Monitor and treat respiratory depression and sedation with supportive emergency measures.

Transcription

1 Versed (midazolam), Nasal Administration of Purpose: Versed (midazolam) is a short-acting benzodiazepine medication that is administered intra-nasally to control status epilepticus, a common life-threatening neurological disorder characterized by an acute, prolonged seizure crisis. Additional Authorities: Research has demonstrated the efficacy and ease of use of intra-nasal Versed (midazolam) with fewer side effects than rectal diazepam. (See references, section 4.0) Nevada Administrative Code (NAC ) {Midazolam is enumerated as a Schedule IV Controlled Substance} Nevada Revised Statutes (NRS , NRS ) {Provides for the general powers of the Nevada State Board of Pharmacy in regulating controlled substances} State of Nevada Nurse Practice Act (NPA) {Guidance for medication administration and delegation only} National Association of School Nurses (NASN) {Guidance for medication administration and delegation only} School Nurse Regulation and Advisory Opinion (SNRAO) {Guidance for medication administration and delegation only} American Nurses Association and National council of School Boards of Nursing Joint Council (ANA-NCSBCJC) {Guidance for medication administration and delegation only} National Association of State School Nurse Consultants (NASSNC) {Guidance for medication administration and delegation only} Scope: It is within the scope of practice for a school nurse to: Develop an Individualized Health Care Plan (IHCP) for the student. Identify and train licensed nurses who will administer medication per Licensed Health Care Provider (LHCP) orders. Educate and train appropriate school staff. It is within the scope of practice for a licensed nurse to: Monitor the student with prolonged seizure activity and recognize the lifethreatening condition of status epilepticus, Monitor the student prior to, during, and after administration of intra-nasal Versed(midazolam). Administer nasal Versed (midazolam) following Licensed Health Care Provider (LHC P) orders, and 1

2 Monitor and treat respiratory depression and sedation with supportive emergency measures. Responsible Party: Health Services Director Distribution: Health Services Coordinators, School Nurses, Specialized Procedure Nurses POLICY 1.0 Policy Statement(s) 1.1 School nurses or a licensed nurse acting in their stead, will monitor the student with prolonged seizure activity, prepare and administer intranasal Versed (midazolam) per licensed health care provider orders, and monitor the student for potentially life-threatening adverse side effects of respiratory depression and sedation. 1.2 No portion of the nursing process may be delegated. Intra-nasal Versed (midazolam) administration may not be delegated to unlicensed personnel, as the student experiencing prolonged seizure activity needs constant monitoring and evaluation utilizing the nursing process. 1.3 A written LHCP (Licensed Health Care Provider) order for intra-nasal Versed (midazolam) must be on file, noting a previous dose has been given without complications. 1.4 Student will receive intra-nasal Versed (midazolam) according to policy 3.0, using either the procedure for a single dose vial or split dose syringes, according to HCP s orders. 2

3 1.5 A student in status epilepticus, who has received a dose of intra-nasal Versed (midazolam), must go home with parent/guardian once stable, or be transported to a hospital as necessary. 1.6 Planning/Outcomes Develop an Individualized Health Care Plan (IHCP) for the student Identify and train licensed nurse(s) who will administer medication in accordance with the LHCP orders and the IHCP, if the school nurse is not present on campus Educate and train appropriate school staff to implement the IHCP Identify student in the HS 140, Emergency Plan for Medically Fragile Students Identify student in the EHR with a special problem listed and medication administration order entered per LHCP orders Identify appropriate location for medication storage and immediate accessibility when needed Intra-nasal Versed (midazolam) should be stored in a light-proof container. 1.7 Intervention Activate EMS by calling Administer intra-nasal Versed (midazolam) using technique in accordance with procedural steps if licensed nurse on campus. (Section 3.0) Seizure Emergency Management Protocol will be followed. 3

4 1.7.4 If a student needs intra-nasal Versed (midazolam) during transport on the bus and a licensed nurse is not on the bus, 911 will be called and emergency care will be provided Treat life-threatening adverse side effects with supportive emergency measures. 1.8 Evaluation Monitor for respiratory depression and sedation immediately following administration of intra-nasal Versed (midazolam) until transfer of care is complete. 2.0 Procedure Assessment, Nursing Diagnosis, Planning/Outcomes, Intervention, Evaluation (ADPIE) 2.1 Assessment Assess the student with prolonged seizure activity and recognize the life-threatening condition of status epilepticus Assess the student for medication allergies. Do not administer intranasal Versed (midazolam) if the student is allergic to midazolam or its components Assess for epistaxis, nasal blockage or trauma. Do not administer nasal Versed if any of these symptoms are present. 4

