2017 School Nurse Conference booklet

7. Hartman AL, Devore CDL, AAP and the SECTION ON NEUROLOGY, et al.
Rescue medicine for epilepsy in education settings. Pediatrics.
2016;137(1):e20153876.
This clinical report highlights issues that providers may consider when
prescribing seizure rescue medications and creating school medical orders
and/or action plans for students with epilepsy. Collaboration among
prescribing providers, families, and schools may be useful in developing plans
for the use of seizure rescue medications.

8. Galemore CA. Rescue medicine for epilepsy. NASN Sch Nurse. 2016:339-
341.
The American Academy of Pediatrics (AAP) recently published a clinical report
recommending expanded options for seizure rescue medications in the school
setting. School nurses can assist health care providers in determining the
rescue medication most easily delivered and monitored in the variety of
activities that are part of the school experience, including transportation to
and from school, field trips, and before- and after-school activities, all
beyond the regular classroom setting.

9. Mula M. The safety and tolerability of intranasal midazolam in
epilepsy. Expert Rev Neurother. 2014;14(7):735-740.
This article aims to provide an overview of intranasal midazolam in the acute
management of epileptic seizures. . . . Local mucosal irritation seems to
occur in less than one-third of cases while serious side effects such as
respiratory depression in about one percent. . . . Moreover, comparisons with
buccal midazolam are warranted.

10. Kalviainen R. Intranasal therapies for acute seizures. Epilepsy Behav.
2015;49:303-306.
Intranasal midazolam (INM) is faster at aborting seizure activity than rectal
diazepam and quicker to administer than intravenous diazepam. . . . [INM’s]
shorter elimination half-life may also be beneficial in that patients may more
quickly return to normal function because of rapid offset of effect. On the
other hand, the faster rate of elimination of midazolam may expose patients
to a higher rate of seizure recurrence compared to diazepam.

11. Humphries LK, Eiland LS. Treatment of acute seizures: Is instranasal
midazolam a viable option? J Pediatr Pharmacol Ther. 2013;18(2):79-87.
This paper will review available data pertaining to the efficacy, safety, cost,
pharmacokinetics of intranasal midazolam versus rectal diazepam as
treatment for acute seizures for children in the prehospital, home, and
emergency department settings.

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12. Holsti M, Dudley N, Schunk J, et al. Intranasal midazolam vs rectal
diazepam for the home treatment of acute seizures in pediatric
patients with epilepsy. Arch Pediatr Adolesc Med. 2010;164(8):747-753.
There was no detectable difference in efficacy between intranasal midazolam
via a Mucosal Atomization Device (IN-MMAD) and rectal diazepam (RD) as a
rescue medication for terminating seizures at home in pediatric patients with
epilepsy. Ease of administration and overall satisfaction was higher in IN-
MMAD compared with RD.

13. Kyrkou M, Harbord M, Kyrkou N, et al. Community use of intranasal
midazolam for managing prolonged seizures. J Intellect Dev Disabil.
2006;31(3):131-138.
Following a literature review, a seizure management training package was
developed to enhance the implementation of a trial treatment protocol for
the administration of intranasal midazolam (INM). Parents, [caregivers], and
education staff were later surveyed about their experiences and perceptions.
INM was administered to 131 people (51 children and 80 adults), with 96.9
percent control of seizures, and only one minor adverse event.

Training/Continuing Education

Presentations
• American Academy of Pediatrics: Rescue Medication and Seizure
Emergency Planning in Education Settings 4
• Neurocritical Care Society: Guidelines for the Evaluation and
Management Status Epilepticus 5

Continuing Education
• Epilepsy Update Part 2: Nursing Care and Evidence-Based Treatment—
Includes Resources, First Aid, and Teaching Points (2.5 hours) 6
• Epilepsy Foundation: Managing Students with Seizures: A Training for
School Nurses (3.2 hours) 7

Tools and Resources

General Guidance
ü American Academy of Pediatrics: School Nurse Poster 8
ü Seattle Children’s Hospital: How to Use Nasal Midazolam (hand-out
with photos) 9
ü New Hampshire Family Voices: Seizure Description Tool—Available
in English and five other languages 10
ü Epilepsy Foundation: Seizure Observation Record; Questionnaire for
Parent of Student with Epilepsy 11

