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health is directly related to his or her ability to learn 2 Students. need to focus on educational tasks they may be impaired by un. Pause and Ponder, met medical needs And children cannot learn if they aren t in How many children who. school so missing school due to chronic or acute illnesses affects receive inhalers at my. learning In each of these areas chronic and acute pharma pharmacy must take them. cists can work with school staff parents guardians and affected to school What barriers. youths to improve their understanding of childhood diseases may exist at school and. and the medications needed to treat them what suggestions can. you make to assist them,RANGE OF DIAGNOSES A CHALLENGE. Many of today s school aged children have chronic health condi. tions Each comes with its own challenges regarding school day. medication administration, Asthma affects 9 of school children requiring children to have. rescue inhalers available at school 3 Expert Panel Report 3 clini. cal practice guidelines the gold standard of asthma treat. ment advise a step wise approach to symptom management in. children 5 to 11 years of age It recommends an inhaled short Can Stock Photo davizro. acting beta2 agonist SABA on an as needed basis as first line. treatment 4 School aged children must have a SABA available at. all times but this presents challenges Proper inhaler use keeps children healthy and out of the hospi. tal Studies show that 28 to 68 of patients do not use MDI or. Children and school personnel often fail to recognize symptoms powder inhalers correctly 5 Researchers have found that. requiring SABA administration Teachers and administrators healthcare providers are often unable to operate devices prop. must recognize symptoms such as coughing and wheezing and erly presenting a unique opportunity for pharmacists 5 Phar. know when to refer a child to the school nurse or another macists should emphasize the most frequent missed steps in. trained adult Also a responsible adult should counsel children MDI administration with children parents and school. on when to report to the nurse for shortness of breath Stu personnel5 6. dents autonomy in medication management such as carrying Shaking Vigorous shaking before each actuation ho. inhalers to self administer leads to fewer medication errors 1 A mogenizes medication clumps into a suspension. pharmacist can teach children to recognize symptoms and ad Priming The first actuation after prolonged storage. minister medication appropriately to help parents and school usually delivers a diminished dose patients should. districts decide whether to allow self medication on a case by waste 3 to 4 puffs in the air when they start a new de. case basis vice and after 14 days of non use,Exhalation Most common error Before actuation. Inhaled SABA come in various formulations Metered dose inhal patients should exhale as much as comfortably possi. ers MDI should be stored at controlled room temperature 20 ble away from the inhaler. 25 C in an upright position to maintain integrity of the Inhale and hold breath Slow deep breaths rather. propellant 5 When it comes to inhalers school nurses need to than rapid breaths prevent drug from adhering to the. know how many doses remain so they can contact back of the throat Spacers commonly used by chil. parents caregivers for a new device when necessary Previously dren increase the amount of medication inhaled ef. recommended techniques for analyzing MDI for remaining dos fectively Additionally after removing devices from the. es like floating it in water or testing to see if the inhaler still mouth patients should hold their breath for 10 sec. puffs are inaccurate and should not be recommended 5 Inte onds or as long as possible. grated dose counters help Only half of MDI marketed in the Wait time between doses Between puffs patients. United States US are equipped with dose counters 5 Pharmacy should breathe normally for one minute This allows. teams should suggest formulations with dose counters for the initial dose to open airways slightly so the second. school aged children If MDI with dose counters are unavailable dose can penetrate deeper into the lungs. or unaffordable teach patients to mark each dose on the inhaler. with a hash mark, UCONN You Asked for It Continuing Education September 2017 Page 2.
