Allergic(Rhini,s( - Ballad Health...ALLERGIC(RHINITIS(AND(OTHER COMORBIDITIES( •...
Transcript of Allergic(Rhini,s( - Ballad Health...ALLERGIC(RHINITIS(AND(OTHER COMORBIDITIES( •...
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Allergic Rhini,s
Dr. Larry Smith, MD
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Allergic Rhini,s Defini,on � Defined as inflamma,on of the nasal mucosa characterized
by two or more of the following symptoms: – nasal conges,on – anterior/posterior rhinorrhoea – sneezing – itchy nose
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Introduc,on
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Allergic Rhini,s
� occurs when these nasal symptoms are the result of IgE-‐mediated inflamma,on following exposure to an allergen
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Prevalence
400 million suffers worldwide > 20% of popula,on in US All ages are affected, peaks in teens Boys more affected than girls but equalizes aTer puberty
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ALLERGIC RHINITIS and ASTHMA
• 30% of pa,ents with AR have asthma • The majority of pa,ents with asthma have AR • AR is a major risk factor for poor asthma control
• All pa,ents with AR should be assessed for asthma
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ALLERGIC RHINITIS AND OTHER COMORBIDITIES
• Up to 80% of pa,ents with bilateral chronic sinusi,s have AR
• O,,s media • Conjunc,vi,s • Lower respiratory tract infec,ons • Dental problems – malocclusion, discolora,on • Sleep disorders
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ALLERGIC RHINITIS AND ITS IMPACT ON QUALITY OF LIFE
� In USA 2 million school days lost per year 4 million work days lost per year 28 million impaired work days
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ALLERGIC RHINITIS (ARIA)
Moderate-‐severe one or more items Abnormal sleep. Impairment of daily ac,vi,es, sport, leisure. Problems caused at school or work. Troublesome symptoms.
Intermi\ent symptoms
< 4 days per week
Or < 4 weeks Mild Normal sleep. Normal daily ac,vi,es. Normal work and school. No troublesome symptoms.
Persistent symptoms
> 4 days per week and > 4 weeks
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DIAGNOSIS • History and Examina,on • Skin prick test • Radioallergoabsorbent tests for specific IgE (RAST)
• (Nasal allergen challenge)
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TREATMENT
• EDUCATION/ALLERGEN AVOIDANCE • PHARMACOTHERAPY • IMMUNOTHERAPY • SURGERY • Others – Nasal douching
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IMMUNOTHERAPY • Involves repeated administra,on of an allergen extract to induce a state of immunological tolerance
• More effec,ve in limited spectrum of allergies in par,cular seasonal pollen allergy
• Severe symptoms failing to respond to usual Px • Subcutaneous injec,on/sublingual route • Studies indicate that 3 years therapy necessary
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ARIA RECOMMENDATIONS • Topical cor,costeroids and oral an,histamines (non-‐seda,ng) form the mainstay of treatment
• The newer topical steroids e.g. Mometasone furoate and Flu,casone propionate were highest recommended
• Other drugs should only be considered as second-‐line treatment
• Immunotherapy in selected pa,ents can be highly effec,ve.
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SPECIAL CIRCUMSTANCES PAEDIATRIC ALLERGIC RHINITIS
• 4 years and older should be treated as for adults • Children (>4) with AR and Asthma can be treated with combina,on of newer genera,on topical and inhaled cor,costeroids with low risk of complica,ons
• Diagnosis in smaller children is difficult as can have up to 6 to 8 colds per year
• Small children – oral an,histamines, saline sprays and cor,costeroids if symptoms severe
• > 2 years fortunately rare
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Bringing Diabetes to School Regional School Health Conference
July 27, 2017
Evan Los, MD East Tennessee State University
Pediatric Endocrinology Mountain States Medical Group
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Disclosures
• No financial conflicts of interest to disclose
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Outline
• Describe roles of student, family, school nurse & healthcare team in management of diabetes at school
• Discuss pearls and piLalls of diabetes management at school
• Diabetes technology and brief look at future of diabetes management
• QuesOons
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Outline
• Describe roles of student, family, school nurse & healthcare team in management of diabetes at school
• Discuss pearls and piLalls of diabetes management at school
• Diabetes technology and brief look at future of diabetes management
• QuesOons
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Diabetes is a team sport
• High burden of disease management placed on child/family
• Requires advanced planning for basic tasks: eaOng, physical acOvity
• Can complicate rouOne illnesses
• Life experience with diabetes influenced by family dynamics, socioeconomics, coping skills
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Diabetes at school: Student role
• Depends on developmental stage
• Expect to parOcipate in (and contribute to) school care plan
• Take diabetes seriously but don’t use it as an excuse • Show up ready to learn like everyone else • Treat your low and get back to class • If struggling, ask for help
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Diabetes at school: Family role
• ParOcipate in and formulate school care plan with RN • Discuss frequency of BG checks, whether/when parent wants to be noOfied, remote monitoring*
• Provide all necessary supplies including low treatments and snacks
• Listen to your feedback
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Diabetes at school: Medical provider role
• Provide “school orders” direcOng the diabetes care of each student
• Update orders as needed
• Be available as resource if orders unclear or do not address situaOon
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Diabetes at school: RN role
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Diabetes at school: RN role
Use your excellent training to provide and direct the hands-‐on care of students with diabetes at school while navigaOng the requests of students, parents, school administraOon and medical providers.
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“School orders”
• Please don’t send extra school orders for us to fill out, if possible
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Outline
• Describe roles of student, family, school nurse & healthcare team in management of diabetes at school
• Discuss pearls and pi8alls of diabetes management at school
• Diabetes technology and brief look at future of diabetes management
• QuesOons
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Typical schoolday paBerns
• Arrive at school
• If breakfast at school: check BG, dose insulin, eat
• +/-‐ mid-‐morning snack
• At lunch: check BG, dose insulin, eat
• +/-‐ extra BG checks per student/family request (PE, before geang on bus, etc., and with sx of low BG
• Depart school
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Supplies
• My preference: Student keeps all supplies with them all the Ome • BG meter, strips, lancets, ketosOx, glucagon, low supplies, insulin, syringes/pens/pump, CGM • Sharps need to be safely disposed of
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Glucagon
• I think all school nurses, teachers of students with diabetes should know how to give glucagon • Probably PE teachers, recess monitors and sports coaches too
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Legal stuff (from a non-‐lawyer)
Tennessee Virginia
Can school staff (not medical professionals) administer insulin? Yes Yes
Can school staff (not medical professionals) administer glucagon? Yes Yes
Can students self-‐manage diabetes at school? Yes Yes
Can students carry all supplies with them at all Omes? Yes Yes
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Legal stuff, conLnued
Must a school provide a trained school staff member while students par?cipate in field trips and extracurricular ac?vi?es? Yes. Failure to provide this care would exclude students from these acOviOes for safety reasons. Schools are required to provide needed care to ensure a student's full and safe parOcipaOon in school-‐sponsored acOviOes. Who is responsible for training school staff? The school is responsible for providing appropriate training to school staff. ‘Safe at School’ training materials available on American Diabetes AssociaOon website.
