization as early as possible in order to
       develop independence.
       Students who need clean intermittent catheterization may be on a training regimen, have
       no bladder control or have residual urine.
       The purpose of catheterization is to empty the bladder, reduce the incidence of urinary
       tract infections, prevent bladder distension, remove residual urine and prevent urinary
       leakage.
       Head Start staff will assist children needing catheterization in the centers. Training will
       be provided by the primary care giver, Health Staff and Nurse Practitioner when
       indicated.




                                                                                                298
PROCEDURE FOR CLEAN INTERMITTENT CATHETERIZATION – FEMALE

PROCEDURE                                                POINTS TO REMEMBER
1. Wash hands with soap and water. Put on
   gloves.                                              If student does procedure unassisted,
                                                        gloves are not needed.
2. Exp1ain the procedure to the child at her level
   of understanding. Have her do as much of the          By encouraging the child to assist in the
   procedure as she is capable of, with                  procedure, the care-giver is helping her to
   supervision as needed.                                achieve maximum self-care skills.
3. Assemble equipment:




     Water-soluble lubricant (K-Y jelly,
      Lubrifax, Surgel)
     Catheters (plastic, robber)
     Wet wipes or cotton ba11s (non-sterile),
      plus mild soap and water
     Storage receptacle for catheter
     Container for urine.
     Gloves (if person other than child is to do
      procedure)
     Mirror

                                                     She may be catheterized lying or sitting. If able,
4. Position the child.                               girls may sit on the toilet with legs straddled. A child
5. Depending on her age, use the mirror to           unable to sit may lie on her back. This procedure
   show the child the location of the urethral       requires a receptacle to catch the flow of urine from
   opening.                                          the catheter.
6. Separate the 1abia (lips) and hold open with
   fingers. Cleanse, in a direction from the top
   of the labia toward the rectum. Wash three
   times: once down each side and once down
   the middle. Use a clean cotton ball each
   time.




                                                                                                      299
7. Locate the urinary meatus (opening). Gently          The female urethra is short and straight. Keep
   insert the catheter until you obtain urine.        the other end of the catheter over the toilet or
                                                      the receptacle.
8. When urine flow stops, insert catheter slightly
   more. If no more urine is obtained, withdraw
   it slightly, rotate catheter so that catheter
   openings have reached all areas of the
   bladder. It‟s also helpful to have the child
   bear down a couple of times to ensure that all
   urine has been completely drained. If you
   have been trained to do so, apply manual
   external pressure until the urine stops
   flowing. This must be done with catheter in
   place.
9. When b1adder is completely empty, pinch
   catheter and withdraw. (If using metal
   catheter, put finger over end.)
10. Wash and dry catheter if it is to be reused.
    Store in appropriate container.                  This prevents urine still in catheter from flowing
                                                     back into the bladder into the bladder during
11. Measure and record urine volume if
    ordered. Dispose of urine and wash               withdrawal.
    receptacle.
                                                     Report to the parent any change such as
12. Remove gloves and wash hands with soap           cloudy urine, mucus, blood, foul odor, color
    and water.                                       changes or unusual wetting between
                                                     catheterizations. These are signs of infection.
13. Note in your log that the procedure was
    done.




                                                                                                          300
              PROCEDURE FOR CLEAN INTERMITTENT CATHETERIZATION - MALE


PROCEDURE                                                 POINTS TO REMEMBER
                                                          If student does procedure unassisted, gloves are not
1. Wash hands with soap and water. Put on gloves.         needed.
2. Explain the procedure to the child at his level of     By encouraging the child to assist in the
   understanding. Have him do as much of the              procedure, the caregiver is helping him to
   procedure as he is capable of, with supervision as     achieve maximum self-care skills.
   needed.
3. Assemble equipment:




                            Lubricant     Catheter Cleansing    Catheter Container Gloves
                                                    Supplies    storage
                                                                  bag
   Lubricant (K -Y jelly, Lubrifax, Surgel) .Catheters
    (p1astic, robber)
   Wet wipes or cotton bal1s (non-sterile) plus mild soap
    and water
   Storage receptacle for catheter
   Container for uriI1e
   Gloves (if person other than chi1d does procedure).