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52

ü Children’s Hospital Colorado: Training, Delegation Authorization and
Supervision Record – Intranasal Midazolam (copyrighted) 12

ü Pediatric Neurology Nurse Video: Administration of Intranasal
Midazolam 13

ü National Association of School Nurses: Medication Administration in
the School Setting; Anti-Epileptic Drugs (AEDs) 14

ü Grapevine-Colleyville ISD School Health Services: Intranasal
Midazolam (Versed) Administration Guidelines with Consent and
Release 15

ü Michigan School Nurse Advisory Council: Guidance Document for
Michigan Schools—Midazolam (Versed) Intranasal Administration in
the School Setting 16

Tools to Personalize
ü New Hampshire Family Voices: Seizure Action Plan 17
ü Nevada (Clark County): Sample Policy and Administration Procedure 18

References

For assistance in obtaining any resources, please contact the DSHS Library
at [email protected] and mention inclusion of the requested resource
in the School Nurse Notes.

1. Facts & Comparisons® eAnswers (complete monograph).
http://online.factsandcomparisons.com/PrintMonoDisp.aspx?id=.
(Accessed on 10/20/16)

2. Facts & Comparisons® eAnswers (off-label use).
http://online.factsandcomparison.com/printsection.aspx?id=fandc-
hcp12786&section=indications. (Accessed on 10/20/16)

3. Facts & Comparisons® eAnswers (Reference list for off-label use).
http://online.factsandcomparisons.com/printsection.aspx?id=fandc-
hcp12786&section=bibliography. (Accessed on 10/20/16)

4. Doerrer S. Rescue medication and seizure emergency planning in
education settings.
http://pediatriccare.solutions.aap.org/MultimediaPlayer.aspx?multimediai
d=13298281#ooid=o2ZWMzNTE6kC9qlEGZ4fm_oY-XKU-MRM. (Accessed
on 11/16/16)

5. Brophy, et al. Guidelines for the evaluation and management status
epilepticus. Neurocritical Care (NCC). 2012;17:3-23.

6. Smith G, Wagner JL, Edwards JC. Epilepsy update part 2: Nursing care
and evidence-based treatment. Am J Nurs. 2015;115(6):34-44.

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53

7. Epilepsy Foundation. Managing students with seizures: School nurse
training program.
http://www.epilepsy.com/get-help/services-and-support/training-
programs/managing-students-seizures-school-nurse-training. (Accessed
on 11/16/16)

8. American Academy of Pediatrics. School Nurse Poster.
https://www.aap.org/en-us/Documents/school_nurse_poster_final.pdf.
(Accessed on 10/20/16)

9. Seattle Children’s Hospital. How to Use Nasal Midazolam.
http://nhfv.org/wp-content/uploads/2015/04/Midazolam-Training-
Seattle.pdf. (Accessed on 11/29/16)

10. New Hampshire Family Voices. Seizure Description Tool.
http://nhfv.org/projectsinitiatives/facets-of-epilepsy/epilepsy-resources-
for-parents-and-caregivers/. (Accessed on 11/28/16)

11. Epilepsy Foundation. Seizure Observation Record; Questionnaire for
Parent of Student with Epilepsy. http://nhfv.org/wp-
content/uploads/2015/04/Sz-observation-record.pdf;
http://nhfv.org/wp-content/uploads/2015/04/Questionnaire-for-Parent-
of-Student-with-Sz.pdf. (Accessed on 11/29/16)

12. Children’s Hospital Colorado. Training, Delegation Authorization and
Supervision Record – Intranasal Midazolam. 2015.
https://www.cde.state.co.us/healthandwellness/intranasalmidazolam.
(Accessed on 11/16/16)

13. Gaelic S. Administration of Intranasal Midazolam. https://youtu.be/g-

43N5X75XU. (Accessed on 11/16/16)