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Bus drivers?
• Some states have clear policies recognizing bus drivers as school officials who are responsible for providing medical care to students • Most states are either vague or have no specific regulaOons • American Diabetes AssociaOon clearly supports the training of bus drivers in the basics of diabetes care including glucagon use • Strong legal protecOons for school officials who help “in good faith”
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Ketones
• A sign the body is burning fat instead of carbs for energy • Why? Not enough insulin, not enough carbs, body stress (e.g. illness, menses)
• Some kids get ketones more frequently than others
• Some kids get ketones a lot • Usually this means a student is missing insulin doses on a regular basis
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Ketones -‐ conLnued
• Trace-‐small • Assess for causes, noOfy family • Give water, more frequent BGs/insulin/carbs/ketone checks • May be able to go back to class
• Moderate-‐large • Assess for causes, noOfy family • Give water, more frequent BGs/insulin/carbs/ketone checks • Will need extra insulin doses – noOfy family; if needed, noOfy provider • Probably won’t feel well enough to go back to class (but might) • If vomiOng, heavy breathing, altered mental status; likely need to go to ED
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Extra insulin/Dose stacking
• Scenario: It’s 10:30am, BG 319 mg/dL, lunch is at 12:00. Tummyache.
• Ask what last BG was. If >300 or unknown, check ketones. • If ketones +, noOfy family (and if needed, noOfy provider); will need insulin • If ketones -‐, have a choice:
• Don’t give extra insulin. Check again at lunch, follow usual plan. • Give high BG correcOon if >3 hours since last insulin. Check BG at lunch; cover carbs but DON’T give high BG correcOon.
(<3 hours since last dose)
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Outline
• Describe roles of student, family, school nurse & healthcare team in management of diabetes at school
• Discuss pearls and piLalls of diabetes management at school
• Diabetes technology and brief look at future of diabetes management
• QuesOons
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Diabetes technology
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CGM -‐ now
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Diabetes technology – what’s coming
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Technology in school: My recommendaLons
• Student, parent, RN and teachers all need to have same understanding of what technology is present and who’s in charge (include in 504 plan) • CGM:
• Lows should be treated based on fingersOck • OK to dose insulin using CGM number if part of school orders; fingersOck preferred • If parents want CGM “trend arrows” to be a part of school orders, they should go through provider
• Device problems: • TroubleshooOng a device is up to the student and parent • If not resolved, contact device helpline • We usually respond in couple hours; device errors usually can’t wait that long
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Device burden
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Outline
• Describe roles of student, family, school nurse & healthcare team in management of diabetes at school
• Discuss pearls and piLalls of diabetes management at school
• Diabetes technology and brief look at future of diabetes management
• Ques?ons
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QuesLons
MSMG Pediatric Diabetes Evan Los, MD George Ford, MD MS Alexis Duty, FNP Morgan Armentrout, RN CDE Amy Kehely, RN Donna Brookshear, LPN
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PEGS, G-TUBES & BUTTONS
ALL YOU NEED TO KNOW...
Anjali Malkani M.D. Professor Pediatric Gastroenterology
.....AND WISH YOU HADN’T ASKED!
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PEGS, G-TUBES & BUTTONS-GOALS
Indications Methods of placement Types of tubes Care of G- tubes Complications of G- tubes
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WHAT IS A GASTROSTOMY TUBE?
• A flexible tube or
“button”
• Placed into the stomach
• Through an opening in the abdominal wall
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Candidates for a G - Tube
IN- Nutrition
Medications OUT- Decompression of gastric contents
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Indications for G-tubes
FTT cardiac disease CF
Swallowing dysfunction neurologically impaired esophageal stricture
Administer special formula metabolic disease Crohn’s disease
Decompression of stomach motility disorders
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Purpose of the G-Tube
To ensure : • Normal growth
and development
• Maintenance of health and wellness
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Types of G-tubes
Conventional catheters MIC Foley
PEG catheter-including one step
Low Profile Devices Balloon-secured
MIC-KEY HIDE-A-PORT MINI-BUTTON
Non-balloon secured BARD AMT
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G-tube placement
OPEN SURGICAL ENDOSCOPIC
(PEG) LAPAROSCOPIC
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Surgical or Open G-tube
Requires laparotomy and general anesthesia Placed under direct vision Sutured into place Low -profile tube can be placed initially Feedings started after post-op ileus resolves
(24-48 hours) Can change conventional tube to low profile
device sooner than with PEG
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G tube- Surgical Technique
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Percutaneous Endoscopic Gastrostomy (PEG)
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Pull Technique
Guidewire placed in stomach
Guidewire brought retrograde through patient’s mouth
PEG tube pulled through abdominal wall
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Percutaneous Endoscopic Gastrostomy placement (PEG)
Based on the principle of sutureless approximation of a hollow viscus to the peritoneum by a catheter
Does not require general anesthesia No post-op ileus - feeds started 6 hours after
placement Less post-op pain Less expensive with shorter hospital stay Changed to low profile device when track matures
- 3 months (except one step PEG)
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PEG tube – gastric view
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Immediate post -op care after PEG placement
Decompression of stomach initially Flush tube to ensure patency Rotate and clean tube site with peroxide NSAIDs for pain Start feeds at 6 hours post op. Begin with
clears at half maintenance rate and advance to goal by 18 hours after initiation.
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PEG : Influence on GERD
Wheatley, J Ped Surg,1991 Of 43 MR pts with no GERD pre PEG (UGI &pH
probe),14% (6)developed GER 10 mos after PEG placement
Anti-reflux procedure not recommended prophylactically if there is no pre PEG GERD.