5 3.0 Intra-nasal Versed (midazolam) Administration Procedure 3.1 Administration Procedure using Single or Split Dose Vial Intra-nasal versed Procedural Steps Precautions A. Assesses student for status epilepticus 1. Time of seizure onset 2. Duration of seizure activity Do not administer if seizure activity ceases prior to the timeframe specified in the LHCP orders. 3. Time seizure ceases 4. Airway integrity 5. Breathing/respiratory rate 6. Pulse B. Activates EMS, Call dispatch Mandatory 1. Contact parent/guardian C. Assembles Equipment 1. Gloves 2. Alcohol/disinfectant wipes 3. Medication vial Note Concentration and delivery according to LHCP order. 4. Syringe 5. Needle/needle device 6. Atomizer 7. CPR mask D. Medication Administration Procedure According to LHCP s orders 1. Washes hands 2. Applies gloves 3. Aspirate the prescribed total volume plus 0.1ml Additional 0.1 ml accounts for the dead space in the atomizer 4. Twist off and remove the syringe from the needle/needle device. 5. Attach the atomizer tip to the end of the syringe. 6. Place one hand on the student s forehead to stabilize head. 7. Briskly compress the syringe plunger to deliver the prescribed dose into nostril. 8. Briskly compress the syringe s plunger to administer the remainder of the dose into the opposite nostril if prescribed in split dose. 5 Dose and delivery to nare(s) per LHCP order. As prescribed

6 9. Dispose of needle and syringe in the sharps container 10. Dispose of the atomizer 11. Dispose of gloves and wash hands E. Monitors student s status post medication administration 1. Remain with the student 2. Monitor and record respiratory rate as follows: a. every 5 minutes x 3 b. every 10 minutes x 3 c. or, until care has been transferred to EMS personnel or parent/guardian assumes responsibility for student. 3. Monitor level of student sedation 4. Treat life-threatening adverse side effects with supportive emergency measures. F. Documents office visit (OV) and medication administration in EMR to include: 1. Student seizure assessment 2. Activation of EMS 3. Adverse side effects from medication 4. Parent/guardian notification 5. Status upon transfer of care to EMS or parent/guardian 6. Incident report G. Notifies 1. Reports incident to School Nurse 2. School Nurse to notify physician, when necessary Respiratory depression Sedation 4.0 References, Sources, Bibliography Buck, M. L. (2013). Intranasal administration of benzodiazepines for the treatment of acute repetitive seizures in children. Pediatric Pharmacology. 19 (10). Holsti, M., Dudley, N., Schunk, J., Adelgais, K., Greenberg, R., Olsen, C., Healy, A.,Firth, S., Filloux, F. (2010) Intranasal midazolam vs. rectal diazepam for the home treatment of acute seizures in pediatric patients with epilepsy. 6

7 Archive of Pediatric and Adolescent Medicine. 164 (8): Humphries, L. K. & Eiland, L.S. (2013). Treatment of acute seizures: Is intranasal midazolam a viable option? Journal of Pharmacological Therapy. Apr.- Jun., 18(2), Javadzadeh, M., Sheibani, K., Hashemieh, M., & Saneifard, H. (2012) Intranasal midazolam compared with intravenous diazepam in patients suffering from acute seizure: A randomized clinical trial. Iranian Journal of Pediatrics, 22(1), 1-8. Klein-Kremer, A. & R. D. Goldman. (2007). Intranasal midazolam for treatment of seizures in children in the emergency setting. Israeli Journal of Emergency Medicine. 7 (2), Kyrkou, M., Harbord, M., Kyrkou, N., Kay, D., Coulthard, K., Bailey, K. (2006). Impact of a protocol using intranasal midazolam for managing seizures. The Epilepsy Report (Nov.) McMullan, J., Sasson, C., Pancioli, A., Silberglett, R. (2010). Midazolam versus diazepam for the treatment of status epilepticus in children and young adults: A meta-analysis. Academy of Emergency Medicine, June, 17 (6): Therapeutic intranasal drug delivery: Intranasal midazolam for acute seizure therapy. (2014). Retrieved from August 29, Ulgey, A., Aksu, R., Bicer, C. (2012) Nasal and buccal treatment of midazolam in 7

8 60. epileptic seizure in pediatrics. Clinical Medicine Insight in Pediatrics. 6: 51- Wilson, M.T., Macleod, S., & O Reagan, M.E. (2004). Nasal/baccal midazolam use in the community. Retrieved from adc.bmj.com, September 14, Wolfe, T. R., Braude, D. A. (2010). Intranasal medication delivery in children: A brief review and update. Pediatrics, 126 (3): Authorizations Policy & Procedure Committee Chair (Print) Signature Date Health Services Director (Print) Signature Date Medical Consultant (Print) Signature Date 8