**TAG M: HEALTH CARE GUIDELINES**

**TABLE OF CONTENTS**

**1.0 INTRODUCTION** 1

1.1 BACKGROUND AND NEED 1

1.2 Expected Benefits Of Specific Written Instructions 1

1.3 POLICY 2

1.4 BASIC CONCEPTS 3

1.4.1 Types of Instructions Required 3

1.4.2 Health Care Guidelines 4

1.4.3 Summary of the Different Documents 5

1.5 THE PROCESS OF REVIEW AND APPROVAL 5

1.6 NATIONAL OFFICE RESPONSIBILITIES 6

1.  The Minimum Set Of Treatment and Symptomatic

> Management Guidelines 6

1.6.2 Technical Assistance 9

1.6.3 Training Assistance 9

1.7 REGIONAL OFFICE RESPONSIBILITIES 9

1.8 AGENCY RESPONSIBILITIES 9

1.9 CENTER RESPONSIBILITIES 9

**2.0 AUTHORIZATIONS** 11

**3.0 PROFESSIONAL STANDARDS OF CARE** 12

3.1 CURSORY PHYSICAL EXAMINATIONS 12

3.2 LABORATORY STUDIES 12

3.3 IMMUNIZATION PROTOCOLS 12

4.  BIOCHEMICAL TESTING (ON ENTRY/ON SUSPICION/

> AFTER INTERVENTION) 12

3.5 MEDICATION PROTOCOLS 13

3.6 MANAGEMENT OF MEDICAL EMERGENCIES 13

3.6.1 Life-threatening Emergencies 13

3.6.2 Urgent Situations 15

3.  Health Emergencies Or Urgencies Occurring When Health Staff

> Are Not Available or Readily Reachable 16

3.6.4 Non-Student Health Problems 16

3.6.5 Reporting of Actions Taken and Referral of Students Off Center 17

3.6.6 Records 17

3.6.7 Physician Visits 18

3.6.8 Emergency Calls 18

3.7 MENTAL HEALTH EMERGENCY 18

3.7.1 Special Consideration for Psychiatric Problems 18

3.7.2 Restraints 18

3.7.3 Suicide Risk 19

3.7.4 Individual Accommodations for Behavioral or Mental Health Reasons
19

3.8 ORAL HEALTH EMERGENCY 20

3.9 PROMOTION OF WELLNESS THINKING AND A HEALTHY LIFESTYLE 20

**4.0 TREATMENT GUIDELINES** 21

**5.0 SYMPTOMATIC MANAGEMENT GUIDELINES** 92

**APPENDICES**

A Job Corps Medications Lists

B Review Package---Sample Cover Memo to Regional Nurse Consultant

C Sample Personal Authorizations

**1.0 INTRODUCTION**

Health Care Guidelines provide information concerning accepted practices
for common health problems and situations in Job Corps. The guidelines
may be used "as is", or modified by the appropriate health care
professional, as documented in a separate guideline for each item.

**1.1 Background And Need**

Before November 1977 when Standing Orders were implemented, documents
that described the delivery of health services, the policies and
procedures that governed the provision of health care, and the staff
members who were authorized to perform health-related functions did not
exist. Although there were documents that described some procedures,
such as how and when wellness check was held, or how sick or injured
students were to be cared for at night and on weekends, etc., these
procedures were often insufficiently described.

Since most Job Corps centers only have the services of a physician[^1]
for a few hours each week, many health and non-health staff are called
upon to assess medical, dental, and mental health problems, and even to
provide treatment in the center physician\'s absence. Thus, "Standing
Orders" were introduced to help staff perform various health-related
functions via specific written instructions.

In 2004, a major overhaul of the original Standing Orders occurred and
are now collectively called "Health Care Guidelines." Technical orders
have been revised to become professional standards of care, treatment
guidelines, and symptomatic management guidelines. Professional
standards of care may require modification to meet individual state
medical and nursing board regulations.

**1.2 Expected Benefits Of Specific Written Instructions**

There are several reasons why it is important that each center has
specific written instructions to be used throughout Job Corps. They are
designed to:

-   Help ensure the safety and comfort of students

-   Provide evidence-based scientific rationale to support decisions
    regarding treatment of students

-   Decrease the possibility of medicolegal concerns for center staff

-   Provide information and training on current health care practices
    for the staff

-   Save time for the consulting medical personnel to address other
    problems requiring their special attention

-   Allow the center physician to assume a supervisory/teaching role
    rather than only a service delivery role

-   Facilitate the orientation of new health and non-health staff

-   Provide non-health staff with direction for action, especially when
    a member of the health services staff is not available or not on
    center.

**1.3 Policy**[^2]

1.  The health care guidelines must include guidance concerning
    emergency procedures, procedures that can be performed by
    non-physician personnel, care of commonly encountered health
    conditions, and authorizations for health and non-health staff.

2.  All health care guidelines must be approved and signed by the center
    physician, center mental health consultant (CMHC), and center
    dentist, as appropriate, at least annually.

3.  The center physician, center mental health consultant, center
    dentist, and health and wellness manager must provide current signed
    and dated health care guidelines, which must be kept in the health
    and wellness center. These health care guidelines must indicate the
    care and procedures to be carried out by the center health
    personnel.

4.  The center physician must specify which tasks each member of the
    health staff is authorized to perform. Health staff authorizations
    must be completed for each health staff member and submitted to the
    regional office when established or changed. A copy of the health
    staff authorizations should be kept in the health and wellness
    center. The original health staff authorizations should be kept in
    the employee's personnel file.

5.  The center physician must provide a set of signed and dated written
    guidelines for the guidance of non-health personnel when dealing
    with health emergencies, urgent situations, and routine illnesses
    (e.g., flu, cold).

6.  The center physician must determine the situations in which the
    nurse and/or physician on call will be contacted in accordance with
    the professional standards of care for the management of an
    emergency or urgent situation.

7.  Non-health staff authorizations shall be completed and approved by
    the center physician for all non-health personnel to indicate the
    level of care that staff may provide after appropriate training.
    Copies of these authorizations will be kept in the employee\'s
    personnel file.

8.  Annually, each center shall submit a memorandum to the regional
    office indicating which health care guidelines have been modified.
    Copies of any individual health staff authorizations and health care
    guidelines that have changed shall be sent to the regional office
    for approval. (Refer to PRH-5: Exhibit 5-2, Plan and Report
    Submission Requirements, for reporting deadlines.)

9.  When health care guidelines are disapproved, the appropriate
    regional health consultant must contact the center health
    professional, discuss any concerns, and request resubmission.

10. When health care guidelines are approved, the regional nurse
    consultant must notify the project manager who will then notify the
    center.

**1.4 BASIC CONCEPTS**

1.  **Types Of Instructions Required**

Four types of written instructions are needed to deal with all
components of the Job Corps health care program.

1.  **Authorizations** are directives that outline the limits of the
    health care activities that specific members of the staff are
    expected to perform in particular situations. (See section 2.0,
    Authorizations.)

    2.  **Professional Standards of Care (PSOC)** are directives that
        are designed to support the health services staff by organizing
        the procedures to be used. These administrative guidelines
        outline policies and basic procedures for situations including
        how to handle emergencies and urgent situations; thus, improving
        the safety of students. PSOC must be consistent with individual
        state medical and nursing board regulations.

    3.  **Treatment and Symptomatic Management Guidelines** are
        directives that outline different points to consider and steps
        to take when the health or non-health staff is presented with a
        student\'s health problem. These guidelines specify the
        treatments to be administered or offered by a staff member.
        These guidelines also outline the steps to determine whether to
        refer a student to the center physician, off-site health
        professional, or emergency service.

4\. **Medications,** found in Appendix A, contain the Job Corps
Medication Lists. These lists includes both prescription and
non-prescription medications used to treat common medical, mental
health, and oral health conditions in a cost-effective manner. These
medications can all be ordered from the Perry Point catalog. This list
is updated biannually.

The Job Corps List of Preferred Medications does not constitute an
exclusive formulary. Center clinicians may prescribe other medications
for Job Corps students. Third party reimbursement for prescriptions
should be sought whenever possible.

The non-prescription medications list contains a recommended list of
medications that each center should make available to the non-health
staff in residential areas so that symptomatic management guidelines can
be instituted until the affected student receives treatment in the
health and wellness center.

**1.4.2 Health Care Guidelines**

Health care guidelines are written directives that must be followed,
especially when the center physician is not present. This ensures that
the center physician knows and approves of how the staff will handle a
problem. Good health care guidelines have the following characteristics:

-   A signature and date when the guidelines were last reviewed; review
    treatment guidelines at least once a year at the time of contract
    renewal for contract centers and at the beginning of the fiscal year
    for conservation centers, as well as when there is a center
    physician personnel change, to keep current.

-   A signature or initial by all responsible persons (e.g., center
    physician, center dentist, center mental health consultant, health
    and wellness manager) as appropriate.

> Note: The center director no longer needs to sign these medical
> documents. The center director needs to assure these medical documents
> are reviewed and signed each year.

-   Clarity and conciseness; all health care guidelines should leave no
    room for guessing and should consist of definite directions
    describing how and who is to handle the problem.

-   A reflection, in writing, of handling a health-related situation
    that combines good health care and good judgment.

They must be implemented by a nurse or non-health staff member whose
training and experience qualifies her/him for the task.

**1.4.3 Summary Of The Different Documents**

TAG M provides an overview of health care guidelines including
recommended treatment and symptomatic management guidelines for health
and non-health staff. These guidelines and all future guidelines
developed by the National Office are considered recommendations. Each
order may be used exactly as is or modified to meet the needs of each
center by the appropriate center health consultant.

Each center should maintain a current copy of all the center's health
care guidelines and authorizations. It is recommended that each center
maintain a copy of TAG M on file in the health and wellness center,
center director's office, residential advisor offices, and security
office.

Once the recommended health care guidelines are reviewed, adopted, or
tailored by the center health consultants, they are no longer
recommendations but actual center health care guidelines that must be
followed by all staff members.

**1.5 THE PROCESS OF REVIEW AND APPROVAL**

This TAG contains a basic set of authorizations, treatment guidelines
for health staff, and symptomatic management guidelines for non-health
staff.

After discussion, the center physician and health and wellness manager
(HWM), as appropriate, may adopt as written or modify any or all of the
guidelines and authorizations in this basic set.

After tailoring the guidelines to the center\'s specific needs, assemble
one review package (see Appendix B), to send to the regional office for
approval each year at the time of contract renewal for contract centers
and at the beginning of the fiscal year for conservation centers. A
review package should consist of a cover memo including:

-   A listing of the health care guidelines that have been changed and
    copies of the modified guideline(s) attached for review. (Guidelines
    without change need not be sent for annual review.)

-   The personal authorizations for new health staff members. If new
    staff have been hired or a major change in authorizations has
    occurred, attach the modified (or new) authorization for review.
    Authorizations for new health staff should be completed and
    forwarded for review within 15 days after employment. Authorizations
    for non-health staff members do not have to be submitted, but should
    be kept on center readily available for use and review.

Send this entire package to the regional office for review annually.
Conservation centers will send the review package through agency
channels. The regional nurse consultant will review and recommend
approval to the project manager; or disapproval to the center health
professional so the guidelines can be discussed and resubmitted as
needed.

**1.6 National Office Responsibilities**

**1.6.1 The Minimum Set of Treatment and Symptomatic Management
Guidelines**

The following list, developed by the National Office, constitutes a
basic set of treatment guidelines for a center\'s **health staff**.

  -------------- ------------------------------ ---- -------------------------------
  **TREATMENT                                        
  GUIDELINES**                                       

  **Medical**                                        

  1              Acne                           28   Hepatitis

  2              Acute Alcohol (Ethanol)        29   Hypertension
                 Intoxication                        

  3              Allergic/Contact Dermatitis    30   Impetigo

  4              Asthma                         31   Infectious Mononucleosis

  5              Bacterial Endocarditis         32   Influenza
                 Prophylaxis                         

  6              Bacterial Vaginosis            33   Lacerations

  7              Bites and Stings               34   Lyme Disease

  8              Bronchitis and Pneumonia       35   Muscle Injury

  9              Burns                          36   Nicotine Replacement Therapy

  10             Candida (Yeast) Vulvovaginitis 37   Nocturnal Enuresis

  11             Chlamydia Infection            38   Oral Herpes Infection

  12             Conjunctivitis                 39   Otitis Externa

  13             Constipation                   40   Otitis Media

  14             Depo-Provera                   41   Pap Smear Abnormalities

  15             Diabetes (Type I/II)           42   Pelvic Inflammatory Disease
                                                     (PID)

  16             Dysmenorrhea                   43   Pubic Lice (Pediculosis Pubis)

  17             Emergency Contraception        44   Scabies (Sarcoptes scabiei)

  18             Fever                          45   Seizure Disorder

  19             Fractures                      46   Sexual Assault

  20             Frostbite                      47   Sprains/Dislocations

  21             Fungal Skin Infections         48   Syphilis (Primary and
                                                     Secondary)

  22             Gastroenteritis/Enteritis      49   Trichomonas Infection

  23             Genital Herpes Infection       50   Tuberculin Skin Test Conversion

  24             Gonococcal Infection           51   URI, Pharyngitis, Sinusitis

  25             Head Injury (Closed Head       52   Urinary Tract Infection
                 Trauma)                             

  26             Headache                       53   Warts (Common)

  27             Heat Injuries                  54   Warts (External Genital)

  **Oral                                             
  Health**                                           

  1              Avulsed Tooth                       

  2              Oral Bleeding                       

  3              Oral Infection                      

  4              Oral Pain                           
  -------------- ------------------------------ ---- -------------------------------

  ---------- ------------------------------------------------------------------
  **Mental   
  Health**   

  1          Alcohol or Drug Use Behavior

  2          Anxiety Disorders (Including Panic and Phobic Disorders)

  3          Attention-Deficit/Hyperactivity Disorder (ADHD)

  4          Depression/Bipolar Disorder

  5          Post-Traumatic Stress Disorder (PTSD)

  6          Psychotic Disorders

  7          Suicidal Behavior
  ---------- ------------------------------------------------------------------

The following list, developed by the National Office, constitutes a
basic set of symptomatic management guidelines for a center's non-health
staff.