Launay,Pediatrics, 1996 Of 20 pts(50% MR) ,65% had pre-PEG reflux 2/10 GER worsened after PEG ,trted medically 1/10 developed GER after PEG,trted medically
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PEG Removal
Removed when indication for placement resolved
Changed to low profile Gutbe in 3 months Gastrocutaneous fistula should be mature Removal technique dependent on PEG
features
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PEG change to Low Profile Device
When? 3 months after placement, so track can mature
How? Endoscopically: as FB removal under GA Traction: confirm with fluoroscopy
Type of tube? Always balloon secured: NEVER “button” which needs
obturator for placement Only with 16 Fr or larger PEGs
Confirm placement? Fluoroscopy if traction method used
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PEG Removal
Malleable internal bumper Remove via
traction technique Initially rotate
tube to disengage from fibrous tract
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Types of G-tubes
Conventional catheters MIC Foley
PEG catheter-including one step
Low Profile Devices Balloon-secured
MICKEY HIDE-A-PORT MINI-BUTTON
Non-balloon secured BARD GENIE (20 FR PEG ) AMT
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Low Profile G-tubes
Non Balloon Balloon
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Low Profile Gtubes
Balloon or Non- Balloon Balloon secured tube can be replaced by parent Non-balloon needs obturator- ONLY by physician
Length Of shaft In cm
Diameter In French
Brand “Mickey” “Mini”
“Cubby”
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Changing Balloon secured Gtubes
INITIAL CHANGE ONLY BY SURGEON/ GI DOC
Check size of balloon secured tube Length French
Use smaller French if unable to replace Don’t use force Send to ER ASAP as the site can close within 30 mins
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Insertion of Non-Balloon
Click here for Non-Balloon Insertion
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G-J tube
Through gastrostomy into jejunum Primary or thru previous Gtube site Interventional Radiology or endoscopy
Single or Double lumen Single lumen- only J port Double lumen- G and J port- feed via J and decompress via G
Type of tube Always balloon secured Low profile or conventional
Size Length of stoma, size of balloon, and length of J tube
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Gastrostomy Care
Cleaning peroxide for the first week, then daily bath
Rotate daily to avoid skin growth and irritation
Dry and open to air OK to swim in pool & ocean; avoid lakes
and ponds Out of reach
“onsie” or pin to diaper if conventional tube
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G – Tube Site Care
Cleanse site with mild soap and water Keep area clean & dry Observe the site for:
Redness Swelling Warmth Drainage/leakage Bleeding Unusual color or odor
Check site for granulation tissue
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Complications of G-tubes
Skin Infection Irritation Granulation tissue
Tube Blockage Leakage Dislodgement Displacement
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Complications of G-tubes- Skin
Infection fungal
bacterial Granulation tissue Irritation
Allergy to soap Irritation by tape Burn
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Skin: Infection-Bacterial
Erythema, gradually spreading
Tenderness Warmth Foul green/pus +/-T Boil
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Skin: Infection-Bacterial
Causes Staph/strep Poor hygiene Tight tube
Tx Antibiotics
Systemic/topical
Clean with saline
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Skin: Infection-Fungal
Red papular rash satellite lesions spreading away from site
Causes Excessive moisture Gtube in deep skin fold Immune suppression, steroids , DM Tx Anti-fungal Keep area clean and dry
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Skin- Irritant Dermatitis
Redness, swelling Leakage of gastric contents Overuse of cleaners, antibacterial meds Tx Acid blocking meds Barrier products Proper tube size Water in balloon
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Skin- Allergic Dermatitis
Papules, vesicles Crusting Itching Skin care products Latex New meds or foods touching skin Tx Remove irritant Barrier cream/powder
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Skin-Granulation tissue
Causes Opening too big Pivoting Excessive moisture, occlusive dressings Too much hydrogen peroxide
Pink cauliflower like ,beefy tissue Bleeds easily Yellow brown drainage
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Granulation Tissue – treatment
Silver nitrate sticks for 3 days Kenalog cream Stabilise tube Change size of tube DO NOT leave extensions on
when not in use Barrier powder-alum
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Tube-Blockage of tube
Causes Thick formulas Pill fragments Failure to flush- prevent this!! Defective tubing Tx Try milking tube , check for kinks Push and pull plunger Flushing with diet soda or 1/2 strength vinegar, baking soda, viokase
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Tube
Dislodgement - migrates into tract traction,seizure,wt gain painful, won’t flush,won’t turn, protrudes
Displacement- balloon deflates or falls out Needs to be replaced within 30 mins with any
tube If less than 12 weeks since placement call surgeon Care-giver can use same tube and tape into place if
they don’t have replacement tube Refer to ER even if site appears closed
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Tube -Leakage
Leakage through the center of tube valve broken- change tube failure to reset valve in button- flush tube Blood through the center of the tube requires medical
attention
Leakage around the tube Water in balloon isn’t enough- check amount Tube too long Don’t increase Fr of tube- makes stoma bigger Can leave tube out for 10 mins daily
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Buried Bumper Syndrome
Excessive traction on PEG tube Overtightening of skin disk
Ischemic necrosis of the gastric mucosa Migration of the internal bolster into the gastric or
abdominal wall
Prevention Confirm some laxity at initial insertion
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Buried Bumper Syndrome
Findings Resistance to flow PEG tube fixed, with surround subcutaneous
erythema Endoscopy
Ulceration, mucosal dimpling Nonvisualization internal bumper
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Buried Bumper Syndrome
Treatment Dissection of the buried appliance from the
abdominal wall Replace with new gastrostomy tube Large gastrocutaneous fistula may warrant
laparotomy/resection
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Different Methods of Tube Feeding
• Intermittent gravity -bolus • Timed intermittent-pump • Continuous-pump
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Farrell Valve Bag
Enteral Gastric Pressure Relief System
A patient suffering from poor gastric motility faces many problems; constant pain and discomfort due to the buildup of fluids and gas, the
threat of aspiration pneumonia, and often the inability to tolerate enteral nutrition.
Provides a channel to constantly decompress the stomach, allowing the stomach to empty at its own pace.
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Mouth Care
Maintain oral hygiene
Brush teeth after each meal Lubricate lips as needed Dental care as directed
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Parents/CareGivers ......
Hands on Teaching Handouts/ videos GI nurses - a phone call away Support groups - insideoutsidecare.com
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Push Technique
PEG tube advanced via modified Seldinger approach
May involve dilators, peel away introducer
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Push Technique
Advantages Single endoscope
passage Decreased “seeding”
from oropharynx (bacteria, malignant cells w/ head & neck ca.)
Disadvantages Loss of
pneumoperitoneum May require additional
T-fasteners
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Relative Contraindications
Coagulopathy Portal hypertension Peritoneal dialysis Large hiatal hernia Fundoplication required for preexisting
GERD Another intraabdominal procedure required
at the same time
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PEG: Basics
Gastric insufflation to bring stomach in apposition
Placement of catheter into gastric lumen Passage of guidewire into stomach Placement of gastrostomy tube Verification of proper position
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Factors to consider when selecting an enteral formula.