14. National Association of School Nurses. Medication Administration in the
School Setting; Anti-Epileptic Drugs (AEDs).
https://www.nasn.org/PolicyAdvocacy/PositionPapersandReports/NASNPo
sitionStatementsFullView/tabid/462/ArticleId/86/Medication-
Administration-in-the-School-Setting-Amended-January-2012;
http://portal.nasn.org/text/6905_W30_1_001-006.pdf. (Accessed on
11/16/16)

15. Grapevine-Colleyville ISD School Health Services. Intranasal Midazolam
(Versed) Administration Guidelines with Consent and Release.
http://www.gcisd-
k12.org/cms/lib4/TX01000829/Centricity/Domain/66/AR%20Intranasel%
20Midazolam.pdf. (Accessed on 11/16/16)

16. Michigan School Nurse Advisory Council. Guidance Document for
Michigan Schools—Midazolam (Versed) Intranasal Administration in the
School Setting. http://nursingnetwork-
groupdata.s3.amazonaws.com/NASN/Michigan_ASN/file/Resources/Guida
nce_for_MI_Schools_Utilization_of_Versed.pdf. (Accessed on 11/16/16)

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54

17. New Hampshire Family Voices. Seizure Action Plan. http://nhfv.org/wp-
content/uploads/2015/04/SeizureActionPlan.pdf. (Accessed on 11/16/16)

18. Nevada (Clark County). Sample Policy and Administration Procedure.
http://shoms.ccsd.net/files/ppt/versedpolicy.pdf. (Accessed on
11/16/16)

External links to other sites appearing here are intended to be informational and do not represent
an endorsement by the DSHS. These sites may also not be accessible to people with disabilities.
External email links are provided to you as a courtesy. Please be advised that you are not
emailing the DSHS and DSHS policies do not apply should you choose to correspond. For
information about any of the initiatives listed, contact the sponsoring organization directly.
Copyright free. Permission granted to forward or make copies in its entirety as needed.

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55

DSHS-School Nurse Notes | May 2017
Wound Care

To address the needs of school nurses, the Texas Department of State Health Services
(DSHS)–School Health Program has developed this repository of information. With each
issue of DSHS-School Nurse Notes, professionals receive the latest research, evidence-
based practices, and resources in school nursing related to a topic of interest. If you have
any questions or comments about this publication, please contact Anita Wheeler, School
Nurse Consultant, at (512) 776-2909 or at [email protected].

Background
The Skin Healing Process

For most children, wound healing is quick, uncomplicated, and requires
minimal specialized attention. 9 A series of physiological events begins once
skin has been broken. 5 The complex, dynamic process of wound healing
unfolds in its four basic phases. 9

Coagulation & Hemostasis: The body attempts to control bleeding and
prevent any bacteria from entering the wound.

Inflammation: Anti-bacterial and anti-inflammatory receptors are released;
a clot forms and the process of phagocytosis begins. 5

Proliferation & Repair: This marks the beginning of dermis restoration and
occurs within five days of injury. New blood vessels form, the wound
contracts, granular tissue develops, and re-epithelialization begins. 5

Wound Maturation & Remodeling: Collagen fibers work to repair the scar
tissue; however, it will never achieve its original tensile strength. This final
phase may continue for years. 5

Chronically ill children, such as those with poor nutritional status, frequent
hospitalization, immune compromise, or neurodevelopmental delays, are
predisposed to poor wound healing and iatrogenic skin injury. 9

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56

Research

The following articles have been compiled from a review of the scientific
literature. For assistance in obtaining an article, please contact the DSHS
Library at [email protected] and mention inclusion of the requested
article in the DSHS-School Nurse Notes. The articles are presented on a
continuum, ranging from those that primarily address wound care
procedures to those that focus on wound healing products. Following each
citation is a portion of the article’s abstract.

1. McGrath JA, Uitto J. Chapter 2: Structure and function of the skin. In
Griffiths CE, Creamer D, Barker J, et al. 9th ed. Rook’s textbook of
dermatology. John Wiley & Sons Ltd; 2016.
A detailed appreciation of the development, structure and function of human
skin is fundamental to understanding diseases that originate in or target the
skin. Recent advances in molecular science have provided fascinating new
insights into stem cell biology and skin homeostasis as well as disease
processes such as inflammation, wound healing, ageing and neoplasia,
providing novel opportunities to improve the diagnosis and therapy of skin
disease.