  4. Position the child.                                  He may be catheterized lying, standing or sitting. If able,
                                                          a boy may stand at the toilet. If unable to sit or stand, he
                                                          may lie on his back. This procedure requires a receptacle
                                                          to catch the flow of urine from the catheter.




  5. Depending on his age, show the child the
     location of the urethral opening.
  6. Cleanse the penis in the following manner:

  a. Hold the penis below the g1ans at a 45 degree
     angle.
  b. If the child is not circumcised, retract the
     foreskin.
  c. Wash the glands with soapy cotton balls. Begin                         Urinary
     at the urethral opening; in a circular manner,                         meatus
     wash away from the meatus. Repeat twice. Use
     a clean cotton ball each time you wash the                Always start at the meatus and wash toward the
     penis.                                                    base of the penis. This helps remove bacteria
                                                               from the area.



                                                                                                                    301
 7. Lubricate the tip of the catheter with water
    soluble lubricant.
 8. Locate the urethral opening. Hold the tip of      ...DO NOT FORCE CATHETER. IF YOU
    penis erect and insert catheter gently into the   FEEL UNUSUAL RESISTANCE, NOT1FY
    urethral opening. Some resistance may be          THE PARENT. ...
    met at the bladder sphincter. Use gentle but      Make sure the other end of the catheter is either
    firm pressure until the muscle relaxes.           in a receptacle to catch urine or over the toilet.
 9. Insert the catheter until there is a good flow
    of urine. When the flow stops, insert
    catheter slightly more and then withdraw a
    little to make sure all urine is drained.
    Rotate the catheter so that catheter openings
    have reached all areas of the bladder.
    It is also helpful to have the child bear down
    a couple of times while the catheter is in
    place. If you have been trained to do so,
    apply external manual pressure to
    encourage the urine flow until the flow
    stops. This must be done with the catheter in
    place.


10. When bladder is emptied, pinch catheter           This prevents urine still in the catheter from
    and withdraw.                                     flowing back into the bladder.
11. If the child is not circumcised, pull the
    foreskin over the glands when finished.
12. Wash, rinse and dry the catheter if it will       Report to the parent any change, such as cloudy
    be used again. Store in an appropriate            urine, mucus, blood, foul odor, color changes or
    container.                                        unusual wetting between catheterizations.
13. Measure and record the urine volume if            These are signs of infection.
    ordered. Dispose of urine and wash
    receptacle.
14. Remove gloves and wash hands with soap
    and water.
15. Note in your log that the procedure was
    done.




                                                                                                       302
        CREDE’S METHOD
        GUIDELINES
        A)      Crede‟s procedures must be performed according to physician‟s special orders.
        B)      Crede‟s technique may be part of routine daily bladder care.
        C)      The procedure is done by the student whenever possible.
        D)      Students who need to have Crede‟s method performed may:
                1)     Be diapered
                2)     Wear an external collection device
                3)     Use toilet or urinal (ambulatory or transfer from wheelchair)
        PURPOSE
        1)      To express residual urine from the bladder
        2)      To reduce chances of bladder infection
        3)      To control odors and prevent skin breakdown
        EQUIPMENT
        1)      None is required to carry out the procedures.
        PERSONNEL RECOMMENDATION
        The procedure for performing Crede‟s method, which follows, may be carried out by
        designated school personnel under indirect supervision.
        PROCEDURE

          ESSENTIAL STEPS                          KEY POINTS AND PRECAUTIONS

1) Have student in appropriate location
   that provides privacy for procedure.
2) Position student lying down or sitting,
   according to needs.
3) Apply repeated firm, inward and
   downward pressure with one or both
   hands over lower abdomen just above
   os pubis or until no more urine is             Use heel of hands to obtain most effective result
   expressed.
4) Record procedure on log and
   permanent health record. Include
   amount of urine expressed.