Patient-related factors Formula-related factors 1.Age 1.Caloric density 2.Underlying diagnosis 2.Osmolality 3.Digestive and absorptive capacity of the GI tract 3.Ease of preparation 4.Fluid, nutrient, and 4.Cost caloric needs 5.Food allergies 5.Insurance coverage 6.Route of administration 6.Availability at home
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Patient Preparation
Bite block May leave NG,
feeding tube Can follow tube down
esophagus Must take NG off
suction to allow for insufflation
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Upper Endoscopy
Routine flexible fiberoptic upper endoscopy
Complete endoscopy recommended 36% incidence of
anomalies Some may affect
procedure (ulcer, gastric outlet obstruction)
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Confirm safe position
Transillumination through skin suggests no other viscera interposed
Transillumination button (“high beams”) on light source
May be difficult in obesity Can assist with digital
pressure
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Confirm Position
Endoscopist watches while assistant indents abdominal wall at proposed insertion
Should see simultaneous indentation of gastric mucosa
Failure to see Reassess position Intervening viscerae Impossible apposition Inadequate insufflation
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Site Preparation
PEG kit opened after endoscopic confirmation of entry site
Select anticipated PEG insertion site Entry ~2 cm below costal
margin
Prep left upper quadrant with antiseptic prep of choice May be included in kit
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Surgical Technique
Kit contains: Local/syringe introducer Prep & drape Guidewire Endoscopic snare Scalpel Hemostat PEG External Bumper
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Surgical Technique
With area prepped and draped, reconfirm insertion site
Inject local anesthetic Skin and SQ Fascia
Make incision Alternate: incision
after wire placed
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Endoscopist
Retrieves snare, PEG tube from kit
Advances snare into
biopsy channel of endoscope
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Access
Insert needle/catheter assembly
Safe tract technique Continuous aspiration
via syringe Return of air without
visualization of needle in stomach signifies malposition
Remove, retry
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Endoscopist
While puncture performed, advance snare near intended puncture site
Snare the catheter prior to removal of needle to prevent loss
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Access
Remove syringe/needle
Cover catheter to prevent loss of insufflation
Advance guidewire into stomach Incision at insertion
site if not placed previously
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Endoscopist
After wire passed through catheter, endoscopist uses snare to grasp wire
Wire advanced Snare/wire pulled out
of mouth with endoscope as a unit
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Endoscopist
Endoscopist secures PEG tube to mouth end of guidewire
PEG internal bumper can be snared to allow easy passage of endoscope
Assembly passed back into stomach
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PEG Tube Position
Guidewire pulled through skin incision
PEG follows, tract dilated by conical dilator at end of PEG
Countertraction at skin level with non-dominant hand facilitates passage
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PEG Tube Position
PEG tube advanced Two resistance points
GE Junction Final position @ gastric
mucosa
Usually in position when external marker between 2-4 cm at skin level
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PEG Tube Position
Guidewire cut at tapered end of tube
Skin disk/external bumper applied over introducer and slid to skin surface
Bumpers should prevent movement but not blanch skin
Endoscopy may confirm no blanching of mucosa
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Completion of Procedure
Endoscope removed Option: place antibiotic ointment and/or
dressing under skin disk Tube cut to appropriate length Adapter secured to cut end of tube Leave to gravity
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Complications & Pitfalls
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Complications of PEG
Direct, major complications: 4% Mortality from complications: 25% High mortality attributed to patient
population Debilitated Cannot tolerate additional insult
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Complications of PEG placement
Pneumoperitoneum Peritonitis and sepsis Gastrocolic fistula Other organ injury-liver, small bowel Esophageal injury Wound infection Dislodgement of tube Development of, or worsening GE reflux
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Pneumoperitoneum after PEG
Expected event Up to 36%
Contributing factors Excessive air insufflation Prolonged procedure time Multiple percutaneous needle punctures of the stomach
Peritonitis <1% of PEGs ~30% mortality
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Pneumoperitoneum after PEG
No additional studies warranted unless signs of inflammation, peritonitis
Contrast study May detect gross extravasation
CT Scan Abdomen Extravasation Lack of apposition with abdominal wall Free fluid, suggestive of visceral perforation,
hemorrhage
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Dislodgement of PEG Tube
Concern when occurs prior to maturation of gastrocutaneous tract
Initial Rx Nasogastric suction Broad spectrum antibiotics
Surgery Failure to improve Overt peritonitis, sepsis
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PEG Removal
Rigid internal bumper Mandates repeat endoscopy PEG tube cut at skin Bumper snared endscopically Bumper may be obstructive, must be removed
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PEG Removal
Secure tube in one hand
Continuous steady traction Caution: “spray” of
gastric fluids May wrap tube around
hand Bumper inverts and
PEG removed
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PEG Removal
Fistula closes within 24 hours Persistent fistula
Granulation tissue/inflammation Silver nitrate sticks Anti acid therapy Rarely require resection/operative closure
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Peristomal Wound Infection
5-30% of cases Prophylactic Antibiotics
Single dose 30 minutes before procedure Narrow spectrum (e.g. cefazolin)
Skin incision Large enough to easily admit tube Smaller incision allows entrapment of bacteria ⇒ postop infection
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Necrotizing Fasciitis
Rare, devastating complication 43% mortality Initial presentation with cellulitis Source control essential
May mandate surgical closure of PEG site
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Gastrocolocutaneous Fistula
Early presentation Drainage of feculant material at PEG site
Late Detected after tube replacement: diarrhea
Colonic interposition during placement Dx: gastrograffin study, CT scan
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Hemorrhage
2.5% of cases Repeat endoscopy indicated for Dx,
possible Rx Often related to gastric ulceration under
internal bumper Pressure necrosis Friction
Caution in patients with coagulopathy
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Tube Migration
Inadequate stabilization Proximal migration
Vomiting, aspiration Migration into distal stomach
Gastric outlet obstruction Distention, vomiting
Distal migration (small bowel) Dumping syndrome
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PEG : Influence on GERD
Andrew, J of Ped Surg,1997 28%(n=39) with no GER pre PEG (onUGI/GES)
developed GER; 20% of these required Nissen within 6mos
Of 8 with pre PEG GER 25% required Nissen and 25% improved post PEG
Current practice for evaluation prior to PEG UGI-R/O anatomical problem eg malrotation pH probe -if symptomatic or neurologically
impaired
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Postoperative Nursing
Local care to prevent complications Especially important while gastrocutaneous
fistula is maturing Allow slack on tubing to prevent pressure/
traction complications
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Resumption of Enteral Nutrition
Postop “ileus” may be related to degree of insufflation
Orders Post PEG placement
Drainage for 4 hours Clamp for 2 hours Pedialyte for 6 hours( ½, then full maint) Formula for 6 hours continuous (1/2 str then full) Hold feeds for 3 hours Give first bolus.
