If a school nurse has standard orders for over-the-counter (OTC) pain relievers, how would those orders help to keep kids in school? Connie Sobon Sensor, RN, MSN, says she often had to send home Union High School students who complained of menstrual cramps or slight fevers, when all they needed was an OTC pain reliever to manage their discomfort.

To keep kids with easy-to-treat symptoms in school, Sobon Sensor, a certified school nurse with the Union Township Board of Education in Union, N.J., helped to spearhead an alternative program — the school now has standing orders for Tylenol and Advil. Today, the school nurses at Union High School can, at their discretion, give pain relievers to students who complain of fevers or menstrual cramps — and send them back to class rather than home.

Plans Translate into Action

Sobon Sensor got the idea after she heard that a California middle school had done the same thing and reported successful results. Armed with the evidence-based practice, she approached her administrator, who asked the school district physician to write the standing orders and the school district to supply the medications. The program has made a significant difference in the numbers of kids who stay in school, according to Sobon Sensor.

For students to be eligible to receive the standing order medications, they must weigh at least 96 pounds and their parents must have given written approval on the emergency medical forms they receive at the start of the year.

Documentation Is Essential

Sobon Sensor keeps all the information about each student’s medication needs on the emergency card that parents fill out in the beginning of the school year. The parents are asked to include the following information on the card —

• Emergency contact information
• Chronic medical conditions
• Medications the student takes on a regular basis
• Name of health care provider(s)
• Whether school nurses are allowed to contact the health care provider(s)
• Whether school nurses are allowed to share medical information about specific conditions with student’s teachers

The question about whether or not parents give permission for their children to receive school-supplied Advil or Tylenol for fevers and menstrual cramps is at the bottom of the form.

“Every time I see the student or give him or her medication, I write on the back of the same form so that I have a record,” Sobon Sensor says. The nurses allow students to make the choice about which OTC pain reliever they want.

Everyday Challenges

The nurses try to limit use of the medications to menstrual cramps and fever, but occasionally give students the pain relievers for headaches. Sobon Sensor and her registered nurse colleagues at Union High School record when they give the OTC medications to students. If a student seeks relief for a headache more than twice, Sobon Sensor calls the student’s parents and recommends a physician evaluation. With a physician’s order, she would then resume giving the student Tylenol or Advil for headaches. “A headache is a symptom of something — it’s not an illness in itself and you really need to see what is causing the headaches,” she says.

One of the challenges of the program is saying “no” to students who don’t seem to need the medications but request them anyway, according to Sobon Sensor. Students have been known to request the standing order medications for allergies, stomachaches, and headaches that might have started only minutes earlier. Sobon Sensor uses the opportunity to ask students about what they might have done beforehand to prompt the symptoms. If they haven’t eaten and they have a stomachache, they need to eat, she says.

“It’s really a nursing judgment,” she says. “The research supports the belief that medicating every time you have a slight headache is inappropriate treatment. Headaches tend to come back more severely and frequently, if you take medication at the immediate onset of a headache. [The explaining and talking] takes a longer time, but I think in the long run we’re doing a better job with our students that way.”

All in a Day’s Work

Like other school nurses, the nurses at Union High School also administer prescription medications. Students have to bring in a signed form from their physicians telling the nurses what the drugs are to be administered for, under what circumstances, and how frequently. Parents also have to sign the form to give nurses permission to administer the medicines. Students then bring their own medicine in prescription containers and Sobon Sensor stores them in the school nursing office. The nurses also report to parents any side effects that students might mention to the nurses and might be related to the medications they are taking.

The nurses are also charged with overseeing a direct observation medicine program for a few students in the school who have active tuberculosis. “They are in a program in which we have to observe them taking the medication, sign for it, and supply those forms to the state,” Sobon Sensor says.

Students who have asthma and need inhalers, as well as those who have insulin pumps, can self-administer the medications throughout the day as long as they have a signed parental consent to do so. Sobon Sensor takes that a step further and calls parents of kids who are eligible to self-administer and asks them if they’d like to supply the nurse’s office with an extra prescription in the prescription container, just in case the student loses or forgets his or her meds during the school day.

The medications the nurses most frequently administer, according to Sobon Sensor, are the Advil, Tylenol, TB meds, and occasionally antibiotics or medicines to treat ADHD. Overall, Sobon Sensor gives high marks to the medicine management program at Union High School. “A few years ago [before having the standing orders for Tylenol and Advil] we sent a lot more students home from school for the day just because they needed to go home to take Advil or Tylenol to manage their cramps,” she says.

Lisette Hilton is a frequent contributor to Nursing Spectrum.