  --------------- ------------------------------ ---- -------------------------------
  **SYMPTOMATIC                                       
  MANAGEMENT                                          
  GUIDELINES**                                        

  **Medical**                                         

  1               Abdominal Pain                 13   Headache

  2               Asthma                         14   Heat Injuries

  3               Burns                          15   Lacerations

  4               Cold and Sinus Congestion      16   Menstrual Cramps

  5               Constipation                   17   Muscle Injury

  6               Coughing and/or Difficulty     18   Nosebleed
                  Breathing                           

  7               Diarrhea and Nausea            19   Rash

  8               Earache                        20   Seizure Disorder

  9               Fever                          21   Sore Throat

  10              Fractures                      22   Sprain/Dislocation

  11              Frostbite                      23   Vomiting

  12              Head Injury                         

  **Oral Health**                                     

  1               Knocked-out Tooth                   

  2               Oral Bleeding                       

  3               Oral Pain                           

  **Mental                                            
  Health**                                            

  1               Alcohol or Drug Use Behavior        

  2               Behavior Changes/Unusual            
                  Behavior                            

  3               Suicide Attempts or Threats         
  --------------- ------------------------------ ---- -------------------------------

**Non-health staff should not attempt to follow Treatment Guidelines
unless a signed and dated authorization exists for the non-health staff
member.**

**1.6.2 Technical Assistance**

In the course of their center visits, regional health consultants (RHCs)
represent the National Office and will clarify the health care
guidelines for the center health staff if necessary. The RHCs and the
National Office will help any center\'s health staff write additional
health care guidelines, on request. Finally, the National Office will
write additional guidelines as the need arises.

**1.6.3 Training Assistance**

New center staff members should be trained in the use of health care
guidelines at the time of hire and/or during RHC technical assistance
visits. In addition, special training may periodically be arranged, if
funds allow. Such training should be requested through the regional
office.

**1.7 Regional Office Responsibilities**

The review package (see Appendix B), containing modified health care
guidelines and/or modified authorizations submitted by the centers, is
reviewed by the RNC within 10 working days. The RNC will review, consult
with other RHCs as needed, and recommend approval to the project
manager; or disapproval to the center health professional so the
guidelines can be discussed and resubmitted as needed.

Regional office responsibilities include:

-   Determining that each center has current signed and dated health
    care guidelines and authorizations on center and that the center
    staff understands and uses them.

-   Handling any problems encountered in obtaining the signatures of the
    responsible center personnel. This should be done on an individual
    basis.

**1.8 Agency Responsibilities**

The agencies responsible for operation of civilian conservation centers
(Departments of Agriculture and Interior) should support the
implementation of health care guidelines at their centers. Support may
include monitoring center operations to ensure that guidelines are
complete and that the health care guidelines are available for use.

**1.9 Center Responsibilities**

At each center, the responsible personnel are encouraged to adopt or
modify health care guidelines as needed and to write additional
guidelines to be added to the center\'s basic set. **Again, it is
stressed that the guidelines for each center should be tailored to that
center\'s needs.**

After the guidelines are tailored to meet a center\'s special needs and
before approval from the regional office, the modified health care
guidelines may be used on a provisional basis if approved by the
responsible persons. These persons include:

-   **Center director and center physician**---the center director is
    responsible for seeing that all staff are trained in the use of
    these guidelines and should provide regular in-service training for
    staff. The center physician is responsible for reviewing, updating,
    and signing the guidelines annually.

-   **Health and wellness manager, center dentist, center mental health
    consultant, and health staff**---these persons are responsible for
    adopting or adapting the basic set of health care guidelines in
    TAG M. In order to carry out this responsibility, the HWM and center
    physician should discuss the center\'s needs with the center
    director. Health staff members should also understand how to use the
    symptomatic management guidelines and should assist in training
    non-health personnel in their use.

It is very important that all staff members understand the health care
guidelines that apply to them. It is staff members, not the center
physician, who spend the most time directly caring for students.
**However, it is also very important that these guidelines be reviewed
and approved by the center physician, because it is the physician who
carries the final responsibility for diagnosing and treating students.**

**2.0 AUTHORIZATIONS**

Authorizations are directives that outline the limits of the health care
activities that specific members of the staff are expected to perform in
particular situations. The center physician will specify which tasks
each health staff member is authorized to perform. All health staff
members will have personal authorizations on file in the health and
wellness center.

The center physician in consultation with the center director, health
and wellness manager, center dentist, and center mental health
consultant will specify which tasks each non-health staff member is
authorized to perform after proper training. It is particularly
important that those staff members who are expected to provide health
services are authorized to perform those services or to call the local
emergency response team. Health and non-health personnel must be told
what medical procedures their authorizations allow. A copy of each staff
member's personal authorization must be filed in his/her personnel
record. The original authorization should be kept in health services.
See Appendix C for detailed sample authorizations for health and
non-health staff.

**3.0 PROFESSIONAL STANDARDS OF CARE**

This section includes examples of professional standards of care (PSOC)
with appropriate references to the Job Corps Policy and Requirements
Handbook (PRH) sections and/or corresponding Technical Assistance Guides
(TAGs). It also includes a brief discussion of the need for health
education, follow-up, and documentation of the use of treatment
guidelines and symptomatic management guidelines in the student's health
record.

For clarification of any of these PSOC, review your state medical and
nursing board regulations and contact your regional health consultants.
(See Job Corps Health and Wellness website, www.jobcorpshealth.com for
contact information.)

## 

## 

## **3.1 Cursory And Physical Examinations**

Cursory and physical examinations will be performed according to PRH-6:
6.10, R1(a,b). Centers will perform these exams according to their
desired schedules, but they must be completed within the PRH-designated
timeframes.

## 

## 

## **3.2 Laboratory Studies**

## 

## All incoming students will have mandatory laboratory studies obtained according to PRH-6: 6.10, R1(c). Whenever possible (unless waived) the nationally contracted laboratories and lower cost state laboratories will be used for economy. Students must be promptly informed of any abnormal results and receive appropriate treatment. Each center may determine if additional optional laboratory studies are obtained at their own expense.

## 

## 

## **3.3 Immunization Protocols**

Immunizations should be given according to guidelines outlined in PRH-6:
6.10,

R1(d,e) and further detailed in TAG B: Immunizations and Communicable
Disease Control.

**3.4 Biochemical Testing (On Entry/On Suspicion/After Intervention)**

Students will receive biochemical testing on entry, on suspicion of use,
and when indicated, after intervention services have been provided.
Mandatory testing requirements and timeframes are found in PRH-6: 6.11,
R1(c). Testing should follow the procedures in the Treatment and
Symptomatic Management Guidelines for Biochemical Testing. Test results
must be documented in the student's health record with appropriate
interventions and referrals as indicated (e.g., to TEAP, CMHC). See TAG
L: Trainee Employee Assistance Program (TEAP) for further details.

**3.5 Medication Protocols**

Medications should be stored and dispensed in accordance with federal
and state practice acts/laws. The appropriate Treatment Guidelines for
Health Staff should be followed. It is the responsibility of the center
physician and HWM to determine the security, accessibility, appropriate
storage, and adequacy of medication supplies. (See Appendix A for list
of Job Corps Preferred Medications and List of Non-Prescription
Medications that should be available at all times to non-health staff.)

**3.6 Management of Medical Emergencies**

This PSOC provides instructions regarding procedures to use when
confronted with an emergency or a health problem urgent enough to
warrant immediate examination by a physician. Since some problems are
more serious than others, and since non-health staff may have to respond
to a problem in the health staff\'s absence at night and on weekends,
there are four disposition options.

###### 3.6.1 Life-threatening Emergencies

[Life threatening emergencies are those that can cause death in
minutes]{.underline}. They include the inability to breathe, inability
of the heart to pump at a normal rate (heart rate \< 40 or \> 200), and
uncontrolled bleeding (with or without the loss of consciousness).
Conditions that may cause these symptoms include:

-   Severe allergic reaction (anaphylaxis)

-   Choking on food

-   Attempted suicide

-   Poisoning/drug overdose

-   Gunshot or knife wounds

-   Head trauma

-   Extensive burns

-   Shock

-   Drowning

-   Severe chest pain/severe asthma with difficulty breathing

**Disposition I** describes what **health staff or authorized non-health
staff trained in first aid and cardiopulmonary resuscitation (CPR)**
should do with any student who presents a life-threatening emergency
condition. Contact the local emergency response team first. It is
expected that all health personnel have knowledge of basic CPR and first
aid (see American National Red Cross Manual, [Standard First Aid
Workbook]{.underline}). Some health staff members may have more advanced
skills. Health staff members should discuss with the center physician
expectations regarding how emergencies should be handled, and what
skills and equipment are necessary and available. All health staff and
authorized non-health staff members should familiarize themselves with
the lifesaving measures included in Disposition I.

# DISPOSITION I

-   **Contact the local emergency response team first (Call 911**).

-   **Maintain airway and administer CPR**. Specific training for the
    specialized skills needed to establish and maintain an airway, and
    to perform artificial respiration and chest compressions, are
    available through the American Red Cross (see PRH-5: Exhibit 5-4).

-   **Control bleeding**. Bleeding is controlled by applying direct
    pressure to the wound or by using a tourniquet. The use of a
    tourniquet is dangerous, and should be reserved only for a severe,
    life-threatening hemorrhage that cannot be controlled when direct
    pressure on appropriate pressure points fails to stop bleeding from
    an arm or leg. The decision to apply a tourniquet is in reality a
    decision to risk sacrifice of a limb in order to save a life. Nearly
    all external bleeding can be controlled by putting pressure over the
    affected vessels. Even minor lacerations (e.g., scalp lacerations)
    can cause significant blood loss if unattended.

-   **Monitor vital signs**. If qualified to do so, measure blood
    pressure, pulse, and respiratory rate to determine if the student is
    developing shock, and monitor every 5 to 10 minutes.

-   **Prevent and treat for shock**. Shock is defined as circulatory
    collapse with low blood pressure. As it progresses, rapid heart
    rate, clammy skin, and loss of consciousness will develop. Shock may
    occur as a result of blood loss, dehydration, massive infection,
    heat stroke, and severe allergic reaction. Appropriate management,
    after establishing an airway and making sure the student is
    breathing, begins with laying the student flat and elevating the
    legs.

> If no health staff member is trained and authorized to administer
> intravenous fluids, other anti-shock measures, including keeping the
> student lying down and warm, should be continued until rescue
> personnel arrive.
>
> In the event of anaphylactic shock due to a severe allergic reaction,
> a staff member who is trained and authorized may administer a
> subcutaneous injection of 0.3 cc of epinephrine 1:1000 solution
> (EpiPen) and diphenhydramine (Benadryl) 50 mg IM or orally once.
> Repeat EpiPen injection every 15 minutes until rescue personnel
> arrive.

-   Inform the rescue crew of student medications, known medical
    history, and details of the event (when began, what changed,
    medications already given, treatment administered, vomiting).

-   Once student is stabilized and/or transported off center, notify
    health staff, center director, and family contact.

-   Document all that occurred in writing for inclusion in the student's
    health record.

###### 3.6.2 Urgent Situations

Urgent situations are health problems that need evaluation by the center
physician, center mental health consultant, or center dentist within a
few hours, as they may soon result in a life-threatening situation or
produce permanent injury. Urgent situations may include:

-   Second degree burns (blistering)

-   Fractures

-   Serious lacerations

-   Diarrhea or vomiting lasting more than 24 hours

-   Abdominal pain

-   Complication of pregnancy

-   Threatened abortion

-   Severe depression or anxiety

-   Foreign body in the eye

-   Wheezing

**Disposition II** describes what **health staff or authorized
non-health staff should do with any student who presents with an urgent
condition**.

# DISPOSITION II

-   Provide basic first aid, if needed.

-   Summarize the student\'s problem to the on-call health staff and/or
    physician (as directed by health staff).

-   Follow the physician\'s referral/treatment guidelines.

-   Complete appropriate records and incident reports and document in
    the student's health record.

When non-health staff (residential living advisors, counselors, etc.)
are confronted with what they think may be an urgent health problem,
they should notify the on-call health staff member immediately. If
health staff is unavailable, contact an emergency response team (call
the hospital emergency room or 911). If the student is sent off-center,
follow the last three steps listed in Disposition I regarding
notification and documentation.

**3.6.3 Health Emergencies Or Urgencies Occurring When Health Staff Are
Not Available or Readily Reachable**

Health emergencies or urgencies occurring **when only non-health staff
are available** fall under **Disposition III**, which provides basic
instructions for non-health staff to follow for an emergency or urgency
until a health staff member or emergency personnel can take over. If a
staff member is unauthorized or unable to administer first aid, he/she
should attempt to locate someone with first aid training to administer
basic care.

## **DISPOSITION III**

For an emergent situation,

-   First, contact the local emergency response team (Call 911).

For an urgent situation,

-   If health staff are not immediately reachable after repeated
    attempts, call local emergency response team.

-   If authorized to do so, follow Symptomatic Management Guidelines for
    non-health staff.

-   Provide the following basic first aid measures if needed:

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-   Keep the student warm and comfortable.

-   Administer CPR if properly trained and certified.

-   Stop bleeding by applying constant, direct pressure on the wound.

The center director should ensure that non-health staff have first aid
and CPR skills, and have available the phone numbers of the physician,
nurse, hospital emergency room, and emergency response team. These
should be updated the first day of each month so as to be current when
needed. The names and numbers should be prominently displayed and
available to all night and weekend staff caring for students.

###### 3.6.4 Non-Student Health Problems

Non-student health problems are urgent conditions that involve staff,
family or other non-students. **Disposition IV** describes what to do
when a center visitor presents with a medical condition.

# DISPOSITION IV

If situation appears to be an emergency (life threatening), follow
Disposition I. Otherwise:

-   Provide basic first aid and make patient comfortable.

-   Suggest person go to private physician or hospital emergency room
    (his/her option).

-   Complete appropriate records and an incident report.

    5.  **Reporting of Actions Taken and Referral of Students Off
        Center**

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-   If any student is sent off center during hours the health and
    wellness center is closed, written notification of that event must
    be given to the health and wellness staff the next time the health
    and wellness center is open. A copy of the written records, incident
    report, or email message should be included with the notification.
    Contact the health professional on call with notification of the
    referral. This can expedite the appropriate follow up and treatment
    necessary the next day.

-   Document that all appropriate parties have been notified of the
    event (center director, health staff, CMHC, TEAP specialist, center
    dentist, etc.).

-   The student's subsequent health record entries should document the
    outcome of all off-center referrals and/or emergent or urgent care
    treatments rendered. Any further diagnostic or therapeutic
    interventions should also be recorded in the medical record. This
    should include medical separation or medical separation with
    reinstatement rights.

**3.6.6 Records**

The following clinical documents, as described in TAG C: Health and
Wellness Administration, need to be maintained in all health records:
Report of Medical History, SF-93; Report of Medical Examinations, SF-88;
and Chronological Record of Medical Care, SF-600, SF-603, and SF-603A.
Other forms are shown in PRH-6: Appendix 604.