Attention Deficit Hyperactivity Disorder, Over the past 2 decades emotional and behavioral problems. including ADHD have increased in school age children Subse. quently more children need stimulant medication during the. school day 1 7 Long acting agents are preferable to short acting. because a student can take a single dose in the morning that Can Stock Photo TheNikon. lasts throughout the school day However not all children with. ADHD respond to long acting formulations alone as the formu. Table 1 Symptoms of ADHD Improved by Medi, lations require unique technology to release the drug over. time This allows for variations in the release and absorption of cation and Possible Side Effects of Stimulant Drugs8. the drug and therefore effectiveness 7 Some insurance formu. laries may exclude certain extended release formulations as Symptoms Showing. Possible Adverse Effects, well For this reason children may need additional medication Improvement. during the school day,Test taking ability Appetite suppression. This proves challenging as 50 of children taking ADHD medi. Concentration Irritability, cation experience adherence barriers at school 1 A study com.
paring medication errors in school aged children showed that Listening Tendency to cry. children with ADHD are less likely to remember to take their. medication than those with other illnesses 1 Missed doses are Note taking Anxiousness. common 12 1 of study participants reported missing a dose. once a week and 27 2 once a month Not surprisingly missed. youths with type 2 DM many require insulin therapy within a. doses in these children were most likely to cause concentration. few years of diagnosis 9 Initial insulin regimens entail injections. deficits 1 Schools need to monitor and remind children with AD. once to twice daily but with increased insulin resistance and. HD to take their medications, the need for tighter control additional meal time doses may be. needed 9 This is where school day administration may be re. ADHD symptoms are most likely to manifest while a child is at. school placing teachers and school nurses in good positions to. assess medication effectiveness 7 Symptoms that should show. Insulin s specific storage requirements can burden school nurs. improvement with treatment are shown in Table 1 These same. es it should be refrigerated 2 8 C until opened Once re. individuals are well placed to detect side effects Pharmacists moved from the fridge and opened a vial or pen is stable for 28. should counsel all caregivers including those at school to days 10 Pharmacists who recognize this dilemma should advise a. watch for the common adverse effects of stimulant medica parent to notify the school to stop using the current supply af. tions in Table 1 ter 28 days and send a replacement promptly Parents and. school personnel share the responsibility of monitoring insulin. Diabetes expiration dates Often children take such small doses of insu. Roughly 215 000 youths live with type 1 or 2 diabetes mellitus lin that insulin vials or pens may have significant content at. DM 3 Three quarters of all type 1 diabetes cases are diag their expiration date Disposal of needles and other hazardous. nosed in children younger than 18 9 Type 2 DM is also on the testing materials also challenges schools Parents provide con. rise among youths The Centers for Disease Control and Preven tainers to schools that need them for proper disposal 10. tion CDC projects that the prevalence of type 2 DM in those. younger than 20 will increase 2 3 per year and quadruple over The American Diabetes Association ADA advises parents to. the next 40 years 9 coordinate diabetes care for their child during the school day. actively Their Safe at School program suggests that children. Most common in children type 1 diabetes requires daily insulin speak with certified diabetes educators CDE to prepare them. injections Recent advances like the increased use of basal bo for what to expect at school 11 Community pharmacists can in. lus regimens has improved glycemic control in children with volve youth in their own care by counseling on what to do if. type 1 DM Parents child and other caregivers must collabo emergent situations arise at school While the ADA also sug. rate on diabetes related tasks 9 The FDA has only approved two gests that parents connect school nurses with a CDE they can. drugs for type 2 DM treatment in children metformin and insu also refer the nurse to their child s local pharmacist 11. lin While metformin controls hyperglycemia in about half of. UCONN You Asked for It Continuing Education September 2017 Page 3. As with inhalers clinicians need to determine each child s abili. ty to self administer insulin and level of supervision needed on. a case by case basis Pharmacists can bolster a child s capacity. with education Important steps to remind those who adminis. ter or supervise a child s insulin injections are10 12. Check the expiration date and never use beyond this. Examine the insulin before injecting to make sure the. product looks normal no clumps crystals discolor,Pause and Ponder. Use a new needle every time and perform an air, shot of at least 2 units to clear bubbles from the nee. Have I taken the time to ask,parents who pick up devices. Pinch and inject into the skin of a soft fatty area on the to treat anaphylaxis if they are. body rotate injection sites inject at a 90o angle aware of their school s policies. Hold the needle in for 10 seconds to prevent insulin Am I aware of those policies. Approximately 37 of children with Type 1 diabetes experience Can Stock Photo jirkaejc. disease related emergencies at school 13 Healthcare clinicians. must discuss symptoms of hypo and hyperglycemia with all. school personnel a child might encounter during the school. Abuse and Addiction, day Additionally these individuals should know how to admin.