2. Proksch E, Brandner JM, Jensen JM. The skin: an indispensable barrier.
Exp Dermatol. 2008;17:1063-1072.
The skin forms an effective barrier between the organism and the
environment preventing invasion of pathogens and fending off chemical and
physical assaults, as well as the unregulated loss of water and solutes. In this
review we provide an overview of several components of the physical barrier,
explaining how barrier function is regulated and altered in dermatoses. . . .
Changes in epidermal differentiation and lipid composition lead to a disturbed
skin barrier, which allows the entry of environmental allergens,
immunological reaction and inflammation in atopic dermatitis. A disturbed
skin barrier is important for the pathogenesis of contact dermatitis,
ichthyosis, psoriasis and atopic dermatitis.

3. Gloster AS, Johnson PJ. How to perform first aid. Nurs Stand.
2016;30(20):36-39.
This article aims to help nurses to perform first aid in a safe, effective and
patient-centered manner. First aid comprises a series of simple, potentially
life-saving steps that an individual can perform with minimal equipment. . . .
First aid is the provision of immediate medical assistance to an ill or injured
person until definitive medical treatment can be accessed. . . . it is essential
that nurses understand the basic principles.

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57

4. Greener, M. Wound care: Treating small wounds in the school setting.
British Journal of School Nursing. 2016;11(8):376-378.
School nurses can manage most minor cuts, scrapes and puncture wounds.
However, the amount of bleeding is a poor guide to severity. Because an
everyday injury occasionally hides serious damage, such as internal bleeding,
nurses should take even seemingly minor cuts and scrapes seriously. In
addition to acute wound care, knowing when to refer to accident and
emergency services and GP practices, as well as advising parents and older
children are essential elements of management.

5. Chau EA. Managing minor wounds. NASN Sch Nurse. 2012;27(5):238-
239.
This brief article describes the importance of skin as our largest organ and
addresses the topics of wound assessment and wound categories. The school
nurse is advised of what kinds of questions to ask students presenting with
an open wound and how to document care. The article also describes the
physiological events that comprise wound healing, how to cleanse a wound,
the effective dressings, and when to consider using each type.

6. Calianno C. How to choose the right treatment and dressing for the
wound. Med/Surg Insider. 2003;6-15.
Identifying the cause of your patient’s wound, initiating the right
interventions, and achieving your wound care goals can be very rewarding—
and challenging. You’re faced with more than 1,000 wound care products and
interventions, with new ones becoming available daily (see Commonly Used
Wound Dressings). . . . In this article, I’ll review basic wound types and how
to manage them with the latest treatment options.

7. Forrest RD. Early history of wound treatment. J R Soc Med.
1982;75:198-205.
Wounds cause pain, bleeding, disability and death. . . . The history of surgery
has been the history of wound therapy during the last four or five millennia
and, despite the causes of the injury generally being obvious and the wound
easily observed, it is only in the last two to three decades that the process
occurring in the wound and the factors influencing them have been
understood. The aim of wound treatment has always been to reduce the risks
caused by the wound itself and to minimize potential complications. Pain,
hemorrhage, loss of skin continuity and tissue substance in a wound have
tested man’s ingenuity throughout the ages.

8. Chang PH, Swan-Mahony A. The ABCs of burn care for school-age
children. NASN Sch Nurse. 2016;31(6):364-367.
Burn injuries are among the most painful injuries any child can endure. This
article explains common sources of burn injuries in student populations,
diagnosis and classification of burn injuries, initial burn management, and
how to determine when a child needs to be evaluated by a physician.

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58

9. King A, Stellar JJ, Blevins A, Shah KN. Dressings and products in
pediatric wound care. Adv Wound Care. 2014;3(4):324-334.
Advances in the understanding of the pathophysiology of wound healing have
contributed to an ever-increasing number of specialized wound care
products, most of which are predominantly marketed to adult patients and
that have not been evaluated for safety and efficacy in the neonatal and
pediatric populations. This review aims to discuss the available data on the
use of both more traditional wound care products and newer wound care
technologies in these populations, including medical-grade honey,
nanocrystalline silver, and soft silicone-based adhesive technology.
(Explanatory graphics are included.)