Place a clinical SOAP (Subjective, Objective, Assessment, Plan) note in
the student's health record for each visit, specifying the reason for
the visit (e.g., wellness check, eye check up), findings, and
disposition. If medications are ordered, indicate name, dose frequency,
and duration. Also describe the nature of the proposed follow-up. The
notes should be legible, dated including time of day, signed, and
co-signed, if appropriate. See TAG C: Health and Wellness Administration
for a sample SOAP note.

**3.6.7 Physician Visits**

Medical supervision of students in the inpatient area is the
responsibility of the center physician. Daily visits may not be
necessary; students recovering from illness or surgery may require less
frequent visits. Telephone consultation with the health staff may be
satisfactory for many students.

**3.6.8 Emergency Calls**

An emergency call list identifying the center physicians and licensed
health professionals who should be called and the sequence in which they
should be called, should be posted in the health and wellness center,
center director's office, security officer's office, telephone
switchboard, and in residential quarters. In the event no one on the
list can be reached during an emergency, refer to section 3.6.3, Health
Emergencies or Urgencies Occurring When Health Staff Are Not Available
or Readily Reachable.

**3.7 Mental Health Emergency**

The on-call personnel should contact the CMHC immediately and follow the
center operating procedure for mental health emergencies. In the event
of a life threatening event, call 911.

###### 3.7.1 Special Consideration For Psychiatric Problems

Physical restraint may be needed in situations where a student with a
psychiatric disorder or substance abuse seriously threatens persons or
property, including suicidal behavior and trained staff must be
available to ensure that appropriate methods are used. However, it is
**rarely** necessary to use restraints on a student, and restraints are
frequently misused because of the staff\'s failure to calm the student
by non-physical means. Restraints are more likely to increase, rather
than decrease, a student\'s agitation. (See TAG D: Mental Health and
Wellness Program.)

**3.7.2 Restraints**

No restraints will be used without approval from the most senior member
of the health staff available and, if possible, from the center
physician. No student will be kept in restraint longer than one hour
without direct, in-person examination by and approval of the center
physician or mental health consultant (PRH-5: 5.4, R8).

When restraints are used, record the reason and the approval in the
student\'s chart and note the time when the restraint was applied. A
student in restraints should have a staff member in direct visual
contact at all times, to make sure no harm is self-inflicted.

Never use restraints for more than 8 hours. Students needing restraints
for longer periods must be hospitalized.

Strait jackets will not be used. Soft, well-padded limb restraints,
applied as loosely as possible to as few limbs as possible, are the only
restraints permitted. Never restrain students in a spread-eagle
position.

Efforts must be made to calm students by friendly, supportive, and
non-threatening activities. If possible, explain the reasons for the
restraints to the student. The student\'s family or friends may be
helpful in providing this assistance and should be utilized if
available. Talking with the student is generally more effective than
restraints or medication.

**3.7.3 Suicide Risk**

The suspicion that a student may attempt suicide should elicit the
concern of all staff. All center staff must take seriously students who
express suicidal thoughts or who attempt suicide, whether it is for
attention or due to a psychiatric disorder. Give attention to depressed
persons, or to those who express feelings of hopelessness or doom.
Again, take all communications of suicide ideas, thoughts, or plans
seriously and engage the assistance of the CMHC. Contact the health
professional on call for assistance. If the CMHC is not available, each
center should have a center operating procedure (COP) for dealing with
suicidal behavior. Follow the COP, which should include a referral to an
off-center mental health facility for an emergency assessment. (See Job
Corps Information Notice No. 02-13.)

**3.7.4 Individual Accommodations for Behavioral or Mental Health
Reasons**

Use of individual accommodations on-center may be needed for temporary
segregation of students from their peers only when behavior constitutes
an immediate threat to themselves, other persons, or property \[PRH-5:
5.4, R8(b)\]. Do not isolate students with psychiatric issues
needlessly. Isolation may cause deterioration in their emotional state.
The following students may require individual accommodations, away from
other students, for mental health or emotional reasons:

-   Students who are agitated, psychotic, delusional, or irrational; for
    emotionally distressed students, individual supervision should only
    be used for the shortest time necessary to arrange for a safer
    treatment option

-   Disoriented students for whom contact with other students would have
    an adverse effect

-   Students who require individual supervision for their own protection
    or for the protection of others

-   Suicidal students (suicidal students should not be left
    unsupervised); for suicidal students, individual supervision should
    only be used for the shortest time necessary to arrange for a safer
    treatment option

-   Some students who are under the influence of alcohol or drugs

-   Students who are a danger to self or others must be supervised
    continuously until the disposition of their cases is resolved; the
    student must be observed and this observation must be documented on
    a signed log giving the exact time of observation and the signature
    of the staff member conducting the observation

Students with psychiatric symptoms who require individual supervision
should be evaluated for immediate hospitalization. A delay in providing
needed hospitalization can result in clinical, economic, and/or legal
complications.

**3.8 Oral Health Emergency**

Staff should call the center dentist to secure applicable services as
soon as possible. If after hours, health staff should follow Treatment
Guidelines, and non-health staff should follow Symptomatic Management
Guidelines.

**3.9 Promotion of Wellness Thinking and a Healthy Lifestyle**

The entire center staff is responsible for promotion of healthy
lifestyles. This can be done in two major ways:

-   Role-modeling good behaviors (e.g., healthy diet and not smoking)

-   Health and wellness education

The health and wellness staff should encourage student and staff
attendance at preventive health seminars on such topic as exercise,
healthy diet, stress reduction, and sexual abstinence or consistent
contraceptive and condom use. The goal is to optimize the functioning of
the mind and body thus maximizing the probability of full employability
for Job Corps students. Outside agencies and/or speakers can be brought
on center for assemblies and dormitory presentations. Health fairs and
participation in community health events (e.g., blood drives) can
reinforce wellness thinking and healthy lifestyle choices. Caregivers
can consistently give such messages to students whenever they visit the
health and wellness center. The center director's understanding and
support of the approach is essential to success.

**4.0 TREATMENT GUIDELINES**

The 2004 revised format of the Treatment Guidelines for Health Staff is
designed specifically to prescribe the most current and cost-effective
medical and behavioral treatments for the most commonly encountered
medical, dental, and psychological diagnoses seen in the national Job
Corps student population.

The treatment regimens presume an accurate evaluation and subsequent
diagnosis have already been accomplished by appropriate health center
staff under the supervision of the center physician, mental health
consultant, and/or dentist.

The person implementing a treatment guideline must have an authorization
to do so.

Before administering any recommended medication, the student should be
asked if he/she is allergic to that medication (had a bad reaction to
it). If possible, also check the student's medical record for similar
information. If the student is allergic, refer to the alternate
treatment in the treatment guideline or consult the center physician for
guidance.

Medications administered as a single dose or prescribed over time must
be carefully documented in the student's health record (dose, route of
administration, frequency of administration, and duration of therapy).
All medication orders should be signed by the center physician or
advanced practice clinician.

In addition, any necessary follow up plan should be detailed in the
health record.

Such notes should be legibly signed by the administering person and may
refer to the specific treatment protocol being used.

Treatment GuidelineS FOR HEALTH STAFF

ACNE

Authorized health and wellness staff may treat acne as follows:

1.  Encourage the student to:

-   Wash the area gently one to two times per day. "Acne soaps" are not
    necessary. Never scrub or use abrasive washes. Allow the skin to dry
    completely before applying medication.

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-   Avoid wearing hats,headbands, or other garb that rests upon the
    forehead. This may aggravate acne.

-   Avoid or minimize the use of hair oils, gels, or greases. This will
    increase the oiliness of the skin and worsen acne.

-   Never pick at acne lesions.

2.  Administer benzoyl peroxide 5% gel, applied lightly to affected
    areas twice daily.

**WHEN TO REFER TO THE CENTER PHYSICIAN**

-   If acne does not begin to improve after 6-8 weeks of daily use of
    the medication

-   If there are large areas of involvement (e.g., chest, shoulders,
    back)

-   If acne is pustular

-   If there are deep lesions that are causing scarring and pitting

-   If female students with significant acne have other signs of
    possible hormonal problems (hirsutism, infrequent or absent menses,
    acanthosis nigricans, etc.)

TREATMENT GUIDELINES FOR HEALTH STAFF

**ACUTE ALCOHOL (ETHANOL) INTOXICATION**

Authorized health and wellness staff may treat alcohol intoxication as
follows:

1.  Clinically assess the student's vital signs and mental status (i.e.,
    alert and oriented to person, time, and place). Obtain a blood
    glucose measurement by Dextrostix or equivalent.

2.  If authorized to do so, conduct an alcohol screening test and urine
    drug screen on suspicion according to center operating procedures.

3.  If student is incoherent, vomiting repeatedly, or losing
    consciousness, or is suspected of having also ingested other drugs,
    transport to emergency center immediately.

4.  Any student under the influence of alcohol or drugs must be observed
    in the dormitory or the health and wellness center to ensure safety
    until symptoms have resolved.

5.  Report the incident with detailed documentation of observed
    behaviors and BAL results to the health and wellness manager and to
    the TEAP specialist for follow-up counseling.

HELPFUL REFERENCE: Emergency Pediatrics -- A Guide to Ambulatory Care,
5^th^ Edition, by Barkin and Rosen, Mosby 1999

# WHEN TO REFER TO CENTER PHYSICIAN 

-   If there appears to be a developing pattern of alcohol misuse or
    abuse, refer to the TEAP specialist and center physician

-   If student continues to show any signs of confusion or unsteadiness,
    after seeming to "sleep off" the acute intoxication

-   If the student doesn't seem to recognize the potentially serious
    nature of his/her intoxication, schedule a meeting with the center
    physician to discuss the episode, especially if there are any
    findings of damage to physical or emotional well being

-   If any depression or other emotional problems were evident when
    intoxicated, refer the next day to the center mental health
    consultant to review and discuss what happened, and to determine if
    any serious emotional problems need attention

**Treatment Guidelines for HEALTH STAFF**

**Allergic/Contact Dermatitis**

Authorized health and wellness staff may treat allergic or contact
dermatitis as follows:

1\. Determine the agent/exposure that triggered the rash (e.g., plants,
soaps, lotions, jewelry, make-up, chemicals).

2\. Instruct the student to avoid any further contact with the trigger.

3\. Have the student wash all affected areas, as well as bedding and
clothing, that may contain the offending agent (e.g., oil from poison
ivy or poison oak).

4\. Apply hydrocortisone 1% cream to the rash twice per day until
resolved if the rash is localized.

6.  Administer diphenhydramine 25-50 mg po every 4-6 hours if there is
    itching. **Warning:** Diphenhydramine may cause sedation.

7.  Alternative treatment with a non-sedating antihistamine such as
    loratadine 10 mg po once a day may be considered.

**WHEN TO REFER TO THE CENTER PHYSICIAN**

-   If the student is experiencing difficulty swallowing or breathing,
    call 911

-   If the rash involves the student's eyes or mucosal areas

-   If the rash is not improved in 2 days

-   If the rash spreads despite treatment

TREATMENT GUIDELINES FOR HEALTH STAFF

**ASTHMA**

Authorized health and wellness staff may treat asthma as follows:

### Acute Management

1.  Any student whose wheezing does not respond within 10-15 minutes to
    two inhalations from an albuterol hydrocarbon free aerosol (HFA)
    should be seen immediately in the health and wellness center.

2.  Any student with severe wheezing, muscle retractions, gasping, blue
    color or other signs of respiratory distress requires immediate
    medical attention. Call 911 for emergency transport. Administer
    oxygen by facemask if available. Albuterol HFA treatments (2
    inhalations) **or** albuterol nebulizer treatments may be
    administered every 15-20 minutes while awaiting transport.

### Chronic Management

3.  All students with asthma should be managed according to the National
    Asthma Education and Prevention Program (NAEPP) Expert Panel Report:
    Guidelines for the Diagnosis and Management of Asthma, most recently
    updated in 2002, and available online at:
    [http://www.nhlbi.nih.gov/guidelines/asthma/asthupdt.htm]{.underline}.

4.  All students with asthma should be **classified** according to the
    NAEPP Step guidelines:

## 

## Step 1 - Mild Intermittent

## symptoms \< 2 times a week

## nighttime symptoms \< 2 times a month

## exacerbations brief - few hours to few days - intensity may vary

## asymptomatic between exacerbations

## 

## Step 2 - Mild Persistent

## symptoms \> 2 times a week but \< 1 time a day

## nighttime symptoms \> 2 times a month

## exacerbations may affect activity

## 

## Step 3 - Moderate Persistent

## daily symptoms 

## nighttime symptoms \> 1 time a week

## daily use of short-acting β~2~-agonist

## exacerbations affect activity

## exacerbations \> 2 times a week - may last days

## Step 4 - Severe Persistent

## continual symptoms 

## nighttime symptoms frequent

## limited physical activity

## frequent exacerbations

5.  All students with asthma should be **treated** according to the
    NAEPP Step guidelines:

# Quick Relief: Steps 1-4

## short-acting bronchodilator: inhaled β~2~-agonists as needed for symptoms (albuterol)

## intensity of treatment depends on severity of exacerbation

## increasing use of short-acting inhaled β~2~ agonists indicates the need for initial or additional long-term control therapy

# 

# Long-Term Control: Step 1

## No daily medication needed

# 

# Long-Term Control: Step 2

## One daily medication:

## inhaled corticosteroid - low dose (preferred)

## inhaled cromolyn or nedocromil

## oral leukotriene modifier (Singulair)

## oral sustained-release theophylline

# Long-Term Control: Step 3

## Daily medication:

## low to medium dose inhaled corticosteroids combined with long-acting inhaled β~2~ agonists (preferred) (Advair) or

## increase inhaled corticosteroids within medium dose range or

## low to medium dose inhaled corticosteroids and either leukotriene modifier or theophylline

# Long-Term Control: Step 4

## Daily medications:

## high dose inhaled corticosteroids combined with long-acting inhaled β~2~ agonists (Advair)

## and if needed

## oral corticosteroids (max 60 mg per day)

6.  Students known to have asthma should have access to an albuterol HFA
    **at all times** on center and on off center trips.

**WHEN TO REFER TO THE CENTER PHYSICIAN**

-   If the student's wheezing does not respond within 10-15 minutes to
    two inhalations from an albuterol HFA

-   If the student presents with severe wheezing, muscle retractions,
    gasping, blue color or other signs of respiratory distress

-   If student requires daily medication for asthma management, should
    be seen at least monthly

**Refer to the Asthma Chronic Care Management Plan for additional
guidance.**

**TREATMENT GUIDELINES FOR HEALTH STAFF**

**INFECTIVE ENDOCARDITIS PROPHYLAXIS PRIOR TO DENTAL PROCEDURES**

Authorized health and wellness staff may provide antibiotic prophylaxis
for the prevention of infective endocarditis in certain dental patients
as follows:

1.  Follow the American Heart Association (AHA) and American Dental
    Association (ADA) Guidelines which recommend that patients take
    antibiotic prophylaxis if there is a history of total joint
    replacement within two years, artificial heart valves, a previous
    history of endocarditis, certain congenital heart conditions and
    certain heart transplant patients. The AHA and ADA do not recommend
    antibiotic prophylaxis for the following conditions: mitral valve
    prolapse, a previous history of endocarditis, certain congenital
    heart conditions such a ventricular septal defect, atrial septal
    defect and hypertrophic cardiomyopathy.