                                                                                              303
2)   OSTOMY CARE
     DEFINITION
     The management and support of a patient with a surgical opening created in the bladder,
     ileum, or colon for the temporary or permanent passage of urine, or feces. In most cases
     the opening is covered with a disposable bag.
     POLICY
     An ostomy pouch can remain secure from one to seven days. Emptying an open-ended
     pouch may need to be done at the Centers. This is usually the result of the pouch being
     full. Change of a pouch may also be done at the centers. This is usually needed only
     because of a leakage and should be done to control leakage, protect and inspect skin, to
     control odor and to provide comfort and security. Irrigation will be done at home.
     Head Start Staff will assist children needing assistance with ostomies in the Centers.
     Training will be provided by the primary care giver, Health Staff and Nurse Practitioners
     when indicated.
     PROCEDURE
     Changing the ostomy bag:
        Assemble equipment in appropriate private location.
        Position student in a lying or sitting position.
        Remove ostomy pouch. Gently peel pouch away from skin, using skin safe solvent
         as necessary.
        Empty the contents into the toilet in the bathroom and dispose of the bag.
        Place absorbent material over stomach to absorb drainage. It is important to protect
         the skin from irritating drainage. Absorbent material remains in place until the new
         pouch is ready to be attached.
        Cut or mold skin barrier to completely seal skin around stoma. Skin barrier should
         be at least as large as a flange pouch. Failure to cover all skin surrounding stoma
         will cause leakage and skin breakdown.
        Prepare pouch for application; cut to fit if necessary and apply additional adhesive if
         necessary.
        Inner flange of pouch should be 1/8 inch (3mm) larger than the stoma. Cut to fit as
         needed.
        Place pouch securely over skin barrier.
        Clean skin thoroughly but gently with washcloth, soap and water, dry thoroughly.
        Apply skin barrier according to skin condition and type of pouch.
        Secure the opening of the pouch and properly secure the bag to the child‟s abdomen.
        Empty the ostomy bag.
        Empty the contents of the ostomy pouch into toilet.
        Save reusable pouch or discard disposable pouch. Know whether pouch is reusable
         or disposable.
        Rinse out reusable pouch over toilet, Send home in a suitable container.
        Discard empty disposable pouch in waste receptacle.
        If pouch is open- ended, secure open end according to package instructions.
        Secure the opening of the pouch and properly secure the bag to the child‟s abdomen.
                                                                                             304
3)   NEBULIZER TREATMENT
     DEFINITION
     NEBULIZATION
     A method of administering a drug by spraying it into the respiratory passage of the
     patient. The medication may be given with or without oxygen to help carry it into the
     lungs.
     NEBULIZER
     A device for producing a fine spray.
     POLICY
     Head Start Staff will assist children needing Nebulizer treatments in the Centers.
     Training will be provided by the primary care giver, Health Staff and/or Nurse
     Practitioners when indicated.
     PROCEDURE
     The purpose of the nebulizer treatment is to provide inhaled medication and to provide a
     mist in order to loosen mucous and to reduce breathing difficulty.
     1)     Assemble equipment.
            a) Air compressor
            b) Medication and saline solution
            c) Connecting tubing
     2)     Wash hands.
     3)     Explain procedure to the child.
     3)     Add medicine and saline to the nebulizer.
     4)     Monitor student‟s breathing pattern.
     5)     Assess respiratory status with peak flow meter if present.
     6)     Disassemble and clean nebulizer, tubing, and mouthpiece.




                                                                                             305
FIGURE 3.19 IPPB hose assembly and breathing pathway for inhalation and exhalation (From White, equipment Theory for
Respiratory Care, Copyright 1992, Delmar Publishers Inc.)

             The cup holds either distilled water or a combination of distilled water and bronchodilator
             medication. The pressurized moisture provided by the water is sufficient to ease breathing
             for some patients, but other patients will need the addition of medication to achieve the
             desired affect. The solution used and its amount will be determined by your physician.