Unfortunately prescription opioid abuse and addiction are. ister emergency agents 11, common among school aged children Among American teens. 1 in 4 23 report abusing or misusing a prescription drug at. Food Allergy least once in their lifetime 14 Misusing prescription opioids is. Eight percent of children have food allergies and allergies are. the most likely entry portal to opioid abuse in teens Prescrip. becoming increasingly common 3 14 Each classroom on average. tion opioids are the second most frequent illicit drug used. has two children with food allergies requiring appropriate pre. among adolescents and young adults second only to, cautions Of these individuals 25 experience their first ana. marijuana 16 Due to opioids high street cost and reduced pre. phylactic reaction at school 14 The American Academy of. scription availability youths may seek more accessible alterna. Asthma Allergy and Immunology AAAAI reports that eight. tives Consequently lifetime use of heroin for 12 to 17 year. foods cause the majority of allergic reactions cow s milk eggs. olds increased from 0 1 in 2013 to 0 8 in 2014 17, fish peanuts shellfish soy tree nuts and wheat 15 Many chil. dren consume breakfast lunch and snacks in schools so the. NASN supports making naloxone available in schools for acute. likelihood of a reaction is high and the need for injectable epi. overdose 2 14 This life saving medication can restore breathing. nephrine is obvious Consequently having properly trained in. to opioid overdose victims but only if administered quickly and. dividuals in schools to respond to life threatening anaphylaxis is. effectively Again schools need to train staff to administer. naloxone described later and pharmacists can provide that. While proper administration will be discussed later pharma. cists need to reinforce that parents and schools share the re. State naloxone laws differ Pharmacy staff can review state and. sponsibility of making emergency injectables available Carrying. local laws and policies and should recommend whenever possi. these medications back and forth to school daily is burden. ble that school districts add the drug to their emergency pre. some so students may need a supply for home and one for. paredness and response plan 18 Some insurers restrict coverage. school These devices often have short expiration dates too. to patients currently taking opioids while others will cover. Parents should make note of when a pen expires and school. naloxone for third parties such as concerned family or commu. nurses should be cognizant of any pen that expires before the. nity members 19 Pharmacists and technicians can work with. school year s end Pharmacists and technicians should dispense. school districts to determine what is most cost efficient and. devices that expire after the school year ends if possible. available under state law, UCONN You Asked for It Continuing Education September 2017 Page 4. Table 2 Emergency Symptoms and How to Treat 15 23 24 26. Emergent Situation Symptoms Treatment,Epinephrine IM injection.
Remove caps, Hoarseness throat tightness lump in throat Inject through clothes at 90 angle into thigh. Anaphylaxis Wheezing chest tightness trouble breathing Hold in place for 3 10 seconds per manufac. Tingling hands feet lips or scalp turer instructions. Give second dose if needed,Naloxone 0 4mg mL IM IN. IM injection into upper thigh or upper arm,Pin point pupils inject through clothes. Opioid overdose Unconsciousness IN administration of full dose into one nostril. Respiratory depression labored breathing must be atomized. Give second dose if needed,Test blood sugar treat if 70mg dL or less. Consume 15 grams of carbohydrate orally,Shaky dizzy lightheaded Glucose tablets gel.
Sweating chills clamminess 4 oz juice regular soda. Hypoglycemia mild,Mood changes 1 tbsp sugar or honey. Skin pallor Hard candy jelly beans or gumdrops,Re check blood sugar in 15 minutes and re. treat if needed,Glucagon IM injection,Have someone call 911. Position student on his her side, Inject all fluid from the syringe into the vial of. Occurs at blood glucose 54mg dL above powder and roll vial to mix. plus Draw prescribed amount of solution back into,Hypoglycemia severe.