2.  For those students at high risk of infective endocarditis, the ADA
    recommends antibiotic prophylaxis before invasive dental procedures
    such as teeth cleaning and extractions.

3.  Administer amoxicillin 2 grams orally in a single dose thirty to
    sixty minutes [before]{.underline} the procedure.

4.  Alternative treatment if allergic to penicillin: administer
    clindamycin 600 mg orally OR azithromycin 500 mg orally OR
    clarithromycin 500 mg orally in a single dose thirty to sixty
    minutes [before]{.underline} the procedure.

5.  Instruct the student to return for re-treatment if vomiting occurs
    before dental treatment is completed.

6\. If the antibiotic dose is inadvertently not administered before the
procedure, the

dose may be administered up to two hours after the procedure.

WHEN TO REFER TO THE CENTER PHYSICIAN

-   If the student's need for endocarditis prophylaxis is unclear

# If the student needs endocarditis prophylaxis for respiratory, gastrointestinal or genitourinary tract procedures (i.e., other than dental).

**TREATMENT GUIDELINES FOR HEALTH STAFF**

**BACTERIAL VAGINOSIS**

Authorized health and wellness staff may treat confirmed bacterial
vaginosis as follows:

1\. Administer metronidazole 500 mg orally with fluids or snack twice a
day for 7 days or metronidazole gel 0.75%, one full applicator (5 g),
intravaginally once per day for 5 days or clindamycin cream 2%, one full
applicator (5 g), intravaginally at bedtime for 7 days.

2.  Alternative treatments with lower efficacy: administer clindamycin
    300 mg po twice per day for 7 days or clindamycin ovules 100 mg
    intravaginally at bedtime for 3 days.

3.  Bacterial vaginosis can be associated with adverse pregnancy
    outcomes. Symptomatic pregnant students should be treated with
    metronidazole 250 mg po with fluids or snack twice per day for 7
    days or clindamycin 300 mg po twice per day for 7 days.

4\. Instruct student to return for re-treatment if vomiting occurs
within 4 hours of treatment with oral regimens.

5\. Caution student to avoid alcohol ingestion during metronidazole
therapy and for 48 hours after the last dose.

6\. Discuss screening for STDs as appropriate, health department
reporting requirements, and prevention of STDs and pregnancy (offer
condoms and contraceptives as appropriate).

7\. Caution student that many vaginal creams are oil-based and may
weaken latex condoms.

8\. Routine treatment of sex partners is not recommended.

WHEN TO REFER TO THE CENTER PHYSICIAN

-   If the student needs additional STD or pregnancy screening

-   If the student reports failure of the above treatment

-   If persistent vaginal discharge

-   If onset of pelvic pain

TREATMENT GUIDELINES FOR HEALTH STAFF

BITES AND STINGS

Authorized health and wellness staff may treat bites and stings as
follows:

For **human** bites

1.  Irrigate the open wound with saline solution.

2.  Debride the wound as indicated.

3.  Assess for possible presence of an imbedded foreign body.

4.  Assess the need for surgical closure (steri-strip or sutures).

5.  Consider the need for tetanus-diphtheria-acellular pertussis (Tdap)
    booster immunization if status unknown or last dose given more than
    5 years ago.

6.  If signs of infection are present or bite wound is on the hand,
    consider antibiotic treatment with amoxicillin/clavulanate
    (Augmentin) 875 mg every 12 hours for 5 days **or** doxycycline
    (Vibramycin) 100 mg twice daily for 5 days (contraindicated if
    pregnant).

7.  Evaluate if human bite is indicative of abuse and/or assault and
    should be reported to authorities.

For **animal** bites

1.  Cleanse the wound with 1% povidone-iodine solution (Betadine), then
    irrigate thoroughly with saline solution.

2.  Debride the wound as necessary and evaluate for surgical closure.

3.  Consider the need for the Tdap booster immunization as with human
    bite.

4.  If signs of infection, consider antibiotic treatment as indicated
    for human bites.

5.  Report domestic animal bites to local authorities for detainment of
    animal.

6.  For wild or domestic animals not observed or tested, consider the
    need for post-exposure rabies prophylaxis. Manage in consultation
    with state or local health department.

7.  Examine the wound in 48 hours and again at the end of antibiotic
    treatment (if initiated at onset).

For **insect and arthropod** bites and stings

1.  For generalized urticaria, wheezing, chest or throat tightness,
    syncope, or dizziness, stabilize airway and give epinephrine
    (1:1,000, 0.3 ml) subcutaneously, diphenhydramine (Benadryl) 50 mg
    IM, nebulized albuterol for bronchospasm, and transport to emergency
    center as soon as possible.

2.  Remove the stinger and cleanse the skin with a disinfectant.

3.  Administer supportive measures, i.e., cool compresses and elevation
    of the body part.

4.  For mild itching, systemic therapy with antihistamines, e.g.,
    diphenhydramine (Benadryl) 25-50 mg po as a single dose or
    hydroxyzine (Atarax/Vistaril) 25 mg po as a single dose, may be
    given. In consultation with the center physician, large local
    reactions may be treated with a short course of prednisone 20 mg po
    twice daily for 3 days.

5.  Antibiotics are **not** normally given unless there are obvious
    signs of bacterial infection. Local erythema and swelling are
    usually due to the chemical envenomation.

6.  Consider antivenom for black widow spider and/or scorpion bites.
    Analgesics and sedation may be needed for pain and/or muscle
    cramping.

For **snake bites**

Consult and manage in consultation with state or local health
department.

HELPFUL REFERENCE: Emergency Pediatrics -- A Guide to Ambulatory Care,
5^th^ Edition, by Barkin and Rosen, Mosby 1999

### WHEN TO REFER TO THE CENTER PHYSICIAN

-   If cat bite, refer to center physician for consideration of
    antibiotic prophylaxis

-   If there are any signs of secondary bacterial infection in a student
    **not yet** begun on antibiotics

-   If the wound is not healing **on** antibiotic therapy

TREATMENT GUIDELINES FOR HEALTH STAFF

# BRONCHITIS AND PNEUMONIA

Authorized health and wellness staff may treat bronchitis and pneumonia
as follows:

1.  Evaluate the student's ability to breathe without pain or
    respiratory distress. Stridor, retractions, use of accessory
    muscles, gasping, blue color, and other signs of acute distress
    suggest that immediate attention is needed. Call 911. Administer
    oxygen by facemask if available.

2.  For fever, offer the student acetaminophen 1000 mg every 4 hours
    \[MDD 4 g\] **or** ibuprofen 400 mg \[MDD 1600 mg\] every 6 hours as
    needed. Encourage oral hydration.

3.  For cough, offer the student cough syrup in a dose containing 30 mg
    of dextromethorphan \[MDD 120 mg\], for use primarily at bedtime,
    but no more often than every 6 hours. Again, encourage oral
    hydration.

4.  While most often viral in etiology in the Job Corps age group,
    bronchitis and pneumonia can be caused by *Mycoplasma* and other
    bacteria. Appropriate antibiotic choices include doxycycline 100 mg
    bid for 7 days **or** azithromycin 500 mg on day 1, followed by 250
    mg once daily for 4 more days.

**WHEN TO REFER TO THE CENTER PHYSICIAN**

-   If the student is short of breath or has a fever of \> 101°F

-   If cough is unresponsive to dextromethorphan

-   If the student has a history of asthma

-   If pertussis is suspected

**TREATMENT GUIDELINES FOR HEALTH STAFF**

**BURNS**

Authorized health and wellness staff may treat burns as follows:

1.  Remove the student from the source of the burns.

2.  Ensure an open airway is present and proceed with CPR if indicated.

3.  If the burn involves the face, head, neck, fingers, toes, genitalia
    or more than 25 percent of the trunk or an extremity, call 911.

4.  Irrigate the burn wound with sterile saline solution for one to two
    minutes.

5.  Cover the burn with sterile gauze soaked in sterile saline solution.
    Use cling gauze to secure the saline soaked gauze. Leave blisters
    intact. Have the wound evaluated by the center physician as soon as
    possible.

6.  Check immunization status and give tetanus-diphtheria-acellular
    pertussis (Tdap) booster immunization when indicated. Refer to TAG
    B: Immunization and Communicable Disease Control.

WHEN TO REFER TO THE CENTER PHYSICIAN

-   If the wound has a broken blister or if only the dermis is injured,
    apply silvadene cream bid until the center physician evaluates the
    patient within 48 hours. Call the center physician regarding the use
    of medication for pain relief.

-   If the injury appears deeper than the dermis or contaminated with
    pathogens or toxins or chemicals remain despite irrigation, refer to
    the center physician or the emergency room immediately. Call the
    center physician regarding the use of medication for pain relief
    prior to transport.

-   If inadequate pain relief

-   If evidence of a secondary infection

**TREATMENT GUIDELINES FOR HEALTH STAFF**

**CANDIDA (YEAST) VULVOVAGINITIS**

Authorized health and wellness staff may treat confirmed candida
vulvovaginitis as follows:

1.  Administer fluconazole 150 mg po once as a single dose directly
    observed therapy with fluids or snack. WARNING: Not recommended for
    use during pregnancy.

2.  An alternative treatment is intravaginal and external topical
    treatment with an antifungal cream such as butoconazole 2%,
    clotrimazole 1%, miconazole 2%, or terconazole 0.8% once daily for
    the duration specified by the manufacturer. May be used during
    pregnancy.

3.  Instruct student to return for re-treatment if vomiting occurs
    within 4 hours of treatment with oral regimen.

4.  Discuss screening for STDs as appropriate, health department
    reporting requirements, and prevention of STDs and pregnancy (offer
    condoms and contraceptives as appropriate).

5.  Caution student that many vaginal creams are oil-based and may
    weaken latex condoms.

6.  Routine treatment of sex partners is not recommended.

WHEN TO REFER TO THE CENTER PHYSICIAN

-   If symptoms persist or recur within 2 months of initial treatment

-   If maintenance therapy is needed in an immunocompromised student,
    e.g., with HIV infection

**TREATMENT GUIDELINES FOR HEALTH STAFF**

**CHLAMYDIA INFECTION**

Authorized health and wellness staff may treat laboratory-confirmed
chlamydia infection as follows:

1.  Administer azithromycin 1 gram po once as a single dose directly
    observed therapy with fluids or snack.

2.  Alternative treatments, or if allergic to azithromycin but not
    pregnant, include doxycycline 100 mg po twice daily for 7 days or
    ofloxacin 300 mg po bid for 7 days or levofloxacin 500 mg po once
    daily for 7 days.

3.  Instruct student to return for re-treatment if vomiting occurs
    within 4 hours of treatment.

4.  Discuss contact(s) treatment, screening for other STDs as
    appropriate, health department reporting requirements, and
    prevention of STDs and pregnancy (offer condoms and contraceptives
    as appropriate).

5.  Instruct student to abstain from sexual intercourse for 7 days and
    until all sex partners have been treated.

6.  Schedule chlamydia retesting in one month.

WHEN TO REFER TO THE CENTER PHYSICIAN

-   If the student has rectal pain suggestive of proctitis

-   If the female student has pelvic pain suggestive of pelvic
    inflammatory disease

-   If the male student has scrotal pain suggestive of epididymitis or
    lower back pain suggestive of prostatitis

**TREATMENT GUIDELINES FOR HEALTH STAFF**

**Conjunctivitis**

Authorized health and wellness staff may treat conjunctivitis as
follows:

1.  When exudate is not present and the conjunctiva is red and
    irritated, irrigate the eye with ophthalmic saline solution. The
    student may repeat use four times daily. Re-evaluate the student in
    24 hours. If the condition is not resolved, have the center
    physician see the student.

2.  Take a careful history for trauma, toxins and irritants in the eye.
    If the history is positive, irrigate the eye(s) and call the center
    physician.

3.  In the presence of exudates, begin ophthalmic antibiotic treatment
    until the center physician evaluates the student.

4.  In the presence of allergic conjunctivitis, begin ophthalmic
    anti-allergy treatment until the center physician evaluates the
    student.

5.  Swelling and redness of the eyelids may indicate the presence of a
    serious infection and requires immediate evaluation by the center
    physician.

# WHEN TO REFER TO CENTER PHYSICIAN

-   If the condition does not resolve in 24 hours after treatment

-   If there is eye pain or change in vision

-   If there is a history of trauma, toxins, or irritants in the eye

-   If swelling and redness of the eyelids is present

**TREATMENT GUIDELINES FOR HEALTH STAFF**

**CONSTIPATION**

Authorized health and wellness staff may treat constipation as follows:

There are two phases of constipation treatment: acute catharsis or
disimpaction (usually over the first 2-5 days), and chronic maintenance
or sustained evacuation (often over several months if the constipation
is long standing).

# 1. Pharmacologic regimens may be instituted in the following order:

-   Milk of magnesia 30 cc (2 tbsp) po twice daily for 3 days maximum.

-   Mineral oil 30 cc (2 tbsp) po twice daily for 3 days. Refrigeration
    of mineral oil may improve palatability.

-   Bisacodyl (Dulcolax) 5 mg po twice daily for 3 days (also available
    as a suppository).

> With center physician approval:

-   Hypertonic phosphate enema (Fleet's) one per rectum every 12 hours
    for three doses maximum.

-   In refractory cases, use polyethylene glycol-electrolyte solution
    (GoLYTELY). After fasting for 3 hours, the adult dose is 240 cc (8
    ounces) po every 10 minutes until 4 liters are consumed or the
    rectal effluent is clear.

2\. Non-Pharmacologic management includes:

-   Increased fluid intake (8 full glasses of 8 oz of water daily).

-   High fiber diet, e.g., bran cereals, popcorn, fruit juices (except
    orange juice), raw unpeeled fruits and vegetables, e.g., prunes,
    figs, dates, raisins, peaches, pears, apricots, beans, celery, peas,
    cauliflower, broccoli, and cabbage.

-   Decrease consumption of constipating foods, e.g., milk, ice cream,
    yogurt, cheese, and cooked carrots.

-   Encourage regular bowel pattern of sitting on the toilet for 10
    minutes twice daily, especially after breakfast.

-   If in acute rectal pain, sit in a warm bath to relax the anal
    sphincter **or** insert a Dulcolax 10 mg suppository.