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Timing of Feeding after PEG placement
Werlin ,GI endoscopy,1994 24 pts had feeding started 6 hrs after PEG. All had
feeds advanced with no intolerance Malkani,NASPGN,1996
Randomised 52 pts (after successful NG feeds) to early and late feeding groups post PEG
No difference in tolerance to feeds or catheter related problems in both groups
90% in early group were ready for discharge at 24 hrs, when the late group were starting feeds.
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Objectives
Indications and contraindications of PEG Upper flexible fiberoptic gastroscopy
Principles Procedures
Monitoring, sedation Surgical procedure
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Contraindications
Inability to perform upper endoscopy Obstructing esophageal tumor Stricture
Ascites Inability to appose gastrotomy to anterior
abdominal wall Previous subtotal gastric resection Hepatomegaly, esp left lobe
Abdominal wall infection or peritonitis
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Legal Issues in School Health
Regional Nurses Conference Kingsport, Tennessee
July 27, 2017 PresentaBon by Mike Billingsley, City AHorney for Kingsport, Tennessee
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LEGAL DISCLAIMER
• Nothing in this handout or presentaBon consBtutes legal advice. It is for general informaBon only, and no aHorney-‐client relaBonship is created. • Always contact your aHorney should you have any specific quesBons about any legal maHer. • Never rely on this informaBon as an alternaBve to legal advice from your aHorney. • Do not delay seeking legal advice, commence or disconBnue any legal acBon or disregard legal advice, or due to informaBon contained in this handout or presentaBon.
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Guidelines for Use of Health Care Professionals And Health Care Procedures in a School SeTng • hHp://www.tennessee.gov/assets/enBBes/educaBon/aHachments/csh_guidelines_healthcare_prof_proc.pdf
• A 121 pages documents that is vital for any school nurse to have and use. • It is free and available for prinBng or download at the website set out above.
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School Nurses are the Gatekeepers of School Children Health
• Do you agree or disagree?
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Privacy of Student Medical and Treatment Records and the Public School Nurse • What law applies Health Insurance Portability and Accountability Act of 1996 (HIPAA) or Family EducaBonal Privacy Rights Act (FERPA)?
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Health Insurance Portability and Accountability Act of 1996 (HIPAA) or Family Educa>onal Privacy Rights Act (FERPA)
• Joint Guidance on the ApplicaBon of the Family EducaBonal Rights and Privacy Act (FERPA) And the Health Insurance Portability and Accountability Act of 1996 (HIPAA) To Student Health Records
• hHps://www2.ed.gov/policy/gen/guid/fpco/doc/ferpa-‐hipaa-‐guidance.pdf
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Helpful InformaBon
• Dear Colleague LeHer to School Officials at InsBtuBons of Higher EducaBon issued August 24, 2016
• hHp://familypolicy.ed.gov/sites/fpco.ed.gov/files/DCL_Medical%20Records_Final%20Signed_dated_9-‐2.pdf
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HIPAA or FERPA
• Does the HIPAA Privacy Rule apply to an elementary or secondary school? • In most cases, the HIPAA Privacy Rule does not apply to an elementary or secondary school because the school either: (1) is not a HIPAA covered enBty or (2) is a HIPAA covered enBty but maintains health informaBon only on students in records that are by definiBon “educaBon records” under FERPA and, therefore, is not subject to the HIPAA Privacy Rule.
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HIPAA and the Public School Nurse
• Generally, a public school is not a HIPAA covered enBty because it does not engage in transacBons covered under HIPAA. • Covered enBBes are a health plan; a health care clearinghouse; or a health care provider who transmits any health informaBon in electronic form in connecBon with a transacBon pertaining to financial or administraBve acBviBes related to health care transacBons. 45 CFR § 160.103 – definiBon of transacBon. • Most schools do not engage in any transacBons covered by the definiBon of transacBon, which includes things such as billing a health plan electronically for payment of service.
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HIPAA and the Public School Nurse
• A school would be subject to a part of HIPAA (SimplificaBon Rules for TransacBons and Code Sets and IdenBfiers with respect to its transacBons -‐ 45 C.F.R. part 162 ) if it employs a health care provider that conducts electronic transacBons covered by HIPAA. • However, many schools, even those that are HIPAA covered enBBes, are not required to comply with the HIPAA Privacy Rule because the only health records maintained by the school are “educaBon records” or “treatment records” of eligible students under FERPA, both of which are excluded from coverage under the HIPAA Privacy Rule.
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Family EducaBonal Privacy Rights Act (FERPA)
• FERPA is a Federal law that protects the privacy of a student’s “educaBon records.” (See 20 U.S.C. § 1232g; 34 CFR Part 99). FERPA applies to educaBonal agencies and insBtuBons that receive funds under any program administered by the U.S. Department of EducaBon. This includes virtually all public schools and school districts and most private and public postsecondary insBtuBons, including medical and other professional schools.
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FERPA Applies to Public School Records
• At the elementary or secondary level, a student’s health records, including immunizaBon records, maintained by an educaBonal agency or insBtuBon, as well as records maintained by a school nurse, are “educaBon records” subject to FERPA. In addiBon, records that schools maintain on special educaBon students, including records on services provided to students under the Individuals with DisabiliBes EducaBon Act (IDEA), are “educaBon records” under FERPA.
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FERPA
• EducaBon records include a range of informaBon about a student that is maintained in schools in any recorded way, such as handwriBng, print, computer media, video or audio tape, film, microfilm, and microfiche • It prohibits a school from disclosing personally idenBfiable informaBon from students’ educaBon records without the consent of a parent or eligible student (18 or older), unless an excepBon to FERPA’s general consent rule applies. • HIPAA specifically excludes educaBon records, including shared treatment records, and unshared treatment records. (See 45 C.F.R. 160.103 definiBon of "Protected Health InformaBon")
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HIPAA or FERPA
• Even though a school employs school nurses, physicians, psychologists, or other health care providers, the school is not generally a HIPAA covered enBty because the providers do not engage in any of the covered transacBons, such as billing a health plan electronically for their services.
• Where a school does employ a health care provider that conducts one or more covered transacBons electronically, such as electronically transmiTng health care claims to a health plan for payment, the school is a HIPAA covered enBty and must comply with the HIPAA TransacBons and Code Sets and IdenBfier Rules with respect to such transacBons. However, even in this case, many schools would not be required to comply with the HIPAA Privacy Rule because the school maintains health informaBon only in student health records that are “educaBon records” under FERPA and, thus, not “protected health informaBon” under HIPAA.