Seizures syringe, Unconsciousness Inject into buttocks thigh or upper arm at. Hold in place for 5 seconds and keep student,on his her side until they regain consciousness. or emergency personnel arrive, Acute Illness and Immunizations In some of these areas e g abuse rape and pregnancy state. Medication use at school is not limited to chronic conditions and federal law govern response and treatment options In oth. Acute illnesses can and do occur on any given school day ers e g infection and outbreaks drug selection and issues as. The most common acute illnesses that are treated at school basic as storage are critical. Anaphylaxis emergency response Adequate immunization can significantly reduce the likelihood. Child abuse or magnitude of infectious illness Most schools have good. Infection tracking methods to ensure students are vaccinated on time. Injury note that up to 31 of acute pediatric injuries oc but one area needs improvement Adolescents are likely to. cur in or around school have missed vaccinations required in pre teen years as many. Outbreaks influenza lice scabies teens avoid pediatrician offices for well visits Meningococcal. Pregnancy rape tetanus diphtheria acellular pertussis boosters and human. Vaccination related gaps papillomavirus HPV are among those recommended at this. peak period of risk Meningococcal disease kills more individ. UCONN You Asked for It Continuing Education September 2017 Page 5. Can Stock Photo csp0101920, uals in the 15 to 24 age group than any other 21 The highest If the first dose of epinephrine is unsuccessful a second dose. prevalence of cancer causing HPV also exists among teenagers should be given 23 24 Pharmacists should advise parents that. and young adults requiring interventions for protection 22 one injector at home and one at school is insufficient a 2 pack. should be available to the child at all times Table 2 outlines. Herd immunity requires the overwhelming majority of people general administration techniques to emphasize. to be immunized against a disease to provide protection to. those who cannot be vaccinated One school system in Indiana Opioid Overdose. dramatically increased the percentage of students in compli Naloxone is the drug of choice for acute opioid overdose First. ance with vaccination recommendations from 66 to 99 6 school personnel need to recognize overdose symptoms Clas. using a school nurse run catch up program 21 However not all sic symptoms referred to as the opioid overdose triad are. schools have a nurse engaged in this process so a pharmacist pinpoint pupils unconsciousness and respiratory depression 25. can be a valuable resource for parents Potential first responders should also be taught that when in. doubt they should administer naloxone The drug is not harm. HEALTH EMERGENCIES, ful If a patient is overdosing prompt administration can save a.
Anaphylaxis life If not he or she will not be harmed Also in some cases a. Parents need to educate school employees about their chil second dose may be required if the first does not reverse the. dren s symptoms of anaphylactic reaction Parents and pharma overdose and restore breathing 19 Pharmacists should suggest. cists can also ensure children know when to seek help for multiple doses on hand at any given time. serious reactions Symptoms that should be reviewed are de. scribed in Table 2 AAAAI also suggests that parents complete Naloxone can be administered intranasally IN or intramuscu. Anaphylaxis Emergency Action Plans and review them with larly IM via pre filled auto injector or by drawing up from a. school administrators 15 vial into a syringe 19 The ready to use packaging is ideal in an. emergency but can be costlier Naloxone kits come with a sy. Epinephrine auto injectors differ Pharmacists should be vigi ringe and a vial The responder gives a 0 4mg mL dose in the. lant to retrain parents and children if a new device is pre victim s upper thigh or upper arm and can give it through. scribed The dispensing pharmacist should review each clothing 19 A naloxone auto injector delivers a single dose with. injector s unique caps safety covers and mechanisms with the a retractable needle to avoid needle sticks The device also pro. child For example certain generic injectables require the user vides step by step instructions on how to use it The responder. to hold the needle in place for 10 seconds rather than the 3 5 should push the auto injector hard into the victim s thigh mus. seconds recommended for more common devices 23 24 Addi cle until the voice directs otherwise 19. tionally pharmacists can recommend talking injectors if re. sponsible individuals have limited understanding IN naloxone comes in ready to use packaging and one requiring. UCONN You Asked for It Continuing Education September 2017 Page 6. assembly 19 The former requires a