-   Once disimpaction is successful, transition to dietary management
    and lubricants, hyperosmolar sugars, or stimulants allow normal
    colorectal sensation and stooling patterns to return over time.
    Increased fluid and dietary fiber intake should be encouraged in all
    cases.

-   Fiber supplements include barley malt (barley cereal, Maltsupex);
    cellulose (Citrucel); psyllium 1-2 rounded teaspoonfuls or 1-2
    packets 1-2 times daily (Metamucil, Fibercon).

-   Lubricants include mineral oil 30 cc (2 tbsp) 1-2 times per day;
    surfactant 100 mg 1-2 times daily (Docusate/Colace).

-   Hyperosmolar sugars include fructose/sorbitol (prune juice);
    lactulose 15-30 cc (1-2 tbsp) daily up to 60 cc (4 tbsp) daily
    maximum (Cephulac).

-   Stimulants include salts (milk of magnesia 30 cc (2 tbsp) per day
    for 3 days, magnesium citrate solution); senna 2 tablets at bedtime
    (Senekot); bisacodyl 5 mg at bedtime for 3 days (Dulcolax).

-   Gradually wean from medications over several weeks.

# WHEN TO REFER TO CENTER PHYSICIAN

-   If student is on a prescribed medication that causes constipation.
    Dosage may need to be adjusted or medication changed if the problem
    persists

-   If the student reports failure of the above treatment regimen to
    resolve the constipation within 48 hours

-   If the student experiences rectal bleeding or hemorrhoids are
    present

**TREATMENT GUIDELINES FOR HEALTH STAFF**

**Depo-Provera**

**(medroxyprogesterone contraceptive injection)**

Authorized health and wellness staff may administer Depo-Provera to a
student as follows:

1.  Student has been thoroughly counseled by the Center Physician and
    nursing staff regarding the benefits, risks, alternatives and side
    effects of using Depo-Provera, as well as the efficacy of the method
    and STD counseling.

2.  Patient has a documented Pap smear and pelvic exam (within 12
    months) in the student health record.

3.  To be certain that the patient is not pregnant, administer the
    initial injection only during the first five days of a normal
    menstrual period.

4.  Blood pressure and weight is documented in the student health record
    for each Depo-Provera visit.

5.  Calcium and Vitamin D (600mg/200 units or 500mg/200units tablets)
    should also be prescribed for student twice daily.

6.  Administer Depo-Provera 150 mg IM in either the deltoid or gluteus
    maximus every 12-14 weeks [or]{.underline} administer
    Depo-subQ-Provera 104 mg subcutaneously into the anterior thigh or
    abdomen every 12-14 weeks.

7.  Depo-Provera injections may be given earlier if needed - as often as
    11 weeks apart.

8.  Students who present for Depo-Provera more than 14 weeks since the
    last injection must have a urine pregnancy test performed to exclude
    pregnancy before administering the injection.

**WHEN TO REFER TO CENTER PHYSICIAN**

-   Moderate to heavy vaginal bleeding

-   Prolonged breakthrough spotting (\> 7-10 days)

-   Significant weight gain (\>10-15 lbs)

-   Significant loss of scalp hair or increase in body hair

-   Onset or worsening episodes of migraine or severe headaches

-   Positive urine pregnancy test

**TREATMENT GUIDELINES FOR HEALTH STAFF**

**DIABETES (TYPE I/II)**

Authorized health wellness staff may treat diabetes as follows:

1.  All students with newly diagnosed diabetes and all newly enrolled
    students who report that they have diabetes should be referred to
    the center physician as soon as possible. If the center physician is
    not on center at the time of the discovery of diabetes, he/she
    should be called in order to discuss what is known about the student
    prior to the appointment.

2.  Each student with diabetes should have a chronic care management
    plan developed which includes at least the following:

    -   The insulin or oral hypoglycemic medication dose and
        administration schedule

    -   The prescribed meal plan to include appropriate snacks

    -   The recommended activities/exercise program

    -   The blood glucose self monitoring plan

    -   The schedule of follow up in the health and wellness center

    -   The medical monitoring plan, including glycohemoglobin
        measurements, urine microalbumen screening, and annual
        ophthalmologic evaluation.

    -   Documentation of which staff have been notified about the
        student's diagnosis

    -   A specific plan of how to manage the student if he/she becomes
        sluggish, confused, or disoriented (i.e., may have excessively
        low or high blood sugar -- and whom to notify immediately)

# WHEN TO REFER TO THE CENTER PHYSICIAN

-   If the student has newly diagnosed diabetes or newly enrolled and
    reports that he/she has diabetes

-   Students with diabetes should be monitored frequently during the
    first few weeks on center

Refer to the Diabetes Chronic Care Management Plan for additional
guidance.

Treatment Guidelines for Health Staff

**Dysmenorrhea**

Authorized health and wellness staff may treat dysmenorrhea as follows:

1.  Determine whether or not the bleeding is at an appropriate time for
    menses and similar to previous periods. If it is not and/or there is
    a question of possible pregnancy, perform a pregnancy test.

2.  Administer non-steroidal, anti-inflammatory medication for relief of
    pain: Ibuprofen 400-600 mg po every 6 hours prn \[MDD 1600 mg\]
    **or** naproxen sodium 440 mg po every 8 hours prn \[MDD 1320 mg\]
    with fluids or snack.

3.  If dysmenorrhea is recurrent, ensure that student has easy access to
    medication during each period. The first dose of medication should
    be given as soon as the student is aware that the period is
    beginning. Scheduled doses of medication should then be taken
    continuously during the time the student typically experiences pain
    (usually the first 2-3 days of bleeding).

4.  Encourage participation in normal activities. Routine daily exercise
    may be helpful with recurrent episodes.

**WHEN TO REFER TO THE CENTER PHYSICIAN**

-   If student appears ill with other symptoms including fever, nausea
    and/or vomiting, or difficult mobility

-   If student is pregnant

-   If heavy bleeding persists beyond 3 days

-   If student's dysmenorrhea is recurrent and not relieved by the above
    medications

**TREATMENT GUIDELINES FOR HEALTH STAFF**

# Emergency Contraception

Authorized health and wellness staff may administer emergency
contraception (EC) to a student as follows:

1.  Student reports unprotected sexual encounter within the past 5 days
    (ideal to use within 72 hours but effective up to 5 days) and
    desires [not]{.underline} to become pregnant.

2.  A brief history will be documented, to include LMP, date and time of
    unprotected sex, current or past use of contraceptive method, and
    risk assessment for STDs.

3.  A pregnancy test will be performed as indicated (indicated if
    history raises concern for established pregnancy). If student is
    already pregnant, EC is not effective and therefore contraindicated.

4.  Student will be counseled on the use, effectiveness and safety of
    EC.

5.  Student will be offered STD testing, as indicated.

6.  Administer a single oral dose of levonorgestrel 1.5 mg (two 0.75 mg
    tablets taken at the same time). This has been shown to be as
    efficacious as two 0.75 mg tablets taken 12 hours apart and taking a
    single dose improves compliance.

7.  Student is advised to return for pregnancy test if no bleeding has
    occurred within 3 weeks.

8.  Student should be counseled that EC is for emergency use only.
    Discuss reasons for failure of previous contraceptive or if not
    previously using contraceptive, discuss more reliable options with
    student.

**WHEN TO REFER TO THE CENTER PHYSICIAN**

-   Positive pregnancy test

-   Positive STD test

-   Request for hormonal contraceptive

**TREATMENT GUIDELINES FOR HEALTH STAFF**

**FEVER**

Authorized health and wellness staff may treat fever as follows:

1.  Obtain a history to identify infection, inflammation or other origin
    for the fever. If a source is determined, refer to the appropriate
    treatment guidelines.

2.  If fever is less than 101°F with no specific origin, offer the
    student acetaminophen 1000 mg every 4 hours \[MDD 4 g\] **or**
    ibuprofen 400 mg every 6 hours \[MDD 1600 mg\] and re-evaluate
    within 24 hours. Encourage oral hydration.

3.  If fever rises above 101°F and then falls below 101°F within 24
    hours, follow #2 and have the clinician evaluate within 24 hours if
    fever persists.

4.  If fever rises and remains above 101°F for more than 24 hours,
    follow #2 and call the clinician for further disposition.

# WHEN TO REFER TO THE CENTER PHYSICIAN

-   If fever does not respond to acetaminophen or ibuprofen in
    appropriate dosage

-   If fever is associated with altered mental status

-   If fever rises [\>]{.underline} 104°F, refer within 1-2 hours

TREATMENT GUIDELINES FOR HEALTH STAFF

**FRACTURES**

Authorized health and wellness staff may treat suspected fractures as
follows:

1.  Assess the extent of injury and minimize movement of the bones. If
    the bone protrudes through the skin the fracture is compound and
    needs immediate treatment. Irrigate the wound with sterile saline
    solution and cover loosely with a dry sterile dressing. If
    tetanus-diphtheria prophylaxis is not current, administer booster
    dose according to the immunization guidelines found in TAG B:
    Immunization and Disease Control. For compound limb fractures,
    splint the extremity across two joints and transport the patient to
    the emergency department.

2.  If the skin is not broken, but there is extensive bruising,
    subcutaneous bleeding or a firm, tender bulge surrounds the injury,
    a hematoma may be present. Apply ice, elevate the limb, and
    immobilize the extremity across two joints and call the clinician
    for further treatment.

3.  If the injured bone is painful, tender or associated with muscle
    spasm, with full range of motion but without hematoma, splint the
    bone across two joints, restrict activity of the extremity for up to
    48 hours by which time the clinician should evaluate the injury. For
    pain, apply ice, elevate the limb, and administer acetaminophen 1000
    mg every 4 hours \[MDD 4 g\] **or** ibuprofen 400 mg every 6 hours
    \[MDD 1600 mg\].

4.  An x-ray should be ordered only after consultation with the
    clinician.

# WHEN TO REFER TO THE CENTER PHYSICIAN

-   If the bone protrudes through the skin, splint and transport to the
    Emergency Department

-   If the skin is not broken, but there is extensive bruising,
    subcutaneous bleeding or a firm, tender bulge surrounds the injury

-   If the injured bone is painful, tender or associated with muscle
    spasm, with full range of motion but without hematoma

-   If there is obvious deformity suggesting a fracture or dislocation
    in need of reduction

-   If the jaw is fractured, refer the student to an oral surgeon

**TREATMENT GUIDELINES FOR HEALTH STAFF**

**FROSTBITE**

Authorized health and wellness staff may treat frostbite as follows:

1.  Immediately cover the affected areas (usually toes, feet, fingers,
    nose, cheeks, and ears) with another warmer body surface and with
    warm clothing while seeking shelter.

2.  Once indoors where there is no danger of refreezing, rapidly rewarm
    the affected areas in tepid water (105^o^ F-110^o^ F) for 20-40
    minutes. Do **not** use local dry heat as it can cause further
    tissue damage.

3.  Damaged skin should **never** be massaged, as this leads to
    mechanical trauma.

4.  Administer/offer pain medication as needed, e.g., acetaminophen 1000
    mg orally every 4 hours \[MDD 4 g\] **or** ibuprofen 400 mg orally
    every 6 hours \[MDD 1600 mg\].

5.  Seek professional medical care to determine if medical and/or
    surgical intervention is necessary for prevention of infection or
    tissue debridement/amputation.

# WHEN TO REFER TO THE CENTER PHYSICIAN

-   All students with frostbite should be evaluated by the center
    physician

**Treatment Guidelines FOR HEALTH STAFF**

**Fungal Skin Infections**

Authorized health and wellness staff may treat fungal skin infections as
follows:

**Athlete's Foot (tinea pedis)**

1\. Clotrimazole 1% cream should be applied to affected areas twice each
day for at least 21 days. It may take up to 4 weeks for successful
treatment and subsequent maintenance therapy once each day may be
necessary.

2\. Students should keep feet as dry as possible at all times. Feet
should be dried thoroughly after bathing before putting on socks. White
cotton socks are preferable. When possible, slip-on shoes and open shoes
are recommended. When possible, sweaty feet should be washed and dried,
and footwear replaced by cool, clean, dry socks and shoes. Shower shoes
are recommended for daily use. Footwear should be alternated on
successive days.

**Ringworm (tinea corporis)**

1.  Clotrimazole 1% cream should be applied to affected areas twice each
    day for at least 21 days. It may take up to 4 weeks for successful
    treatment.

2.  Students should be told not to share towels, clothing or athletic
    equipment.

**Jock Itch (tinea cruris) and other intertriginous fungal infections**

1.  Clotrimazole 1% cream should be applied to affected areas twice each
    day for at least 21 days. It may take up to 4 weeks for successful
    treatment.

2.  Students should be told not to share towels, clothing or athletic
    equipment.

3.  Students with jock itch and other fungal rashes in areas where skin
    meets skin should keep these areas as cool and dry as possible at
    all times. The areas should be dried thoroughly after bathing and
    before dressing. Loose fitting, cotton underwear and clothing are
    preferable when possible. Also when possible, students with such
    rashes should wash and dry themselves thoroughly whenever hot and
    sweaty. Clothing should be replaced by cool, clean, and dry apparel.

# Tinea Versicolor

A thin layer of selenium sulfide 2% lotion should be applied to the
entire affected area (usually the trunk) overnight once each week for 4
weeks. The body should be thoroughly washed in the morning and all
clothing and bed linen laundered. After 4 weeks, the treatment should be
applied one night each month for at least 3-4 months to prevent
recurrence of the rash. An alternative treatment consists of a single
dose of ketoconazole 400 mg by mouth once.

Students should not be excluded from class or recreational activities
due to fungal skin infections.

**WHEN TO REFER TO THE CENTER PHYSICIAN**

-   If the rash/lesion(s) does not clear after 4 weeks of therapy

-   If unsure whether the diagnosis is fungal infection

TREATMENT GUIDELINES FOR HEALTH STAFF

# Gastroenteritis/Enteritis

Authorized health and wellness staff may treat gastroenteritis/enteritis
as follows:

1.  For vomiting, encourage careful handwashing, and offer clear,
    non-caffeinated liquids in small amounts frequently.

2.  For diarrhea, encourage careful handwashing, and after 12 hours of
    clear liquids introduce bland solid foods.

3.  For mild abdominal cramps caused by diarrhea, offer the student
    loperamide caplets (Imodium AD), 2 caplets initially, then 1 caplet
    with each subsequent loose stool, not to exceed 4 caplets in 24
    hours. Take caplets with 8 ounces of water.

4.  If febrile, the student may be given acetaminophen, 1000 mg, every 4
    hours \[MDD 4 g\]. **Avoid** aspirin and/or non-steroidal
    anti-inflammatory medications, which may lead to further GI upset.

5.  No student with gastroenteritis/enteritis should be permitted to
    work in food services until all symptoms have completely resolved.