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HIPAA or FERPA
• The school would have to comply with FERPA’s privacy requirements with respect to its educaBon records, including the requirement to obtain parental consent (34 CFR § 99.30) in order to disclose to Medicaid billing informaBon about a service provided to a student.
• If the nurse is hired as a school official (or contractor), the records maintained by the nurse or clinic are “educaBon records” subject to FERPA.
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HIPAA or FERPA
• Does HIPAA or FERPA or apply to elementary or secondary school student health records maintained by a health care provider that is not employed by a school? • If a person or enBty acBng on behalf of a school subject to FERPA, such as a school nurse that provides services to students under contract with or otherwise under the direct control of the school, maintains student health records, these records are educaBon records under FERPA, just as they would be if the school maintained the records directly. This is the case regardless of whether the health care is provided to students on school grounds or off-‐site.
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Disclosure of Records Under FERPA
• Parents have a right under FERPA to inspect and review these health and medical records because they are “educaBon records” under FERPA. See 34 CFR §§ 99.10 – 99.12. • Parents may also seek to amend educaBon records believed to be inaccurate; and • Parents may consent to the disclosure of personally idenBfiable informaBon from educaBon records, except as specified by law.
• In addiBon, these records may not be shared with third parBes without wriHen parental consent unless the disclosure meets one of the excepBons to FERPA’s general consent requirement.
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DefiniBon of Parent Under FERPA
• Under FERPA, a “parent” means a parent of a student and includes a natural parent, a guardian, or an individual acBng as a parent in the absence of a parent or guardian. 34 CFR § 99.3 definiBon of “Parent.” AddiBonally, in the case of the divorce or separaBon of a student’s parents, schools are required to give full rights under FERPA to either parent, unless the school has been provided with evidence that there is a court order, State statute, or legally binding document relaBng to such maHers as divorce, separaBon, or custody that specifically revokes these rights. 34 CFR § 99.4.
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Disclosure of Records Under FERPA without Parental Consent • A school may disclose a student’s health and medical informaBon and other “educaBon records” to teachers and other school officials, without wriHen consent, if these school officials have “legiBmate educaBonal interests” in accordance with school policy. See 34 CFR § 99.31(a)(1). • A school may permit disclosure of educaBon records, without consent, to appropriate parBes in connecBon with an emergency, if knowledge of the informaBon is necessary to protect the health or safety of the student or other individuals. See 34 CFR §§ 99.31(a)(10) and 99.36. Instances of abuse or neglect. • Instances of abuse or neglect.
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Disclosure to Medical Providers Under FERPA
• The HIPAA Privacy Rule allows covered health care providers to disclose PHI about students to school nurses, physicians, or other health care providers for treatment purposes, without the authorizaBon of the student or student’s parent. • Disclosures under FERPA can only be made with the consent of a parent or eligible students or under one of the excepBon listed in 34 C.F.R. § 99.31.
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Disclosure to Medical Providers Under FERPA
• Disclosure may be made to appropriate parBes, if the disclosure is in connecBon with a health or safety emergency. See 34 CFR §§ 99.31(a)(10) and 99.36. • hHps://www2.ed.gov/policy/gen/guid/fpco/pdf/ferparegs.pdf
• A student’s treatment records may be shared with health care professionals who are providing treatment to the student, including health care professionals who are not part of or not acBng on behalf of the educaBonal insBtuBon (i.e., third-‐party health care provider), as long as the informaBon is being disclosed only for the purpose of providing treatment to the student. Only allowed as long as the informaBon is being disclosed only for the purpose of providing treatment to the student.
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Consent to Disclose Records Under FERPA
• Under FERPA, a parent or eligible student (i.e., a student who has reached 18 years of age) generally must provide a signed and dated wriHen consent before the agency or insBtuBon discloses personally idenBfiable informaBon ("PII") from the student's educaBon records. 34 CFR § 99.30. • FERPA allows a parent to consent to the disclosure of a minor child’s educaBonal records, which includes personally idenBfiable informaBon, to third parBes. • Model Form for Disclosure to Parents of Dependent Students and Consent Form for Disclosure to Parents • hHps://www2.ed.gov/policy/gen/guid/fpco/ferpa/safeschools/modelform2.html
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Disclosures Under FERPA Without Consent (parBal list) • Schools are generally prohibited from disclosing personally idenBfiable informaBon about a student without the parent’s wriHen consent. • ExcepBons to this rule include: • disclosures made to school officials, including teachers, with legiBmate educaBonal interests; • In an emergency "if knowledge of the informaBon is necessary to protect the health or safety of the student or other individuals" (See 34 C.F.R. §99.36(a)).
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Disclosures under FERPA
• Can a list of students' health issues be distributed to teachers or other staff?
• A school-‐wide health concerns distribuBon list violates FERPA.
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Disclosures under FERPA
• Can school personnel talk to a student's health care provider without consent?
• Generally, schools must have wriHen permission from the parent or eligible student in order to release any informaBon from a student's educaBon record to outside parBes including providers. However, a school nurse may call a student's health care provider to clarify facts surrounding a student's condiBon or treatment plan.
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AdministraBon Of Meds and Procedures
• For the most part, the statutory authorizaBons are found in Tennessee Code Annotated (T.C.A.) secBon 49-‐50-‐1601 et seq.
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AdministraBon of Meds and Procedures -‐ T.C.A. § 49-‐50-‐1601 • T.C.A. § 49-‐50-‐1601 allows the self-‐administraBon of pancreaBc enzymes with wriHen authorizaBon from the healthcare provider and parent. A student with pancreaBc insufficiency or cysBc fibrosis is allowed to carry and self-‐administer prescribed pancreaBc enzymes.
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AdministraBon Of Meds and Procedures -‐ T.C.A. § 49-‐50-‐1602 • T.C.A. § 49-‐50-‐1602 requires certain health care procedures, including the administraBon of medicaBons during the school day or at related events, to be performed by appropriately licensed health care professionals. • T.C.A. § 50-‐1602 allows “...school personnel who volunteer under no duress or pressure and who have been properly trained by a registered nurse” to administer Glucagon in the event of a diabetes emergency in the absence of the school nurse. The guidelines were revised to address this change in law and to provide further clarificaBon for medical and nursing procedures performed in the school seTng. • T.C.A. § 49-‐50-‐1602 permits possession and self-‐administraBon of a prescribed, metered dosage, asthma-‐reliever inhaler by any asthmaBc student.