              You will need to give your patient instructions to breathe as deeply as possible during therapy. The
              patient should hold the mouthpiece without biting down, but seal it completely with his or her lips.
              Instruct the patient not to breathe through the nose.




                                                                                                                       306
4)   GASTROSTOMY FEEDING
     DEFINITION
     The introduction of a nutrient solution through a tube that has been surgically inserted
     into the stomach through the abdominal wall.
     POLICY
     Head Start staff will assist children needing gastrostomy feeding in the centers. Training
     will be provided by the primary care giver, Health Staff and/or Nurse Practitioners when
     indicated.




                                                                                                307
                   GASTROSTOMY BUTTON FEEDING PROCEDURE - BOLUS METHOD A


                                                          POINTS TO REMEMBER
PROCEDURE

1. Wash hands
2. Assemble equipment




    Liquid feeding solution./formula at room
     temperature                                      Some children get cramps if the feeding solution is too
                                                      cold.
    60 ml or cc catheter-tipped syringe or other
     container for feeding (e.g., bottle, bag)
    Adaptor with tubing and clamp
                                                      The adaptor will vary with the size of the button.
                                                      Used to flush tubing after feeding.
    Water (if prescribed)
3. Explain the procedure to the child at his/her      By encouraging the child to assist in the procedure, the
   level of understanding. Encourage the child        care-giver is helping the child to achieve maximum self-
   to participate as much as possible.                care skills.
4. Position child.                                    Child may be sitting or lying on right side with head
                                                      elevated at a thirty degree angle.
5.   Remove plunger from syringe and attach the
     adaptor to feeding syringe.
6. Open safety plug form button and insert
   tubing into button.
                                                    Stomach




7. Clamp or pinch off tubing.                         If medications are prescribed, administer first, and
8. Pour feeding into syringe.                         then proceed with feeding. If another type of
                                                      container is used for feeding solution, unclamp tubing
                                                      and allow to flow in by gravity.


9. Elevate syringe and unclamp tubing.                Syringe should be held six inches above level of
                                                      stomach, or at prescribed height.




                                                                                                              308
     GASTROSTOMY BUTTON FEEDING PROCEDURE - BOLUS METHOD (cont'd.)



10. Continue to pour feeding into syringe as           Depending on the age and capabilities of the child,
    contents empty into stomach.                       have him/her assist with the feeding by holding
                                                       syringe or pouring fluid into it. Keep syringe partially
11. Raise or lower syringe or container to adjust      filled to prevent air from entering stomach.
    flow to the prescribed rate.



                                                    ...BE ALERT TO ANY UNUSUAL
                                                    CHANGES IN THE CHILD’S TOLERANCE OF
                                                    THE FEEDING. NAUSEA/VOMITING, CRAMPING
                                                    OR DIARRHEA MAY INDICATE THAT THE
                                                    FEEDING IS BEING GIVEN TOO QU1CKLY OR
                                                    FORMULA IS TOO COLD...




                                                    This will clear button of feeding and medication.
12. Flush button with water, if ordered.


13. When feeding is complete, remove the            Wash catheter-tipped syringe, and tubing with
    adaptor with feeding syringe.                   warm water and mild soap and store in clean
                                                    area.

14. Close safety plug.


15. Wash hands.


16. Refer to child-specific guidelines regarding
    activity after feeding.




                                                                                                            309
    PROCEDURE FOR GASTROSTOMY FEEDING - BOLUS METHOD B.


PROCEDURE                                          POINTS TO REMEMBER
1. Wash hands.
2. Assemble
   equipment:




   Liquid feeding solution/formula at room         Some children get cramps if the feeding solution
    temperature                                     is too cold.
   60 ml or cc catheter-tipped syringe or other
    container for feeding
   Clamp or cap for end of tube (optiona1)
   Water (if prescribed)                           Used to flush tubing after feeding.
   Rubber bands and safety pins                    To secure G-tube to clothing.
                                                    By encouraging the child to assist in the procedure,
3. Explain the procedure to the child at            the care-giver is helping the child to achieve
   his/her level of understanding.                  maximum self-care skills.
   Encourage the student to participate as
   much as possible.                                Child may be sitting or lying on right side with head
                                                    elevated at a thirty degree angle. When positioning
4. Position child.                                  child, make sure clamp is not pressing on skin.
                                                    Tubing may be pinned to shirt. Remember to unpin
5. Remove cap or plug from G-tube and insert        G-tube before proceeding with feeding.
   a catheter-tipped syringe into the end of        G-tube is still clamped. Do not apply undue traction
   feeding tube.                                    or pull on gastrostomy tubing.