separate device to atomize enhances quality of life of children with chronic illnesses 2. the drug This device is sold separately without a prescription While ideal many school systems budgets are tight and they. pharmacists should advise schools to have both the drug and may not be able to provide case management or lack school. delivery device on hand The already assembled product needs nurses entirely. no extra device for administration In both cases the responder. gives the drug by inserting the nozzle into one of the victim s Similar to NASN the American Academy of Pediatrics AAP. nostrils and spraying the entire dose into one nostril 19 publishes voluntary guidelines for schools AAP suggests that. prescription medications brought to school should be in original. Responders should call emergency personnel immediately when containers as labeled by a pharmacist or physician 29 However. an overdose occurs regardless of naloxone administration the same does not apply to over the counter medications. School administration must understand this where state regulations differ vastly When medication does. not require refrigeration or special security AAP proposes that. Hypoglycemia responsible students should be permitted to carry medication. Hypoglycemia can occur as a result of insufficient carbohydrate for urgent needs 29 This creates gray area as school administra. consumption following insulin administration 9 Additionally tors differ on security needs and student responsibility School. children younger than age 6 are likely to have hypoglycemia districts develop their own guidelines in accordance with state. unawareness They are particularly vulnerable to severe hypo laws and implement protocols as they see fit Again this is op. glycemia because they don t recognize symptoms or communi portunity for pharmacy to collaborate. cate their needs 9 Symptoms of low blood glucose are outlined. in Table 2 Pharmacists can counsel children on hypoglycemia s No national laws or regulations govern school day medical care. signs and when to call for help Additionally many indicators of Section 504 of the Rehabilitation Act states that federally fund. low blood sugar can be mistaken for misbehavior School per ed school districts must provide medication at school and make. sonnel should be trained to take these symptoms seriously in reasonable accommodations for students with disabilities 28. children with diabetes and always seek medical attention This national directive ensures care however is vague about. procedures State and local regulations are disjointed too Re. If children present with any of these symptoms a trained indi searchers in Iowa surveyed 396 schools and found varying pro. vidual should test the child s blood glucose If the reading is 70 tocols statewide for medication administration While 97. mg dL or less the child should consume 15 grams of carbohy indicated that they had written guidelines for medication ad. drate immediately 26 School nurse or other designated individu ministration these guidelines varied greatly between schools 30. als should administer one of the recommended agents in Table Day to day responsibility of administration rested on a variety. 2 When a patient experiencing clinically significant hypoglyce of individuals primarily school nurses 48 but also secretar. mia is unable or unwilling to consume carbohydrates by mouth ies 38 health aides 11 teachers 2 other individuals. injectable glucagon is indicated 9 The responder should inject 1 30 Additionally policies regarding field trips only existed in. this medication following manufacturer instructions outlined in 73 6 of schools most commonly those with younger. Table 2 Pharmacists should counsel caregivers to treat even if students 22 Pharmacists therefore can work with school admin. they re in doubt because severe hypoglycemia can cause brain istration and the tools provided to coordinate care better for. damage or death Although children may be nauseous or vomit school aged children. when they regain consciousness glucagon is harmless even if. blood sugar is high 27 It may take 15 to 20 minutes for diabetics. to regain consciousness and here too a responsible adult. should call 911 while waiting 27,POLICY AND PROCEDURE VARIES. Policy and procedure surrounding medication administration at Pause and Ponder. school is inconsistent While many organizations have recom A school district approaches you about what. mendations no universal guidelines exist NASN publishes its naloxone formulation to maintain on hand. position on this issue publicly NASN believes that children with Assuming state law allows this what formulation. unmet health needs have a difficult time learning and that all might you suggest. schools should be equipped with a full time registered nurse 2. They also state that