**WHEN TO REFER TO THE CENTER PHYSICIAN**

-   If the student has blood in the emesis or stool

-   If the student has bilious emesis

-   If the student has diminished urine output

-   If the student has a temperature [\>]{.underline}101°F

-   If the student has more than mild, crampy abdominal pain

-   If the symptoms persist more than 3 days

**TREATMENT GUIDELINES FOR HEALTH STAFF**

**GENITAL HERPES INFECTION**

Authorized health and wellness staff may treat genital herpes infection
as follows:

1.  First clinical episode: administer valacyclovir 1 gram po twice per
    day for 10 days or acyclovir 400 mg po three times per day for 10
    days.

2.  For recurrent episodes, administer valacyclovir 1 gram po once per
    day for 5 days or acyclovir 800 mg po twice per day for 5 days.

3.  Suppressive therapy to prevent recurrence (if [\>]{.underline} 6
    episodes per year): administer valacyclovir 1 gram po once daily or
    acyclovir 400 mg po twice per day. Reassess the need for continued
    prophylaxis by discontinuing therapy after 1 year.

4.  Discuss contact(s) treatment, screening for other STDs as
    appropriate, health department reporting requirements, and
    prevention of STDs and pregnancy (offer condoms and contraception as
    appropriate).

5.  Asymptomatic sex partners should be counseled but need not be
    treated.

WHEN TO REFER TO THE CENTER PHYSICIAN

-   If the student has symptoms suggestive of another sexually
    transmitted infection

-   If the student has HIV infection

-   If the student is pregnant

-   If the student needs suppressive therapy

**TREATMENT GUIDELINES FOR HEALTH STAFF**

**GONOCOCCAL INFECTION**

Authorized health and wellness staff may treat laboratory-confirmed
gonococcal infection as follows:

1.  Administer ceftriaxone 125 mg intramuscularly or cefixime 400 mg po
    once.

2.  If allergic to penicillin and cephalosporins, a single IM dose of
    spectinomycin 2 g is recommended.

3.  Unless laboratory testing for chlamydia infection is negative, treat
    for coinfection with chlamydia. (Refer to Treatment Guideline for
    Chlamydia Infection.)

4.  Instruct student to return for retreatment if vomiting occurs within
    4 hours of treatment with oral regimens.

5.  Discuss contact(s) treatment, screening for other STDs as
    appropriate, health department reporting requirements, and
    prevention of STDs and pregnancy (offer condoms and contraception as
    appropriate).

6.  Instruct student to abstain from sexual intercourse for 7 days and
    until all sexual partners have been treated.

7.  Schedule gonorrhea and chlamydia retesting in 1 month.

WHEN TO REFER TO THE CENTER PHYSICIAN

-   If the student has rectal pain suggestive of proctitis

-   If the female student has pelvic pain suggestive of PID

-   If the male student has scrotal pain suggestive of epididymitis or
    low back pain suggestive of prostatitis

**TREATMENT GUIDELINES FOR HEALTH STAFF**

**HEAD INJURY (Closed Head Trauma)**

Authorized health and wellness staff may treat a head injury, which is a
common problem with the potential for rare, but serious complications,
as follows:

1.  Observation is key. Keep the student at the health and wellness
    center for at least one hour after head injury. Monitor vital signs
    and neurological status.

2.  Call 911 and/or immediately transport patient to the hospital if
    consciousness is lost or any of these six findings are present: (1)
    ataxia, (2) double vision/loss of vision/altered visual fields, (3)
    progressive incapacitating headache, (4) repetitive projectile
    vomiting, (5) declining level of alertness/consciousness or
    inability to arouse, (6) change in mood and increased combativeness.

3.  The use of medication is discouraged during the initial observation
    period. Acetaminophen 1000 mg \[MDD 4 g\] **or** ibuprofen 400 mg
    \[MDD 1600 mg\] may be administered if the patient complains of
    headache. No other analgesic or psychotropic medication should be
    given. If the patient complains of severe pain requiring narcotic
    medications, refer to the clinician.

# WHEN TO REFER TO THE CENTER PHYSICIAN

-   If the headache is progressively worse and/or does not respond to
    acetaminophen or ibuprofen in appropriate doses

**TREATMENT GuidelineS FOR HEALTH STAFF**

**HEADACHE**

Authorized health and wellness staff may treat headache as follows:

1.  Obtain a careful history and vital signs.

2.  Stress is the most common origin of headache in teenagers and
    adults. Offer the student with frequent headaches a referral for
    counseling regarding stress management.

3.  Provide ibuprofen 400 mg po every 6 hours \[MDD 1600 mg\] or
    acetaminophen 1000 mg \[MDD 4 g\] po every 4 hours as needed for
    headache.

4.  Offer bed rest for 2-4 hours when headache prevents daily function.

5.  Refer to the center physician if headache persists for more than 24
    hours or frequently recurs.

# WHEN TO REFER TO CENTER PHYSICIAN

-   If trauma, migraine, hypertension, infection, or other specific
    problems exist

-   If the headache is associated with changes in vision or vomiting, or
    does not respond to the treatment recommendations

-   If the headache persists for more than 24 hours or frequently recurs

TREATMENT GUIDELINES FOR HEALTH STAFF

**HEAT INJURIES**

Authorized health and wellness staff may treat heat cramps, heat
exhaustion, and heat stroke, which are progressive forms of
hyperthermia, as follows:

# Heat Cramps (brief muscle contractions without rigidity of skeletal and abdominal muscles)

1.  Supportive treatment includes removal to cool environment and rest
    from exercise.

2.  Gentle massage of cramping muscles.

3.  Oral replacement of water and electrolytes with an electrolyte-based
    sports drink such as Gatorade, Powerade, or equivalent.

# Heat Exhaustion (core body temperature greater than 100^ο^F but less than 104^ο^F with complaints of malaise, weakness, headache, anorexia, nausea, and/or vomiting)

1.  Supportive treatment includes removal to cool environment and rest
    from exercise.

2.  Oral replacement of water and electrolytes with an electrolyte-based
    sports drink such as Gatorade, Powerade, or equivalent.

3.  In severe cases involving vomiting, may require intravenous
    replacement of fluid and electrolytes with normal saline solution.
    Contact the clinician for further advice.

# Heat Stroke (core body temperature 104^ο^F or above with tachycardia, hypotension, and mental changes -- often incoherent and combative)

1.  Remove from source of heat and call 911 to transport for emergency
    care.

2.  Remove clothing and apply cold packs, wet sheets, or wet cold towels
    to neck, head, abdomen, and inner thighs.

3.  Use a fan or fanning motion to circulate air over the patient.

4.  Maintain airway and be alert for vomiting to prevent aspiration.

5.  If authorized to do so, administer intravenous normal saline
    solution and monitor cardiac function, urinary output, and core
    temperature.

Follow up by teaching prevention strategies (maintaining hydration;
acclimatizing to and avoiding overexertion in hot, humid climates; using
appropriate clothing such as sunshades, hats, and light reflective
shirts that allow ventilation) to prevent recurrence.

# WHEN TO REFER TO THE CENTER PHYSICIAN

-   If the student does not respond to supportive treatment

-   If IV rehydration is indicated

-   If there are mental status changes (confusion, incoherent, altered
    consciousness)

**TREATMENT GUIDELINES FOR HEALTH STAFF**

## **HEPATITIS**

Authorized health and wellness staff may treat clinically confirmed
hepatitis as follows:

1.  All students with a new or existing diagnosis of acute or chronic
    hepatitis of any type should be referred to the center physician for
    evaluation. The center physician should discuss treatment options
    and management plans. If the center physician is not on center, call
    him/her to discuss what is known and to get any orders for
    laboratory testing necessary before the appointment. MSWR, if
    appropriate, can be discussed at the appointment time.

2.  If the student remains on center, attention should be paid to
    prevention of transmission of infectious hepatitis to others. If it
    is an acute infectious case, the health department may be asked to
    assist in the prophylaxis of other students/staff, and the student
    should be given and agree to abide by specific guidelines to
    practice for non-transmission techniques (strict hand-washing, no
    sharing of meal utensils or personal toiletries, no blood donation,
    and no sharing of bodily fluids (i.e., no kissing and no unprotected
    sexual activity).

# WHEN TO REFER TO THE CENTER PHYSICIAN

-   To assess indications for immunization against hepatitis A and/or
    hepatitis B infection

**Treatment Guidelines for HEALTH STAFF**

# hypertension

Authorized health and wellness staff may treat elevated blood pressure
as follows:

1\. When a systolic blood pressure ≥ 140 mm or diastolic blood pressure
of ≥ 90 mm is recorded for a student, repeat the blood pressure at three
10-minutes intervals, making sure that proper technique and cuff size
are used.

2\. If the blood pressure reading remains elevated, schedule the student
to return to the health and wellness center on three separate occasions
in the following 3-4 weeks for repeat blood pressure readings, then
schedule an appointment with the center physician.

3\. Students with "borderline" blood pressures (blood pressure readings
are systolic between 125 and 139 and diastolic between 81 and 89) or who
have a family history of hypertension should be encouraged to have their
blood pressure checked every 3-6 months.

Each student with hypertension should have a chronic care management
plan developed and implemented.

**WHEN TO REFER TO** **THE CENTER PHYSICIAN**

-   If a systolic reading ≥ 180 mm has been recorded

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-   If a diastolic reading ≥110 mm has been recorded

-   If systolic blood pressure readings of ≥140 mm have been recorded on
    three separate occasions

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-   If diastolic blood pressure readings of ≥ 90 mm have been recorded
    on three separate occasions

-   Students with "borderline" blood pressures should be counseled on
    the meaning of high blood pressure, its consequences, and lifestyle
    choices that can alleviate the problem (such as lowering salt
    intake, smoking cessation, proper exercise, and weight management)

**Refer to the Hypertension Chronic Care Management Plan for additional
guidance.**

**TREATMENT GUIDELINES FOR HEALTH STAFF**

# IMPETIGO

Authorized health and wellness staff may treat impetigo as follows:

1.  Check the student's temperature.

2.  Cleanse the lesion with a topical antiseptic.

3.  Cover exposed lesions, if possible. Caution the student to avoid
    direct skin-to-skin contact with other students while the lesions
    remain.

4.  Initiate oral antibiotics to cover staphylococcal and streptococcal
    skin infections, with cephalexin (Keflex) 500 mg po twice daily for
    10 days.

5.  Alternative treatment with mupirocin (Bactroban) cream/ointment
    applied 3 times a day for 10 days may be considered for small
    lesions.

6.  If methicillin-resistant *Staphylococcus aureus* (MRSA) is
    suspected, administer trimethoprim/sulfamethoxazole (Bactrim DS)
    twice daily for 10 days.

7.  Question the student about whether or not he/she is aware of other
    students with similar lesions. If so, call affected students into
    the health and wellness center for evaluation and treatment.

**WHEN TO REFER TO THE CENTER PHYSICIAN**

-   If lesions are not improving on antibiotics or there are signs of
    cellulitis (surrounding erythema, streaking from the lesions, local
    tenderness)

-   If the student has a fever of [\>]{.underline}101°F

**TREATMENT GUIDELINES FOR HEALTH STAFF**

## **INFECTIOUS MONONUCLEOSIS**

Authorized health and wellness staff may treat infectious mononucleosis
as follows:

1.  All students with a diagnosis of acute mononucleosis should be
    referred to the center physician for evaluation and development of a
    management plan. MSWR can be discussed at that time.

2.  Screen the student for simultaneous streptococcal throat infection.

3.  Advise the student to avoid sharing drinks utensils, or toiletries,
    and to avoid exchange of bodily fluids (e.g., no kissing and no
    unprotected sexual behavior).

4.  Avoid contact sports and heavy exertion for 6-8 weeks after onset of
    infection, until cleared by the center physician.

Note: Steroids are useful only in patients with complications as
determined by the center physician; antiviral medications have no proven
benefit.

**WHEN TO REFER TO THE CENTER PHYSICIAN**

-   If the student has difficulty breathing

-   If the student cannot swallow and maintain adequate hydration

-   If the student's symptoms (malaise, fatigue) worsen, and the student
    is unable to attend class

**TREATMENT GuidelineS for HEALTH STAFF**

# INFLUENZA

Influenza outbreaks commonly occur in the winter months, from December
through March. Authorized health and wellness staff may treat influenza
as follows:

1.  Bed rest is indicated. In case of a center-wide outbreak, centers
    may wish to confine symptomatic students to their dormitory rooms
    and to provide supportive care on site in the dorms.

2.  Symptomatic students wishing to return home should [not]{.underline}
    travel via public transportation. Family members or center staff
    should provide transportation if practical, otherwise symptomatic
    students should remain on center.

3.  Encourage oral hydration. Adequate fluids are necessary to prevent
    dehydration and adequate nutrition fosters recovery.

4.  For fever and muscle pain, offer the student acetaminophen 1000 mg
    po every 4 hours \[MDD 4 g\] or ibuprofen 400 mg po every 6 hours
    \[MDD 1600 mg\] as needed. Aspirin should [not]{.underline} be given
    to students under age18, as its use with influenza is associated
    with Reye Syndrome.

5.  For sore throat, offer the student analgesic throat lozenges or
    throat spray for relief of symptoms, in addition to the medications
    listed in #4 above.

6.  For nasal congestion, offer saline nasal spray OR nasal decongestant
    spray OR pseudoephedrine (Sudafed) 30 mg - 60 mg every 8 hours. Note
    that nasal decongestant spray should not be used for more than 3
    days.

7.  For earache, offer the student medications listed in #4 above, and
    refer to the clinician for further evaluation.

8.  Antiviral medications should be used for the prevention or treatment
    of influenza on center [only]{.underline} in consultation with state
    or local public health authorities. Antiviral treatment lasts for 5
    days and must be started within 2 days of illness to be effective.

9.  Preventive measures should be stressed with well students and staff,
    including annual vaccination, avoiding close contact with
    symptomatic patients, frequent handwashing, plus adequate sleep and
    nutrition.

**WHEN TO REFER TO THE CENTER PHYSICIAN**

-   If the student has a persistent fever [\>]{.underline} 101°F for
    more than 48 hours

-   If pneumonia is suspected

-   If sinusitis is suspected

-   If the student has a persistent earache

**TREATMENT GUIDELINES FOR HEALTH STAFF**

**LACERATIONS**

Authorized health and wellness staff may treat lacerations as follows:

1.  Stop bleeding by direct compression to the wound with sterile gauze.
    Elevate the extremity with the laceration.

2.  If bleeding does not slow or stop with five minutes of direct
    pressure, call 911.

3.  Irrigate the laceration with sterile saline, cover the wound with
    clean gauze, and have the student evaluated by the center physician
    as soon as possible. Address any other injuries.