6. Unclamp the tubing and gently draw back on     Some children may not need to have residuals checked.
   the plunger to remove any liquid or medication
                                                  Note the amount that was withdrawn from the feeding
   that may be left in the stomach (residuals).
                                                  tube and return the contents to the stomach (if
7. Clamp the gastrostomy tubing, disconnect the ordered). Adjust the feeding volume according to
   syringe and remove plunger from syringe.       doctor’s orders if a residual is present. If the residual
                                                  is greater than recommended, hold feeding, wait thirty
8. Reinsert catheter tip of syringe into tubing.  to forty-five minutes and re-check.

9. Unclamp tube, allow bubbles to escape.
                                                   Syringe should be held six inches above level of
                                                   stomach, or at prescribed height.




                                                                                                       310
     PROCEDURE FOR GASTROSTOMY FEEDING - BOLUS METHOD (cont‟d.)
                                                     If medications are prescribed, administer first, and
 10. Pour feeding/fluid into syringe and
                                                     then proceed with feeding. If a container other than a
     allow to flow in by gravity
                                                     syringe is used for the feeding, unclamp tubing and
                                                     allow to flow in by gravity, following the same
                                                     procedure.

                                                     ...BE ALERT TO ANY UNUSUAL
                                                     CHANGES IN THE CHILD'S TOLERANCE OF
                                                     THE FEEDING. NAUSEA/VOMITING,
                                                     CRAMPING OR DIARRHEA MAY INDICATE
                                                     THAT THE FEEDING IS BEING GIVEN TOO
                                                     QUICKLY OR FORMULA IS TOO COLD...




                                                     Depending on the age and capabilities of the
11. Continue to pour feeding into syringe            child, have him/her assist with the feeding by
    as contents empty into stomach.                  holding syringe or pouring fluid into it. Keep
                                                     syringe partially filled to prevent air from entering
12. Raise or lower syringe or container to adjust    stomach.
    flow to prescribed rate.
                                                     This will clear tubing of feeding and
13. When feeding is completed, pour prescribed       medication.
    amount of water into syringe and flush tubing.
14. Vent G-tube if ordered. (Open G-tube to air.)    Venting allows drainage of fluid or release of
                                                     gas bubbles in the stomach. Some children may
15. Clamp tubing; remove barrel of syringe           have problems with gas otherwise.
    and reinsert cap into end of tubing.




16. Make sure tubing is secure and tucked
    inside clothing.                                 Tubing may be pinned to shirt.

17. Refer to child-specific guidelines regarding
    activity after feeding.
18. Apply dressing if needed, using universal
    precautions. (See page 17.)

19. Wash syringe and other reusable equipment
    in soapy water. Store in a clean area.

20. Wash hands.
21. Document feeding/medication, residual              Report to parent any change in the child’s usual
    amount and feeding tolerance on log sheet.         pattern.