10. Murphy PS, Evans GR. Advances in wound healing: A review of current
wound healing products. Plast Surg Int. 2012;2012:190436.
Successful wound care involves optimizing patient local and systemic
conditions in conjunction with an ideal wound healing environment. Many
different products have been developed to influence this wound environment
to provide a pathogen-free, protected, and moist area for healing to occur.
Newer products are currently being used to replace or augment various
substrates in the wound healing cascade. This review of the current state of
the art in wound-healing products looks at the latest applications of silver in
microbial prophylaxis and treatment, including issues involving resistance
and side effects, the latest uses of negative pressure wound devices,
advanced dressings and skin substitutes, biologic wound products including
growth factor applications, and hyperbaric oxygen as an adjunct in wound
healing.

11. Rippon MG, Ousey K, Cutting KF. Wound healing and hyper-hydration: a
counterintuitive model. J Wound Care. 2016;25(2):68-75.
Winter’s seminal work in the 1960s relating to providing an optimal level of
moisture to aid wound healing (granulation and re-epithelialization) has been
the single most effective advance in wound care over many decades. As such
the development of advanced wound dressings that manage the fluidic
wound environment have provided significant benefits in terms of healing to
both patient and clinician. Although moist wound healing provides the
guiding management principle, confusion may arise between what is deemed
to be an adequate level of tissue hydration and the risk of developing
maceration. . . . This paper discusses tissue hydration, the cause and effect
of maceration and distinguishes these from hyper-hydration of tissue.

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59

12. Eberlein T, Gerke P, Lorenz H, Ammer R. Advantages in wound healing
by a topical easy to use wound healing lipo-gel for abrasive wounds—
Evidence from a randomized, controlled experimental clinical study.
Wound Medicine. 2016;15:11-19.
Objective: Study’s purpose was to compare wound healing properties of
topical healing agent (Medigel®) (moist environment) versus standard
plaster (dry environment) versus well-established standard Bepanthen®
Wund- und Heilsalbe. Methods: Healthy volunteers were enrolled into an
observer-blind, randomized, controlled, intra-individual experimental
comparison study. Three standardized abrasions were induced on each
subject’s forearms. . . . Results: Evaluation showed significantly faster wound
healing results (**relative differences to baseline) for investigational product
vs. standard plaster (all time points) and with significant AUC difference and
slightly faster results vs. reference product (day 5 to 10). . . . Conclusion:
Clinically relevant accelerated wound healing and reduced wound contraction
were measured for investigational product compared to traditional treatment
indicating a superiority of moist wound environment.

13. Sibbald RG, Elliott JA. The role of Inadine in wound care: a consensus
document. Int Wound J. 2017;14:316-321.
Iodine-based products are anti-bacterial. The small iodine molecular size is
ideally suited to treat surface critical colonization. Inadine is a 10 percent
povidone iodine dressing with the equivalent of 1 percent available iodine
that is easily extracted from the viscose backing by serum or exudate. . . . In
this study, we developed a short online survey completed by 23 wound-care
key opinion leaders from the nursing, medical and podiatry professions. A
computerized modified Delphi technique was used to achieve 80 percent
consensus on 11 statements related to the utility and everyday topical
wound-care use of this product.

14. Dissemond J, Assadian O, Gerber V, et al. Classification of wounds at
risk and their antimicrobial treatment with polihexanide: A practice-
oriented expert recommendation. Skin Pharmacol Physiol. 2011;24:245-
255.
Currently there are no generally accepted definitions for wounds at risk of
infection. In clinical practice, too many chronic wounds are regarded as being
at risk of infection, and therefore many antimicrobials – in terms of
frequency and duration of use – are applied to wounds. Based on expert
discussion and current knowledge, a clinical assessment score was
developed. The objective of this wounds at risk (W.A.R.) score is to allow
decision-making on the indication for the use of antiseptics on the basis of
polihexanide. . . . The indication for the use of antiseptics results from the
addition of differently weighted risk causes, for which points are assigned.
Antimicrobial treatment is justified in the case of three or more points.