case management by a school nurse. UCONN You Asked for It Continuing Education September 2017 Page 7. PHARMACY TEAM S ROLE Table 3 Additional Resources for Pharmacy Teams. Recognize pediatric medications and potential problems. School districts and parents are often dissatisfied with the lack Resource. of guidance and regulation surrounding medications at school National Association of School Nurses. One study found that the most common barriers to addressing https www nasn org home. children s health concerns were lack of student and parent 866 627 6767. knowledge lack of parent school physician communication. Guidelines and position statements on medication administra. and lack of resources e g can t afford a second inhaler for tion in schools. school 3 Families and school systems should see community. pharmacists as valuable resources to address these issues and American Diabetes Association Safe at School. http www diabetes org living with diabetes parents and. others Table 3 lists valuable resources to be recommended by. kids diabetes care at school,the pharmacy team, Resources for parents on meeting diabetes management needs. Half to two thirds of school nurses and other administrators re for their child while they are at school. port medication administration errors 1 29 Missed dose is American Academy of Pediatricians. most common 1 29 31 Missed doses of maintenance medications https www aap org en us Pages Default aspx. affect a child s ability to focus on education The most common. Guidelines for parents and providers on pediatric medication use. reasons for these errors include students not coming to the. and school day care, nurse s office staff error and lack of communication between. Naloxone training, parents and schools 1 29 Additionally when students share the. http www getnaloxonenow org, responsibility of medication administration such as carrying.
their own inhalers fewer errors occur 1 If pharmacists under Bystander training on naloxone administration. stand how school medication errors occur they can counsel Glucagon training. children and school administrators on ways to anticipate and http web diabetes org Advocacy school glucagon pdf. avoid them, Proper administration techniques for glucagon and clinical pearls. for school personnel, Label medication appropriately Simple steps open lines of. communication and develop cooperative relationships between. students parents schools and pharmacists This process be. gins at data entry Pharmacy technicians filling pediatric medi. cations with multiple daily doses or for emergencies should ask Teach autonomy While children infrequently accompany par. if the drug may be administered at school Especially for new ents to retrieve prescriptions pharmacists should capitalize on. medications simply offering an additional properly labeled con opportunities to counsel school aged kids directly By age 5 to. tainer can galvanize communication with parents Additionally 7 most children are able to understand medication instruc. if pharmacists send a vial or device to school with identical la tions so their participation in counseling is important 32 This. bels parents and school administration have the same contact becomes especially important in situations where parents can t. information to reach out to the pharmacist advocate for them like school The most commonly self admin. istered medications by school aged children are inhalers 70. Suggest alternatives Pharmacists and technicians who work asthma medications 48 and insulin 44 31 Counseling chil. with insurance billing can help parents find cost efficient op dren on proper administration techniques and focusing on. tions The pharmacy team can work with prescribers and insur these drug classes could make them feel more confident at. ances to obtain approval for sufficient medication and supplies school. The pharmacy team can also suggest long acting alternatives if. appropriate to reduce or avoid school day administration. CONCLUSION, School aged children suffering from chronic and acute illness. Opportunities exist with epinephrine auto injectors Costs are. are often poorly managed In the absence of universal regula. on the rise but generic versions have recently become avail. tions pharmacists have an opportunity to aid caregivers and. able Pharmacists should work with insurers and prescribers to. educate all parties involved in school day healthcare Commu. select the best product for patients Coupons are available to. nity pharmacists are uniquely positioned to facilitate medica. reduce costs for nearly every formulation, tion administration at school and prevent it whenever possible. UCONN You Asked for It Continuing Education September 2017 Page 8. REFERENCES, 17 Rollins JA Heroin Addiction Not a Laughing Matter Pedia.