                                                                                                             311
                       GASTROSTOMY FEEDING BUTTON - C



PURPOSE

The gastrostomy is surgical opening into the stomach through the surface of the abdomen. The
gastrostomy feeding button is a “T” shaped plastic device held in place by a mushroom-shaped dome
inside the stomach. The button remains in place at all times and is capped by an attached safety plug
between feedings. In addition, the dome has an anti-reflux valve to further prevent leakage of stomach
contents. A feeding is administered by inserting a small tube through the button into the stomach. When
the feeding is completed the tube is removed and the safety plug closed. The gastrostomy may be used to
administer food and fluids directly into the stomach. This method is used to bypass the usual route of
feeding by mouth when:
   There is an obstruction of the esophagus (food pipe).
   Swallowing is impaired and the child is at risk for choking/aspiration.
   The child has difficulty taking enough food by mouth to maintain adequate nutrition.
A child may receive a gastrostomy button feeding by either bolus, continuous or slow-drip method. A bolus
is a specific amount of feeding given at one time (over 20-30 minutes). A slow drip is a feeding that is given
slowly over a number of hours, running continuously.
The gastrostorny button may also be used to drain abdominal contents or to release air or gas in conditions
where venting is required. This is done by inserting a special adaptor or tube to open the anti-reflux valve.


SUGGESTED SETTINGS
There are no restrictions where the child may be
fed. He or she may be fed with other children or, if
the child prefers, in the health room. Some
children receive feedings every 2-3 hours. These                                    Anti-Reflex Valve:
children may have their feeding administered in                                     Open Closed
                                                                             I,
the classroom. They will need to remain stationary                                                         Abdominal
and should be able to continue sedentary school                                                            Wall
activities, e.g., reading, art, singing, computer,
                                                                                                           Safety Plug In
social studies.                                                                                            I Opening

Some children will not require feedings during the
school hours. Their buttons are used to supplement                                                             Stomach
oral intake of food and fluids or are used when the                                                              Wall
child is ill or when oral in-take is not adequate.

For children whose gastrostomy button requires
venting or drainage, the procedures should be done
in the health room or another private area. These
procedures may be done after each feeding or
according to physician‟s orders.

Gastrostomy buttons are usually covered by
clothing. Children with these devices should be
able to participate in all school activities, but
participation in physical education should be
determined on an individual basis.


                                                                                                         312
                                   GASTROSTOMY TUBE – D.

   PURPOSE
   A gastrostomy is a surgical opening into the stomach through the surface of the abdomen.
   The gastrostomy tube is a flexible rubber catheter held in place by a balloon or a widened flat
   ”mushroom” at the tip of the tube inside the stomach. The tube remains in place at all times and is
   clamped between feedings to prevent leakage of stomach contents. G-tubes cause no discomfort.
   The gastrostomy tube may be used to administer food and f1uids directly into the stomach. This
   method is used to bypass the usual route of feeding by mouth when:
      There is an obstruction of the esophagus (food pipe).
      Swallowing is impaired and the child is at risk for choking/aspiration.
      The child has difficulty taking enough food by mouth to maintain adequate nutrition.

       A child may receive a gastrostomy tube
       feeding by either bolus, continuous or
       slow-drip method. A bolus is a specific
       amount of feeding given at one time
       (over 20-30 minutes). A slow drip is a
       feeding that is given slowly over a
       number of hours, running continuously.

       The gastrostomy tube may also be used to drain
       abdominal contents or to release air or gas in
       conditions where venting is required.




SUGGESTED SETTINGS
There are no restrictions where the child may be fed. He or she may be fed with other children
or if the child prefers, in the health room. Some children receive feedings every 2-3 hours. These children may
have their feeding administered in the classroom. They will need to remain stationary and should be able to
continue sedentary school activities, e.g., reading, art, singing, computer, social studies.

Some children will not require feedings during the school hours. Their G-tubes are used to supplement ora1
intake of food and fluids or are used when the child is ill or when ora1 intake is not adequate.

For children whose gastrostomy tube requires venting or drainage, the procedures should be done in the health
room or another private area. These procedures may be done after each feeding or according to physician's
orders.