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15. Dissemond J, Gerber V, Kramer A, et al. A practice-oriented
recommendation for treatment of critically colonized and locally
infected wounds using polihexanide. J Tissue Viability. 2010;19:106-
115.
The problem of wound infection presents a special challenge in the treatment
of acute as well as chronic wounds. Typical complications not only jeopardize
the successful outcome of treatment modalities as a whole; they may result
in amputation or even become life-threatening. Polihexanide is an
antimicrobial substance, which is highly appropriate for use in critically
colonized or infected acute and chronic wounds. This finding is based
primarily on the broad antimicrobial spectrum and good cell and tissue
compatibility of polihexanide, its capability of binding to organic matrix, the
low risk of contact sensitization, and the fact that it promotes wound healing.
Up to now there are no microbial resistances observed.

16. Rollins H, Nathwani N, Morrison D. Optimizing wound care in a child
with an infected gastronomy exit site. Br J Nurs. 2013;22(22):1272-
1279.
The percutaneous endoscopic gastrostomy (PEG) tube has become a widely
used feeding tube for long-term delivery of fluids, liquid feed and medicines.
. . . In pediatric practice, children experience care shared across several
healthcare settings, meeting clinical teams with varying levels of knowledge
and experience of PEG care. This can lead to conflicting advice, which can
have a negative effect on patient safety and experience. The case history in
this article demonstrates how PEG tube insertion is never a minor procedure
for a child and family . . . . It highlights areas of potential conflict in clinical
management of PEG exit sites, and it shows how application of wound care
principles, along with a range of modern products can have a positive
outcome.

Resources

Materials
ü American Red Cross - Participant Materials: Digital class materials may
be downloaded free of charge.
• Pediatric First Aid/CPR/AED Ready Reference
• Wilderness and Remote First Aid Pocket Guide
• Babysitter’s Training Emergency Reference Guide
• Bloodborne Pathogens Training Fact and Skill Sheets

Organizations that Provide Training for a Fee
ü American Red Cross: Courses available in classrooms and online.
• First Aid/CPR/AED

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61

• First Aid, Health and Safety for Coaches
• Anaphylaxis and Epinephrine
ü National Safety Council: Courses available onsite and online.
• Bloodborne Pathogens Training
• Advanced Pediatric First Aid, CPR & AED
ü American Heart Association:
• Pediatric Advanced Life Support (PALS) course
• Pediatric Advanced Emergency Assessment, Recognition and

Stabilization (PEARS)® course
ü International Society for Pediatric Wound Care (ISPeW):

Membership fee is required to access medical articles.
ü Pharmaceutical Society of Australia: ACTION kit – Wound care.

Membership as a pharmacist is required to view these supplementary
materials.

External links to other sites appearing here are intended to be informational and do not represent
an endorsement by the DSHS. These sites may also not be accessible to people with disabilities.
External email links are provided to you as a courtesy. Please be advised that you are not
emailing the DSHS, and DSHS policies do not apply should you choose to correspond. For
information about any of the initiatives listed, contact the sponsoring organization directly.
Copyright free. Permission granted to forward or make copies in its entirety as needed.

Page 7|7

62

upcoming training

SEPTEMBER

Vision Certification September 11, 2017 | #064766
Hearing Certification September 12, 2017 | #064768
Vision Certification September 25, 2017 | #064768
Hearing Certification September 26, 2017 | #064776

OCTOBER

School Health Expo October 9, 2017 | #064921
Nurse Networking Meeting October 11, 2017 | #064925

Vision Certification October 16, 2017 | #064770
Hearing Certification October 17, 2017 | #064778
Spinal/Scoliosis Screening October 18, 2017 | #064794
V&H Recertification October 20, 2017 | #064785

NOVEMBER

Healthcare Provider CPR November 6, 2017 | #067093

DECEMBER

V&H Certification December 4, 2017 | #064787
Heartsaver CPR / First Aid December 8, 2017 | #067099

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sponsors / donations

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DESIGNS CREATED & PRINTED BY

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