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AdministraBon Of Meds and Procedures -‐ T.C.A. § 49-‐50-‐1602 (conBnued) • T.C.A. § 49-‐50-‐1602 permits “school personnel to volunteer to assist with the care of students with diabetes, excluding the administraBon of insulin; • T.C.A. § 49-‐50-‐1602 allows school staff, who under no duress, volunteer to be trained in the administraBon of anB-‐seizure medicaBon, including diazepam rectal gel as prescribed by a licensed health care provider. • T.C.A. § 49-‐50-‐1602 provides that each school is authorized to maintain at least two epinephrine auto-‐injectors so that epinephrine may be administered to any student believed to be having a life-‐threatening allergic or anaphylacBc reacBon.
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AdministraBon Of Meds and Procedures -‐ T.C.A. § 49-‐50-‐1602 (conBnued) • T.C.A. § 49-‐50-‐1602 allows “...school personnel who volunteer under no duress or pressure and who have been properly trained by a registered nurse” to administer daily insulin to a student based on the student’s individual health plan in the absence of the school nurse. The guidelines were revised to address this change in law and to provide further clarificaBon for medical and nursing procedures performed in the school seTng.
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AdministraBon Of Meds and Procedures -‐ T.C.A. § 49-‐50-‐1603 • T.C.A. § 49-‐50-‐1603 (2017 Public Chapter 84) -‐ State Board of EducaBon will adopt rules for the administraBon of adrenal insufficiency medicaBon by school personnel if the healthcare provider is not immediately available. The school system is only required train personnel if noBfied by a parent/guardian that a student has the condiBon. The school system must adopt a policy. Removes liability when administering the medicaBon. EffecBve July 1, 2017.
• hHp://publicaBons.tnsosfiles.com/acts/110/pub/pc0084.pdf
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AdministraBon Of Meds and Procedures – 2017 Public Chapter 256 • 2017 Public Chapter 256 (likely to be added as T.C.A. § 49-‐50-‐1604) -‐ State Board of EducaBon will develop guidelines for the administraBon of an opioid antagonist for students experiencing an opioid overdose. The prescripBon will be held in the name of the school system. The school nurse, SRO, or other trained personnel may administer the medicaBon. There are provisions removing liability if a student is injured due to the administraBon of the medicaBon. This is effecBve July 1, 2017.
• hHp://publicaBons.tnsosfiles.com/acts/110/pub/pc0256.pdf
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Administra>on Of Meds and Procedures – Related Statutes • T.C.A. § 49-‐5-‐414 encourages LEAs to have CPR -‐ cerBfied individuals in their employment or as a volunteer. • T.C.A. § 49-‐3-‐359(b)(2) each public school nurse employed or contracted by an LEA will maintain current CPR cerBficaBon consistent with the guidelines of the American Heart AssociaBon • T.C.A. § 49-‐6-‐5004 authorizes health care professionals to indicate the need for a dental or vision screening on any report or form used in relaBonship to reporBng immunizaBon status for a child. Health care professionals shall provide a copy of the report or form to the parents or guardians indicaBng the need to seek appropriate follow up.
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Other Legisla>on – Telehealth Services
• Changes made by Public Chapter 130 to T.C.A. § 56-‐7-‐1002 -‐ Telehealth services • (ii) The paBent is at a qualified site or at a school clinic staffed by a healthcare services provider and equipped to engage in the telecommunicaBons described in this secBon; and equipped to engage in the telecommunicaBons described in this secBon; and, or at a public elementary or secondary school staffed by a healthcare services provider and
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Proposed Legisla>on S>ll Under Considera>on
• Changes by proposed SB534/HB503 would amend T.C.A. § 49-‐3-‐359 -‐ BEP funding for teacher's supplies, duty-‐free lunch periods, and school nurses.
• There is included in the Tennessee BEP an amount of money sufficient to fund one (1) full-‐Bme public school nurse posiBon for each three thousand (3,000) seven hundred fi9y (750) students or one (1) full-‐Bme posiBon for each LEA, whichever is greater.
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Proposed Legisla>on S>ll Under Considera>on
• Changes by proposed SB1055/HB1099 would amend T.C.A. § 68-‐55-‐501 -‐ Part definiBons.
• (3) "Health care provider" means a Tennessee licensed medical doctor (M.D.), osteopathic physician (D.O.), clinical neuropsychologist with concussion training, or physician assistant (P.A.) with concussion training who is a member of a health care team supervised by a Tennessee licensed medical doctor or osteopathic physician; or nurse prac??oner with concussion training who is a member of a health care team supervised by a Tennessee licensed medical doctor or osteopathic physician.
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Proposed Legisla>on S>ll Under Considera>on
• Changes by Proposed SB190/HB145 would amend T.C.A. § 68-‐11-‐313 -‐ AuthenBcaBon of verbal orders.
• (d) For the purposes of this secBon, telephone orders and orders by electronic means are considered verbal orders.
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Pediatric Sleep Apnea
Kelly Hare, FNP-‐BC Indian Path Center for Sleep Disorders
July 27, 2017
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Objectives:
1. Review Pediatric sleep architecture norms. 2. Define and describe Pediatric ObstrucKve
Sleep Apnea. 3. IdenKfy treatment opKons for Pediatric OSA. 4. Detail “CHAT” study findings. 5. Case Studies
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Sleep Architecture
A. NREM Sleep 1. Includes Stages 1, 2, SWS 2. Occupies 75% of TST
B. REM Sleep 1. AcKvated EEG (similar to wake) with
decreased or no muscle tone 2. Alternates with NREM every 90-‐100 minutes
with progressive lengthening in the la]er 1/3 on the night
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American Thoracic Society defines OSA
• A disorder of breathing during sleep characterized by prolonged parKal airway obstrucKon and/or intermi]ent complete obstrucKon that disrupts normal venKlaKon during sleep and normal sleep pa]erns.
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Pediatric OSA Incidence and Prevalence
1. Occurs in all ages with peak between 2-‐8 years
2. Occurs in 1-‐4% of the general pediatric populaKon
3. More likely to be seen in boys versus girls
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Risk Factors for OSA
1. Adenotonsillar Hypertrophy 2. Obesity 3. Craniofacial Anomalies 4. Familial PredisposiKon 5. Ethnicity 6. Prematurity
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Nocturnal Symptoms
1. Snoring 2. Paradoxical Breathing 3. Witnessed Apnea
4. Restless Sleep 5. Frequent Awakenings 6. Nocturnal Enuresis 7. Night SweaKng
Most sensiKve and specific
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DayKme Symptoms
1. Abnormal DayKme FuncKoning -‐ Less than 15% report dayKme sleepiness -‐ May present in children as irritability, nervousness, and aggressiveness. -‐ Impaired cogniKve funcKon
2. ADHD 3. Poor School Performance
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DayKme Symptoms – other consideraKons
1. Mouth breathing due to hypertrophied tonsils
and adenoids.
2. Recurrent URI
3. Hearing and speech difficulties
4. Morning headaches much less common than
adults but may be reported.