Gastrostomy tubes are usually covered by clothing. Children with G-tubes should be able to participate in all
school activities, but participation in physical education should be determined on an individual basis.
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5)   GLUCOSE MONITORING
     DEFINITION
     Glucose is a simple sugar found in certain foods and is a major source of energy for
     humans.
     The determination of glucose levels is important diagnostic test in diabetes and other
     disorders.
     POLICY
     Head Start staff will assist children needing glucose monitoring in the centers. Training
     will be provided by the primary care giver, Health Staff and/or Nurse Practitioners when
     indicated.
     PROCEDURE
     1)     Finger-sticks for blood glucose will adhere to the finger-sticks for anemia unless
            specifically prescribed differently by a physician.
     2)     Head Start Staff will use the glucose machine per direction of the manufacturer
            and parent demonstration of correct usage of the machine.
     3)     Glucose strips will be purchased by Parents unless assistance is requested in
            writing by the parents.
     4)     Glucose guidelines (hypo/hyperglycemia) will be adhered to by the protocol
            written by the health care provider.
     5)     Special training will be held for all involved staff.
     6)     EMS procedures will be discussed with parents and staff concerning child‟s
            potential need.
6)   TRACHEA RE-INSERTION
     Tracheotomy is an incision made into the trachea through the neck below the larynx,
     performed to gain access to the airway below a blockage or edema of the glottis.
     Tracheotomy tube is a curved hollow tube inserted in the trachea to relieve breathing
     obstruction.
     POLICY
     Head Start staff will assist children needing emergency reinsertion of the tracheotomy
     tube in the centers. Training will be provided by the primary care giver, Health Staff
     and/or Nurse Practitioners when indicated.
     1)     Tracheotomy insertion can only be done by staff with current training.
     2)     Re-insertion should only be done in an emergency situation.
     3)     Procedures for re-insertion will be adhered to per protocol of primary health care
            provider.

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     POLICY (cont‟d.)
     4)     An extra tracheotomy tube with an obturator should be available at the center at
            all times.
     5)     If a problem develops with re-insertion, EMS should be called immediately.
7)   EPI-PEN/EPI-PEN JR. AUTO INJECTOR
     DEFINTION
     The Epi-Pen Auto Injector is a single dose disposable drug delivery system featuring
     spring activation and a concealed needle. It is designed for the self-administration of
     epinephrine in acute allergic emergencies.
     The Epi-Pen is commonly prescribed for individuals who are anaphylactic – that is, who
     have prior severe allergic reactions or those who may be at high risk (e.g. a family
     history of severe reactions or a highly allergic individual). These reactions can be
     caused by a number of things: certain foods (nuts, eggs, shellfish), food additives, drugs
     (penicillin), stings from insects (bees, wasps, ants, etc.), or a reaction from exercising or
     items containing latex (balloons, elastic, etc). An allergic reaction to any of these may
     be so severe that it can be life threatening. An emergency injection of Epi-Pen can help
     stabilize the person until the ambulance arrives, or until you can reach the emergency
     room for follow-up. The effects of the Epi-Pen begin to wear off after 10-20 minutes;
     therefore it is important for the child to seek further assistance (ER or call 911).
     HEAD START POLICY
     Head Start staff will assist children needing emergency administration of the Epi-Pen for
     an allergic reaction in the centers. The primary care giver, Health staff and/or Nurse
     Practitioner, when indicated will provide training.
     PROCEDURE
     1)     Head start staff will adhere to the procedures for Special procedures.
     2)     Head Start staff will use the auto injector per direction of the manufacture.
     3)     Training will be provided per parent and Health Staff.
     The following steps are generic for administration of the Epi-Pen.
     a) Form a fist around the auto-injector with the black tip facing down.
     b) Pull off the gray safety cap (do not remove the gray cap until ready to use the auto
        injector).
     c) Don‟t put your fingers over the black tip when removing the safety cap.
     d) Once the safety cap is removed, the auto injector is ready for use and can be
        activated.
     e) Place the black tip against the outer thigh (not necessary to remove clothing)
     f) With a quick motion, push the auto-injector firmly against the thigh. This will
        release a spring-activated mechanism that will inject a dose of epinephrine.
     g) Hold the auto injector in-place for a few seconds after activation.


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PROCEDURE (cont‟d.)
h) Remove the auto injector from the thigh and have available for the ambulance tech/
   or ER physician for proper disposal.
i) Carefully re-insert the injector in the plastic unit without touching the tip or
   replacing the safety cap.




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