4.  For small wounds with straight edges, gently pull the edges together
    narrowing the gap of the wound and apply steri-strips or butterfly
    adhesives to keep the edges approximated. Larger wounds will likely
    require local anesthesia for debridement and suturing.

5.  Check immunization status and give tetanus-diphtheria-acellular
    pertussis (Tdap) booster immunization when indicated. Refer to TAG
    B: Immunization and Communicable Disease Control.

6.  For wounds on the extremities, if you are alone and CPR is needed,
    assess the airway, place a tourniquet on the bleeding extremity and
    resume CPR.

7.  For wounds on the trunk and head, assess the airway, stop or control
    bleeding, and resume CPR.

# WHEN TO REFER TO THE CENTER PHYSICIAN

-   If the wound appears contaminated with pathogens, toxins, or
    chemicals despite irrigation

-   If it is a large or deep wound needing sutures

**TREATMENT GUIDELINES FOR HEALTH STAFF**

**LYME DISEASE**

Authorized health and wellness staff may treat clinically-confirmed Lyme
disease as follows:

1.  Administer doxycycline 100 mg po twice daily for 21 days.

2.  Alternative treatment: administer amoxicillin 1 gram twice daily for
    21 days.

3.  Instruct student to return for re-treatment if vomiting occurs
    within 4 hours of any dose.

4.  Any student with the characteristic rash of erythema migrans should
    be treated presumptively, regardless of serologic testing results.

5.  Instruct female students that Candida vaginitis may occur as a
    result of the 3-week course of antibiotic therapy. Refer to
    Treatment Guideline for Candida Vulvovaginitis if necessary.

Note: Lyme disease vaccine is no longer available.

WHEN TO REFER TO THE CENTER PHYSICIAN

-   If the student has symptoms suggestive of neurologic involvement
    such as confusion, neck stiffness, blurred vision, or facial
    weakness

-   If the student has signs of arthritis or carditis

#  

**TREATMENT GUIDELINES FOR HEALTH STAFF**

**MUSCLE INJURY**

Authorized health and wellness staff may treat muscle injuries as
follows:

1.  Assess the extent of muscle injury and any associated injuries.

2.  Apply basic first aid for musculoskeletal injury: Rest, Ice,
    Compression, Elevation (RICE)

3.  Assess the muscle for a firm, tender bulge indicating a possible
    hematoma. When present, immobilize the muscle, apply an ice pack,
    and refer to the clinician for evaluation of the injury.

4.  Assess the muscle's range of adjacent joint motion. If motion is
    compromised, immobilize the muscle, apply an ice pack, and refer to
    the clinician or emergency department within 24 hours. Administer
    ibuprofen 400 mg every 6 hours \[MDD 1600 mg\] as needed for pain.

5.  If the muscle is tender or in spasm without hematoma and with full
    range of adjacent joint motion, apply an ice pack, restrict activity
    for two days and administer ibuprofen 400 mg every 6 hours \[MDD
    1600 mg\]. If pain does not resolve within 48 hours or fever occurs
    post injury, refer to the clinician for evaluation.

# WHEN TO REFER TO THE CENTER PHYSICIAN

-   If swelling or limited mobility increases

-   If pain relief is inadequate with ibuprofen

**TREATMENT GUIDELINES FOR HEALTH STAFF**

**Nicotine Replacement Therapy**

Authorized health and wellness staff may provide students with a weekly
supply of Nicotine Replacement Therapy product under the following
conditions:

1.  Nicotine Replacement Therapy (NRT) risks, benefits, alternatives and
    side effects should be thoroughly reviewed with student before
    initiation of therapy.

2.  NRT is indicated for students with physiologic dependence on
    nicotine, generally defined as smoking 10 cigarettes (1/2 pack) or
    more daily.

3.  The student should be counseled on the potential for nicotine
    withdrawal.

4.  Student should be actively enrolled in Tobacco Use and Prevention
    Program (TUPP).

5.  Student should verbalize a serious commitment to cease use of
    tobacco products.

6.  Student should understand the correct use of nicotine replacement
    product (nicotine patch, gum, inhaler, nasal spray or lozenge).

7.  Student should be educated in the proper and safe disposal of
    nicotine patches (as these can be toxic to children and pets).

8.  Students should be routinely scheduled for weekly follow-up visits
    for monitoring and tapering of NRT.

**WHEN TO REFER TO THE CENTER PHYSICIAN**

-   If the student experiences any side effect from NRT

-   If the student is reported to continue the use of any tobacco
    product while concurrently using NRT

-   If the student becomes pregnant while using NRT

-   If the student expresses a desire to try Zyban (bupropion) for
    assistance with nicotine cravings while using NRT

**TREATMENT GUIDELINES FOR HEALTH STAFF**

**NOCTURNAL ENURESIS**

# 

Authorized health and wellness staff may treat nocturnal enuresis as
follows:

# 1. Non-Pharmacologic regimens (patient education) include:

-   Restrict fluid intake 2 hours or more before bedtime, especially
    drinks with caffeine, which stimulate urine production.

-   Empty bladder fully at bedtime.

-   Awaken one or more times per night to urinate (self-pep talk to
    awaken, practice feeling full bladder and emptying, alarm clock,
    clock radio, residential advisor awakening).

-   If awakened by wetting at night, get up and change to dry clothes
    and put dry towel over wet spot in bed.

-   Change wet clothing and bedding upon arising in the morning and
    thoroughly cleanse body to eradicate any odor of urine.

-   Bed-wetting alarms are effective (approximate cost \$60 - \$100),
    usually within 3-4 weeks, but may be inconvenient in a dormitory
    setting. A vibrating alarm may be preferable to avoid waking
    roommates.

# 

# 2. Pharmacologic regimens include:

-   **DDAVP** can be administered intranasally or orally. Initial
    intranasal dose is20 micrograms at bedtime (one 10 microgram spray
    per nostril). This can be increased by 10 micrograms per week to a
    maximum dose of 40 micrograms. Oral desmopressin 200 micrograms can
    be taken orally at bedtime and may be increased to 600 micrograms
    maximum if needed.

-   **Imipramine (Tofranil)** is taken 1 hour before bedtime, beginning
    with 25 mg po and titrated upward by 25 mg every 2 weeks until
    dryness occurs or until the maximum dosage of 75 mg is reached.

-   **Oxybutynin (Ditropan)** is available as a sustained release
    formulation of 10 mg po per day or is also available as a 5 mg po
    dose 2-3 times daily.

### Helpful Websites For Teens With Enuresis

<http://www.peds.umn.edu/centers/nes/>

<http://www.enuresis.org.uk/main.html>

<http://www.chmed.com/enu.htm>

**WHEN TO REFER TO THE CENTER PHYSICIAN**

-   If the student reports failure of the above regimens to control
    enuresis

-   If there is daytime urinary incontinence

-   If polydipsia and polyuria are present

-   If there are any symptoms of urinary tract infection (urgency,
    frequency, dysuria, fever, abdominal pain)

**TREATMENT GUIDELINES FOR HEALTH STAFF**

**ORAL HERPES INFECTION**

Authorized health and wellness staff may treat herpes labialis (cold
sores) as follows:

1.  In an acute episode, oral acyclovir is of minimal benefit, and
    topical acyclovir is ineffective in treating non-genital herpes
    simplex infection in an immunocompetent host.

2.  Recurrent episodes of herpes labialis ([\>]{.underline} 6 episodes
    per year) may be reduced by administering valacyclovir 1 gram po
    once daily or acyclovir 400 mg po twice per day. Reassess the need
    for continued prophylaxis by discontinuing therapy after 1 year.

3.  Symptomatic treatment with oral or topical analgesics may be
    prescribed.

4.  Contact precautions are indicated to prevent the spread of
    infection.

WHEN TO REFER TO THE CENTER PHYSICIAN

-   If the student has HIV infection

-   If the student has ocular lesions, referral to an ophthalmologist is
    indicated immediately

#  

TREATMENT GUIDELINES FOR HEALTH STAFF

# OTITIS EXTERNA

Authorized health and wellness staff may treat otitis externa as
follows:

1.  Administer Cortisporin Otic Suspension, 4 drops in affected ear qid
    for 10 days, or ofloxacin 0.3% otic solution two drops bid for 10
    days. (Shake container well before using.)

2.  Do not administer ofloxacin if the tympanic membrane is perforated.

3.  Avoid water in the ear canals by using ear plugs when showering,
    shampooing or swimming for 10 days.

4.  Offer the student acetaminophen 1000 mg every 4 hours \[MDD 4 g\]
    **or** ibuprofen 400 mg every 6 hours \[MDD 1600 mg\] as needed for
    pain.

**WHEN TO REFER TO THE CENTER PHYSICIAN**

-   If the student has a perforated tympanic membrane

-   If the student's ear pain or discharge is not resolved with the
    above treatment or recurs

# TREATMENT GUIDELINES FOR HEALTH STAFF

## **OTITIS MEDIA**

Authorized health and wellness staff may treat otitis media as follows:

1.  Administer amoxicillin 500 mg po tid for 10 days.

2.  If allergic to penicillin, administer azithromycin 500 mg on day 1
    and 250 mg on day 2 through day 5.

3.  Instruct the student to return if ear pain or fever is not improved
    by day 3 of treatment or if pus begins to drain from the ear canal.

4.  Offer the student acetaminophen 1000 mg every 4 hours \[MDD 4 g\]
    **or** ibuprofen 400 mg every 6 hours \[MDD 1600 mg\] as needed for
    pain.

5.  Instruct female students that Candida vulvovaginitis may occur as a
    result of oral antibiotic therapy.

**WHEN TO REFER TO THE CENTER PHYSICIAN**

-   If the student has a perforated tympanic membrane

-   If the student also has otitis externa

**TREATMENT GUIDELINES FOR HEALTH STAFF**

**PAP SMEAR ABNORMALITIES**

Authorized health and wellness staff may arrange for follow-up of Pap
smear abnormalities as follows:

1.  Students with a normal Pap smear, with endocervical cells present,
    should have a Pap smear repeated annually.

2.  Students with a Pap smear demonstrating absent endocervical cells,
    inadequate cellularity, or obscuring artifact should have a Pap
    smear repeated to obtain an adequate specimen.

3.  Students with a Pap smear demonstrating inflammation should be
    evaluated for infection and treated as indicated by the results of
    testing.

4.  Students with a Pap smear demonstrating atypical squamous cells of
    undetermined significance (ASCUS) should have a Pap smear repeated
    within 6 months. Colposcopy is indicated if the abnormal cytology
    persists.

5.  Students with a Pap smear demonstrating mild dysplasia (Low-grade
    Squamous Intraepithelial Lesion/LSIL) should have a Pap smear
    repeated within 6 months. Colposcopy is indicated if the abnormal
    cytology persists.

6.  Students with a Pap smear demonstrating moderate or severe dysplasia
    (High-grade Squamous Intraepithelial Lesions/HSIL) or
    carcinoma-in-situ should be referred immediately for colposcopy.

WHEN TO REFER TO THE CENTER PHYSICIAN

-   All students in need of colposcopy

-   If the student has questions about her Pap smear abnormalities and
    the indications for follow-up

-   If the student has questions or anxiety about colposcopy referral

**TREATMENT GUIDELINES FOR HEALTH STAFF**

**PELVIC INFLAMMATORY DISEASE (PID)**

Authorized health and wellness staff may treat clinically confirmed
pelvic inflammatory disease as follows:

1.  Administer ceftriaxone 250 mg IM in a single dose plus doxycycline
    100 mg po twice per day for 14 days. (Doxycycline is contraindicated
    in pregnancy.)

2.  Alternative treatment: administer ofloxacin 400 mg po twice a day
    for 14 days or levofloxacin 500 mg po once daily for 14 days plus
    metronidazole 500 mg po with fluids or snack twice per day for 14
    days.

3.  Instruct student to return for re-treatment if vomiting occurs
    within 4 hours of any dose of oral medication.

4.  Caution student to avoid alcohol ingestion during metronidazole
    therapy and for 48 hours after the last dose.

5.  Discuss contact(s) treatment, screening for other STDs as
    appropriate, health department reporting requirements, and
    prevention of STDs and pregnancy (offer condoms and contraception as
    appropriate).

6.  Schedule a follow-up visit for reexamination in 24 to 48 hours.

WHEN TO REFER TO THE CENTER PHYSICIAN

-   If the student is pregnant: Because of the high risk for maternal
    morbidity, fetal loss and preterm delivery, pregnant women with
    suspected PID should be hospitalized and treated with parenteral
    antibiotics

-   If the diagnosis of PID is uncertain or tubo-ovarian abscess is
    suspected

-   If the student has fever [\>]{.underline} 101^o^F or fever with
    chills or vomiting

-   If the student has not responded clinically to oral antibiotics in
    24 to 48 hours

**TREATMENT GUIDELINES FOR HEALTH STAFF**

**PUBIC LICE (Pediculosis pubis)**

Authorized health and wellness staff may treat pubic lice as follows:

# 1. Pharmacologic regimens include:

-   Permethrin 1% creme rinse (Nix) applied topically to infested area
    until entirely wet, then thoroughly washed off after 10 minutes
    **OR**

-   Pyrethrins with piperonyl butoxide (Rid) applied topically to
    infested area until entirely wet, then thoroughly washed off after
    10 minutes **OR**

-   Lindane 1% shampoo (Kwell) worked into a lather on the infested
    area, then thoroughly washed off after 4 minutes. Note: Lindane is
    **contraindicated** if pregnant or lactating.

-   Petrolatum ointment (Vaseline) applied topically twice daily for 10
    days for infestation of the eyelashes.

-   Oral antihistamines (diphenhydramine/Benadryl **or**
    hydroxyzine/Atarax, Vistaril **or** cetirizine/Zyrtec) can be given
    to reduce itching.

# 2. Non-Pharmocologic regimens include:

-   Bedding and clothing recently worn should be decontaminated (either
    machine-washed in hottest water and machine-dried on hottest cycle
    for 20 minutes or dry-cleaned) or removed from body contact for at
    least 72 hours. Fumigation of living areas is **not** necessary.

-   Although the nits/eggs are dead, they may stay tightly adherent. Wet
    hair with warm vinegar and water 50:50 mixture. After 30 minutes,
    rinse hair and then mechanically remove nits with a fine-toothed
    comb.

-   Sexually active patients with pediculosis should also be evaluated
    for other STDs. Sex partners within the last month should be treated
    for lice and also evaluated for other STDs. (It may take 2-3 weeks
    for adult lice to appear after exposure.)

-   Follow up with patients after 1 week to see if symptoms persist.
    Retreatment with an alternative regimen is indicated if lice are
    found or if new nits/eggs are observed at the hair-skin junction.