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Clinical Consequences – likely resulKng from intermi]ent hypoxia, sleep fragmentaKon, and inflammaKon. 1. RV and LV dysfunction
2. Systemic Hypertension
3. Pulmonary Hypertension
4. Poor Growth
5. Behavioral and Cognitive Impairment
6. ADHD
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EvaluaKon
1. Sleep Consultation
-focused sleep history
-physical exam including detailed exam of oropharynx
2. Polysomnography- the “Gold Standard” for diagnosis
of OSA. The only tool capable of definitively identifying
obstructive events and quantifying severity of OSA, including
gas exchange abnormalities and sleep disruption.
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Polysomnography
1. Nasal and oral airflow sensors
2. Snore microphone
3. Respiratory impedance plethysmography
(RIP Belts)
4. Pulse oximetry
5. EKG
6. Capnography
7. EEG
8. Body position
9. Muscle tone (chin and lower extremities)
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Diagnosis
1. Clinical Criteria – one or more of the following: snoring,
labored, paradoxical, or obstructed breathing in sleep
WITH
2. Polysomnographic criteria – one obstructive apnea,
mixed apnea or hypopnea per hour of sleep and/or
obstructive hypoventilation with at least 25% TST with
hypercapnia (PaCO2>50mmHg) with snoring, flattening of
the nasal pressure waveform, paradoxical
thoracoabdominal motion.
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Assessment of Severity – no clear cut classificaKon of OSA in children has gained uniform acceptance. PSG findings should be interpreted by a Sleep Medicine Physician using all the PSG parameters and in the context of the child’s symptoms and contribuKng risk factors.
1. Mild OSA –AHI 1-4.9
2. Moderate OSA – AHI 5-9.9
3. Severe OSA – AHI >10
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ObstrucKve Sleep Apnea • Treatment OpKons
• Tonsillectomy and Adenoidectomy • CPAP (conKnuous posiKve airway pressure) • “Watchful WaiKng?”
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ObstrucKve Sleep Apnea • The Childhood Adenotonsillectomy Trial (CHAT) 2013
– Hypothesis: In children with OSA without prolonged
oxyhemoglobin desaturation, early AT, as compared
to “watchful waiting” would result in improved
outcomes.
– Multi-center, single blind, randomized, controlled trial
– 464 children ages 5-9
– Excluded for Severe OSA and/or oxyhemoglobin
saturations <90% for 2% TST or longer, recurrent
tonsillitis, meds for ADHD, and z score based on BMI
of 3 or greater
– PSG and cognitive/behavioral testing at baseline and
then again at 7 months. Caregiver surveys and
behavioral assessments from teachers also collected
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ObstrucKve Sleep Apnea
• The Childhood Adenotonsillectomy Trial (CHAT)
2013
Early AT group: improvements in symptoms, behavior,
QOL, and PSG findings
Effect size: moderate to large indicating clinical
significance
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ObstrucKve Sleep Apnea
BUT-
No significant improvements in attention or
executive function and no decline in the “watchful
waiting” group.
SO-
Medical management and reassessment after a
period of observation may be a valid therapeutic
option.
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CASE STUDY 1
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Case Studies
B.M. 3y/o male
CC: “He stops breathing in the
middle of the night.”
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Case Studies Hx:
Little witness to sleep until moved into grandparents
home in a shared bedroom with mom in his own bed.
Snores in all sleep positions.
Sleeps with mouth open.
+Sleeptalking
Mom questions effort to breathe.
Breathes “funny.”
Bedtime 9p/10p weekend
Rise time 0615 / 1000 weekend
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Case Studies
Social history:
Headstart
No behavioral problems
Behind in learning for age
Grandparents smoke “outside”
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Case Studies
Past Medical History:
Abnormal chromosome analysis
Microcephaly
RAD
Small Stature
Speech Delay
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Case Studies FH: Sleep apnea in 1 cousin
Meds: None
PE:
BP 100/65
HR 123
O2 sats 98%
Ht: 38in
Wt: 26lbs
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Case Studies PSG Findings
Sleep Eff: 88.4%
N1: 0.1%
N2: 33.4%
SWS: 56.6%
REM: 9.8%
Arousals: 27.4/hr
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Case Studies PSG Findings
OH: 113
OA: 5
CA: 32
MA: 7
**AHI: 23.1
REM AHI: 69
Supine AHI: 17.9
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Case Studies PSG Findings
PLMS: 1.6
EKG: NSR/SA
Capnography: WNL
Lsat 50%
Sat<88% 50min TST
PLAN: ENT evaluation for T&A
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CASE STUDY 2
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Case Studies
A.L. 7 y/o male
-Referred by ENT for snores
-Snores in all sleeping positions
-Oral breathing in sleep and wake
-Restless in sleep/moves frequently
-Whines and whimpers in sleep
-Rare bedwetting
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Case Studies
-Bedtime 830p/10p on weekends
-LSO 30 minutes
-Uses tablet and TV before bed
-Shares bedroom with 14y/o brother
-Rise time 7a/8a weekend – difficult to wake
-No problems at school
-FT/no delivery complications
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Case Studies PMH
-PE Tubes
-ADHD
-Obesity
-New onset absence seizures
FH
-RLS – Aunt, GGM.
-OSA - GF
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Case Studies SOC
-Mom deceased/Grandmother with custody
-2nd
grade
-No tobacco exposure
MEDS
-Keppra
-Loratadine
-Fluticasone
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Case Studies
EXAM
BP: 112/67
HR: 98
Pulse Ox: 99%
Ht: 56.5in
Wt: 140lbs
Remainder of exam unremarkable except for 3+ tonsils
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Case Studies
PSG
SE 91%
OH 118
MA 12
OA 1
CA 82
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Case Studies PSG
AHI 33
LSAT 86%
2% TST with CO2 56-60mmHg
PLMI 2/hr
No arrhythmia
No seizure activity
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Case Studies
PLAN: Referred to ENT for T & A.
Repeat PSG:
AHI 5.2
CO2 never above 50mmHg
Plan: CPAP at 5cm with full face mask
Sleeping better, Likes cpap, No snores on therapy,
No restlessness, Easier to wake
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Pediatric Sleep Disorders
References:
www.uptodate.com
www.aasmnet.org American Academy of Sleep Medicine
www.sleepfoundation.org National Sleep Foundation
Principles and Practice of Pediatric Sleep Medicine. 2nd
ed.
Sheldon, DO FAAP, Stephen H.
“A Randomized Trial of Adenotonsillectomy for Childhood Sleep
Apnea.” Carol L. Marcus, et al. NEJM 2013; 368; 2366-76.
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