1 Clay D Farris K McCarthy AM Kelly MW Howarth R Fami tr Nurs 2016 42 109 111. ly perceptions of medication administration at school er 18 National Association of School Nurses 2015 Naloxone. rors risk factors and consequences J Sch Nurs use in the school setting The role of the school nurse Posi. 2008 24 95 102 tion Statement Silver Spring MD Author. 2 No author The Role of the 21st century school nurse 19 Get Naloxone Now Information On How To Administer. NASN Sch Nurse 2017 Jan 32 1 56 58 Naloxone 2015 Available at. 3 Lineberry MJ Ickes MJ The role and impact of nurses in www getnaloxonenow org INFO ON HOW TO ADMINIS. American elementary schools a systematic review of the TER NALOXONE pdf Accessed April 12 2017. research J Sch Nurs 2015 31 22 33 20 Guttu M Engelke MK Swanson M Does the school nurse. 4 National Asthma Education and Prevention Program Third to student ratio make a difference J Sch Health 2004. Expert Panel on the Diagnosis and Management of Asthma Jan 74 1 6 9. Expert Panel Report 3 Guidelines for the Diagnosis and 21 Swallow W Roberts JC An evidence based project demon. Management of Asthma Bethesda MD National Heart strating increased school immunization compliance follow. Lung and Blood Institute US 2007 Aug ing a school nurse initiated vaccine compliance strategy J. 5 Cogan P Sucher B Appropriate Use of Pressurized Me Sch Nurs 2016 32 385 389. tered Dose Inhalers for Asthma US 22 Grandahl M Rosenblad A Stenhammar C et al School. Pharmacist 2015 40 7 36 41 based intervention for the prevention of HPV among ado. 6 No author Inhaler technique for people with asthma or lescents a cluster randomised controlled study BMJ Open. COPD National Asthma Council Australia Melbourne 2016 6 1 e009875. 2016 23 EPIPEN Auto Injector package insert Morgantown WV. 7 Platt LM Koch RL How the school nurse can help improve Mylan Specialty L P 2016. the effectiveness of ADHD medication NASN Sch Nurse 24 Epinephrine injection USP auto injector package insert. 2016 31 153 157 McPherson KS Hospira Inc 2016, 8 Rajeh A et al Interventions in ADHD A comparative re 25 World Health Organization Information Sheet on Opioid. view of stimulant medications and behavioral therapies Overdose 2014 Available at. AJP 2017 25 131 135 http www who int substance abuse information. 9 American Diabetes Association Standards of Medical Care sheet en Accessed April 12 2017. in Diabetes 2017 Diabetes Care 2017 40 26 American Diabetes Association Hypoglycemia 2014 Avail. 10 American Diabetes Association Insulin Storage and Syringe able at http professional diabetes org PatientEd Ac. Safety 2014 Available at http www diabetes org living cessed April 12 2017. with diabetes treatment and 27 American Diabetes Association Glucagon Training Stan. care medication insulin insulin storage and syringe dards for School Personnel Providing Emergency Medical. safety html Accessed April 12 2017 Assistance to Pupils with Diabetes May 2006 Available at. 11 American Diabetes Association Safe at School 2017 Avail web diabetes org Advocacy school glucagon pdf Accessed. able at http www diabetes org living with April 12 2017. diabetes parents and kids diabetes care at school Ac 28 American Academy of Pediatrics Policy Statement Guid. cessed April 12 2017 ance for the Administration of Medication in School 2009. 12 Diabetes Digital Media Ltd How to Inject Insulin 2017 Available at. Available at http www diabetes co uk insulin how to in www pediatrics org cgi doi 10 1542 peds 2009 1953 Ac. ject insulin html Accessed April 12 2017 cessed January 30 2017. 13 Engelke MK Swanson M Guttu M Warren MB Lovern S 29 Kelly MW McCarthy AM Mordhorst MJ School nurses ex. School nurses and children with diabetes a descriptive periences with medication administration J Sch Nurs. study N C Med J 2011 72 351 8 2003 19 281 287, 14 Zadikoff EH Whyte SA Desantiago Cardenas L Harvey 30 Farris KB McCarthy AM Kelly MW Clay D Gross JN Issues. Gintoft B Gupta RS The development and implementation of medication administration and control in Iowa schools J. of the Chicago public schools emergency EpiPen policy J Sch Health 2003 73 331 337. Sch Health 2014 84 342 347 31 Ficca M Welk D Medication Administration Practices in. 15 American Academy of Allergy Asthma Immunology Food Pennsylvania Schools J Sch Nurs 2006 22 148 155. Allergies Symptoms Diagnosis Treatment 2016 Avail 32 Carpenter DM Abraham O Alexander DS Horowitz K. able at https www aaaai org conditions and Counseling of children and adolescents in community phar. treatments allergies food allergies Accessed April 12 macies Results from a 14 day observational study J Am. 2017 Pharm Assoc 2003 2016 56 266 269, 16 King R Science Over Stigma Saving Lives Implementation. of naloxone use in the school setting NASN Sch Nurse. 2016 31 96 101, UCONN You Asked for It Continuing Education September 2017 Page 9.

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5. A small skit portraying the theme of honesty or dishonesty. After the skit few processing question can be asked: (a) What was the effect on the people who were cheated? (b) Ask the students to think and reflect about their true feelings and the need for being honest. Situation Cards

A View from Kenya!

A View from Kenya

as he led us in a Bible study. He came running up to me early one morning and said two of his cows had been stolen and asked for prayers. You see, the Masai people love to steal cows. Sylvester went running back home for 15 miles along the muddy roads. He put out a call and 50 friends and neighbors turned out to help hunt down the thieves. They ...

Frequently Asked Questions - For Applicants Frontline ...

Frequently Asked Questions For Applicants Frontline

Frequently Asked Questions - For Applicants Frontline/Entry Level Management If you require reasonable accommodation to complete this video interview process, please contact HireVue Support at you require



foreign policy in his own words and compare it with formal definitions from the experts. B. The student will be able. to define terms basic to. study of foreign policy. 1. The student will be asked to tifine foreign policy in his or her own words. 2. References: DeConde, A History of American Foreign.Polfcy, or Holt, United States Policy in ...

UNIT 8 Complaints and disruptive passengers

UNIT 8 Complaints and disruptive passengers

64. Unit 8. Managing disruptive passengers. 1 Sometimes difficult situations with passengers get out of control. Passengers become aggressive, insulting or drunk and refuse to do what they are asked.

100 Most Frequently Asked Questions about the End Times

100 Most Frequently Asked Questions about the End Times

100 Most Frequently Asked Questions about the End Times 1. Why is it important that we study the and the Book of Revelation? ... (common sense reading),

to starting a new club -

to starting a new club dsr wa gov au

to starting a new club 1 A guide for sport and recreation clubs and associations in Western Australia. Booklet Sport and recreation builds stronger, healthier, happier and safer communities. 2 Frequently asked questions Do we have to have a written constitution? No. But it is more businesslike and it does ensure that you define your objectives and you can become incorporated. How do we write a ...

Analyzing Facebook Privacy Settings: User Expectations vs ...

Analyzing Facebook Privacy Settings User Expectations vs

asked about 10 di?erent uploaded photos. potentially attractive way of quickly recruiting signi?cant numbers of survey users. 3. METHODOLOGY We now describe our approach for collecting data from Facebook users concerning privacy settings. We then detail a few statistics of the collected data set, and examine the

A Step By Step Guide to Use eBay

A Step By Step Guide to Use eBay

For some items, eBay might have pre-filled item information available. This may be in the case of books, Ds, DVDs or videogames. You will be asked to enter limited information such as the title, author, artist and ISBN number etc. and the rest of the information on the product



bystander. However, Fletcher renounced this version of events after a detective informed him that fingernail scrapings had been collected from Googe to test for DNA evidence. The officer observed that Fletcher had scratch marks on his hands and arms, whereas Brown did not, and asked Fletcher if there was any reason why his

Witnesses: Competency, Examination, and Impeachment

Witnesses Competency Examination and Impeachment

three months and admitted using drugs on two occasions in that time, her answers to questions by government and defense attorneys were lucid and discriminating. The trial judge asked no questions, nor were expert witnesses employed. At the end of the hearing, the judge declared Jackson competent to testify.

Jupiter Success Reading -

Jupiter Success Reading psychic answer com

you don't invest so much in material things that you forget to also nurture your spiritual life. Jupiter in 1st house: What to expect: If asked to describe you then the word that would come to most peoples minds is 'honest'. If anything, your quest for the honest word or thought can become counterproductive, if that is possible. You arent a ...

DOCUMENT RESUME ED 371 973 AUTHOR Oliker, Michael A., Ed ...

DOCUMENT RESUME ED 371 973 AUTHOR Oliker Michael A Ed

convention the question--Dare Progressive Education Be Progressive?(2) In that same year, Counts broadened his challenging question and asked American educators--Dare the School Build a New Social Order? When Counts asked that queion which has won him a place in the history of American education, the United States was in the darkest days of the

Health Insurance Portability and Accountability Act (HIPAA ...

Health Insurance Portability and Accountability Act HIPAA

This document of Frequently Asked Questions (FAQs) is organized in two sections. The first section provides some working knowledge of what HIPAA is and what it is not. The answers to the FAQs in this section provide context and reference points for the wide range of HIPAA regulations and requirements.

Blood Pressure Assessment Program Screening Guidelines

Blood Pressure Assessment Program Screening Guidelines

health care provider informing him/her of the elevated blood pressure reading. Client should be asked to provide information and sign the letter; Provide a list of local resources so that they may seek additional support; Stress the need to conduct follow- up in the appropriate time frame. Counseling Points If BP is below 130/85 Provide recommendation that should be used to detect onset of ...

Take Charge of Your Diabetes - Centers for Disease Control ...

Take Charge of Your Diabetes Centers for Disease Control

Take Charge of Your Diabetes: A Guide for Care, printed in 1991. We asked people with diabetes who read the first book to help us make the second book even more useful. For this fourth edition of the book, we have updated the scientific facts, resources, and art.