Note: These treatment guidelines apply to head lice as well as pubic
lice

**WHEN TO REFER TO CENTER PHYSICIAN**

-   If above treatments fail to resolve lice infestation

-   If there is a need for other STD evaluation

**TREATMENT GUIDELINES FOR HEALTH STAFF**

**SCABIES (Sarcoptes Scabiei)**

Authorized health and wellness staff may treat scabies as follows:

# 1. Pharmacologic regimens include:

-   Permethrin cream 5% (Elimite) applied topically in a thin layer to
    the entire body from the neck down and washed off after 8-14 hours
    **OR**

-   Lindane 1% (Kwell), 1 oz of lotion or 30 grams of cream, applied
    topically in a thin layer to the entire body from the neck down and
    thoroughly washed off after 8 hours. NOTE: Lindane should **not** be
    used immediately after a bath or shower and is **contraindicated**
    in persons with extensive dermatitis, or are pregnant or lactating.

-   Oral antihistamines (diphenhydramine/Benadryl **or**
    hydroxyzine/Atarax, Vistaril **or** cetirizine/Zyrtec) can be given
    to reduce itching. Cool baths (Aveeno) and topical 1% hydrocortisone
    cream topically may also relieve itching.

-   Topical or systemic antibiotic therapy is indicated ONLY for
    secondary bacterial infection of excoriated lesions.

# Non-Pharmacologic regimens include:

-   Bedding and clothing recently worn should be decontaminated (either
    machine-washed in hottest water and machine-dried on hottest cycle
    for 20 minutes or dry-cleaned) or removed from body contact for at
    least 72 hours. Fumigation of living areas is **not** necessary.

-   Patients should be informed that the rash and itching of scabies may
    persist for up to 2 weeks after treatment.

-   If patients are still symptomatic after 2 weeks, they may be
    retreated with an alternative regimen.

-   Sexual contacts should also be treated. Symptoms may take 30 days
    after exposure to develop.

**WHEN TO REFER TO THE CENTER PHYSICIAN**

-   If the above treatment fails to resolve the scabies infestation

-   If there is a need for other STD evaluation

**TREATMENT GUIDELINES FOR HEALTH STAFF**

## **SEIZURE DISORDER**

Authorized health and wellness staff may treat seizures as follows:

1.  All students with newly diagnosed seizures and all newly enrolled
    students who report that they have seizures should be referred to
    the center physician as soon as possible. If the center physician is
    not on center at the time of the discovery of a history of seizures,
    he/she should be called in order to discuss what is known about the
    student and get any orders prior to the appointment.

2.  Each student with seizures should have a chronic care management
    plan developed which includes at least the following:

    -   The anticonvulsant medication dose and administration schedule

    -   Any limitation to physical activities or exercise programs

    -   The schedule of follow up in the health and wellness center

    -   The medical monitoring plan, including anticonvulsant blood
        levels if indicated

    -   Need for follow up by neurologist

    -   Documentation of which staff have been notified about the
        student's diagnosis

    -   Specific plan for how non-health staff will manage any break
        though seizure on center (see Seizure Disorder Symptomatic
        Management Guideline.)

# WHEN TO REFER TO THE CENTER PHYSICIAN

-   If seizure activity occurs on or off center

-   If student does not adhere to anticonvulsant therapy

**Refer to the Seizure Disorder Chronic Care Management Plan for
additional guidance.**

**TREATMENT GUIDELINES FOR HEALTH STAFF**

**SEXUAL ASSAULT**

Authorized health and wellness staff may treat to prevent sexually
transmitted infection and pregnancy following a sexual assault as
follows:

1.  Examination and laboratory testing should be conducted at the
    designated sexual assault site or Emergency Department prior to
    initiating treatment according to the center's Sexual Assault
    Response Team (SART) protocol. Clothing and laboratory specimens
    should be secured while preserving chain-of-custody.

2.  For STD prophylaxis: administer ceftriaxone 125 mg IM in a single
    dose [plus]{.underline} metronidazole 2 grams po with fluids or
    snack in a single dose [plus]{.underline} azithromycin 1 gram po in
    a single dose.

3.  For hepatitis B prophylaxis: if the student's hepatitis B
    vaccination status or immunity cannot be confirmed, administer the
    first dose of hepatitis B vaccine at the initial examination, and
    administer the second and third doses of hepatitis B vaccine at
    appropriate intervals. Hepatitis B immune globulin (HBIG) is not
    indicated.

4.  For HIV prophylaxis: assess risk for HIV infection in assailant and
    consider offering antiretroviral post exposure prophylaxis according
    to the latest Centers for Disease Control recommendations:
    http://www.cdc.gov/mmwr/PDF/rr/rr5011.pdf.

5.  For pregnancy prevention: offer the student emergency contraception
    with two levonorgestrel 0.75 mg tablets, administered po together,
    no later than 120 hours after the assault.

6.  Instruct student to return for re-treatment if vomiting occurs
    within 4 hours of any dose of oral medication.

7.  Caution student to avoid alcohol ingestion during metronidazole
    therapy and for 48 hours after the last dose.

8.  Schedule retesting for STDs at 6, 12, and 24 weeks after the assault
    if initial test results were negative.

WHEN TO REFER TO THE CENTER PHYSICIAN AND MENTAL HEALTH CONSULTANT

-   All students who have experienced sexual assault

**TREATMENT GUIDELINES FOR HEALTH STAFF**

**SPRAINS/DISLOCATIONS**

Authorized health and wellness staff may treat sprains and dislocations
as follows:

1.  Assess the extent of injury. Apply ice, compression, and elevation
    as appropriate.

2.  A student with a visibly dislocated joint should be referred to the
    emergency department for urgent evaluation.

3.  Assess the injured joint and surrounding areas for bruising and
    subcutaneous bleeding indicating a possible hemarthrosis. When
    present, immobilize the joint with a splint across both sides of the
    joint.

4.  Gently assess joint's range of motion and if range is compromised
    immobilize the joint with a splint and refer to the center physician
    within 24 hours. Administer ibuprofen 400 mg po every 6 hours \[MDD
    1600 mg\] for pain and inflammation. Provide crutches if needed.

5.  If joint is tender and swollen but without bleeding or bruising,
    restrict activity of the joint for 3 days and administer ibuprofen
    400 mg po every 6 hours \[MDD 1600 mg\]. If pain does not resolve or
    recurs within 48 hours post injury, refer to the center physician.
    If daily function is compromised, excuse from duty until the center
    physician evaluates the student.

# WHEN TO REFER TO CENTER PHYSICIAN

-   If pain does not diminish with ibuprofen treatment

-   If student is unable to participate in activities or has persistent
    limited range of joint motion

**TREATMENT GUIDELINES FOR HEALTH STAFF**

**SYPHILIS (PRIMARY AND SECONDARY)**

Authorized health and wellness staff may treat laboratory-confirmed
syphilis infection as follows:

1.  Administer benzathine penicillin G 2.4 million units in a single
    intramuscular (IM) dose once. Note that this must be long-acting
    benzathine penicillin (Bicillin L-A) [only]{.underline}.

2.  If student is allergic to penicillin, prescribe doxycycline 100 mg
    po bid for 14 days. Note: Doxycycline is contraindicated in
    pregnancy.

3.  Discuss contact(s) treatment, screening for other STDs as
    appropriate, health department reporting requirements, and
    prevention of STDs and pregnancy (offer condoms and contraception as
    appropriate).

4.  All students with syphilis should be tested for HIV infection.

5.  Persons exposed within 90 days of the diagnosis of syphilis in a
    sexual partner should be treated presumptively, even if
    seronegative.

6.  Schedule repeat serological testing for syphilis at 6 and 12 months
    after treatment. Failure of titers to decline fourfold within 6
    months of treatment for syphilis indicates probable treatment
    failure.

WHEN TO REFER TO THE CENTER PHYSICIAN

-   If the student has symptoms suggestive of another sexually
    transmitted infection

-   If syphilis serology titers have not declined at least fourfold 6
    months after treatment

-   If student is allergic to penicillin and pregnant, desensitize and
    treat with penicillin

**TREATMENT GUIDELINES FOR HEALTH STAFF**

**TRICHOMONAS INFECTION**

Authorized health and wellness staff may treat confirmed trichomonas
infection as follows:

1.  Administer metronidazole 2 grams po once as single dose directly
    observed therapy with fluids or snack.

2.  Alternative treatment: administer metronidazole 500 mg po twice per
    day for 7 days.

3.  Instruct student to return for re-treatment if vomiting occurs
    within 4 hours of treatment.

4.  Caution student to avoid alcohol ingestion during metronidazole
    therapy and for 48 hours after the last dose.

5.  Discuss contact(s) treatment, screening for other STDs as
    appropriate, health department reporting requirements, and
    prevention of STDs and pregnancy (offer condoms and contraception as
    appropriate).

6.  Instruct student to abstain from sexual intercourse for 7 days and
    until all sex partners have been treated.

7.  Pregnant students who are symptomatic may be treated with
    metronidazole 2 grams in a single oral dose or metronidazole 500 mg
    po bid for 7 days. Metronidazole use during pregnancy is not
    associated with teratogenic or mutagenic effects in infants.

8.  Note that oral metronidazole is the only effective drug for the
    treatment of trichomoniasis, and that topical regimens are not
    effective.

WHEN TO REFER TO THE CENTER PHYSICIAN

-   If vaginal symptoms persist despite treatment

#  

TREATMENT GUIDELINES FOR HEALTH STAFF

**TUBERCULIN SKIN TESTING**

Authorized health and wellness staff may evaluate and treat tuberculin
skin testing as follows:

Note: Patients with a previous history of tuberculosis or positive
tuberculin skin testing should not receive a repeat tuberculin skin
test.

Tuberculin skin tests should be interpreted 48-72 hours after
intradermal placement according to the following CDC guidelines:

-   **\<** 5 mm induration -- consider negative

-   **[\>]{.underline}** 5 mm induration -- consider positive in a
    patient with HIV infection, recent contacts of active TB patients,
    patients with fibrotic changes on chest radiograph consistent with
    prior TB, patients with organ transplants, and other
    immunosuppressed patients

-   **[\>]{.underline}** 10 mm induration -- consider positive in recent
    immigrants (within the last 5 years) from high-prevalence countries,
    injection drug users, patients with clinical conditions that place
    them at high risk: diabetes mellitus, chronic renal failure, some
    hematologic disorders (e.g., leukemias and lymphomas), other
    specific malignancies, malnutrition with weight loss of
    **[\>]{.underline}**10% of ideal body weight, jejunoileal bypass,
    and adolescents exposed to adults at high-risk of TB infection

-   **[\>]{.underline}** 15 mm induration -- consider positive in a
    patient with no known risk factors for TB and no symptoms or signs
    of infection

Tuberculin skin test results should be interpreted without regard to a
prior history of BCG vaccination.

A patient with a tuberculosis skin test (TST) conversion as defined
above must have a chest x-ray to exclude active pulmonary tuberculosis.
If the radiograph is either normal or reveals only granulomas or
calcification in the lung and/or regional lymph nodes, then the patient
is considered to have Latent Tuberculosis Infection (LTBI).

Pharmacologic management of latent tuberculosis infection includes:

1.  Isoniazid (INH) 300 mg po in a single dose daily for 9 months. If
    daily therapy is not possible or adherence is poor, 900 milligrams
    directly observed treatment (DOT) can be given twice per week for 9
    months. (HIV positive patients should be treated for 12 months.)

2.  Pyridoxine supplements need not be given with isoniazid in otherwise
    healthy youth.

3.  Monitoring liver function tests is not indicated in otherwise
    healthy students with no history of liver disease.

4.  If the original chest film was considered negative and the patient
    remains asymptomatic, no repeat study is needed at the conclusion of
    therapy.

5.  Record completed INH therapy in the medical record, and report same
    to the state or local Public Health Department so the patient will
    not have to undergo LTBI therapy again.

Note: Many local health departments provide evaluation and treatment
services for reactive tuberculin skin tests, including chest x-rays and
monthly medication at no cost to the center.

### WHEN TO REFER TO THE CENTER PHYSICIAN

-   If measurements of skin test reading are uncertain

-   If student has an abnormal chest x-ray

-   If student has a history of liver disease

-   If the student does not adhere to isoniazid therapy

**TREATMENT GuidelineS for HEALTH STAFF**

# URI, PHARYNGITIS, SINUSITIS

These are among the most common illnesses to occur on Job Corps centers,
and are usually of viral etiology. Authorized health and wellness staff
may treat URI, pharyngitis, and sinusitis as follows:

1.  For fever, offer the student acetaminophen 1000 mg po every 4 hours
    \[MDD 4 g\] or ibuprofen 400 mg po every 6 hours \[MDD 1600 mg\] as
    needed. Encourage oral hydration.

2.  For cough, offer the student cough syrup in a dose containing 30 mg
    of dextromethorphan, for use primarily at bedtime, but no more often
    than every 6 hours \[MDD 120 mg\]. Again, encourage oral hydration.

3.  For sore throat, offer the student analgesic throat lozenges or
    throat spray for relief of symptoms, in addition to the medications
    listed in #1 above.

4.  Students with sore throat should be evaluated by the clinician for
    possible strep testing. Negative rapid streptococcal antigen tests
    should be confirmed by throat culture. Students with a positive
    strep test should be treated with penicillin VK 500 mg po bid for 10
    days or cephalexin (Kelfex) 500 mg po bid for 10 days in
    non-allergic patients.

5.  For suspected sinusitis, offer saline nasal spray OR nasal
    decongestant spray OR pseudoephedrine (Sudafed) 30 mg - 60 mg every
    8 hours until evaluated by the clinician for possible antibiotic
    and/or nasal steroid spray prescription. Note that nasal
    decongestant spray should not be used for more than 3 days.

6.  For earache, offer the student medications listed in #1 above, and
    refer to the clinician for further evaluation.

**WHEN TO REFER TO THE CENTER PHYSICIAN**

-   If the student has a persistent fever [\>]{.underline} 101°F for
    more than 48 hours

-   If the student has a persistent or worsening sore throat

-   If the student has a rash

-   If sinusitis is suspected

-   If the student has a persistent earache

**TREATMENT GUIDELINES FOR HEALTH STAFF**

**URINARY TRACT INFECTION (UTI)**

Authorized health and wellness staff may treat lower urinary tract
infection (cystitis) as follows:

1\. Administer one trimethoprim 160 mg/sulfamethoxazole 800 mg double
strength tablet (Bactrim DS) twice daily for 3 days.

2\. Alternative treatment if allergic to sulfa drugs: administer
amoxicillin 500 mg twice daily for 3 days.

3\. Change antibiotic regimen based upon urine culture and sensitivity
results if clinical response is not noted within 24-48 hours. Consider
local antibiotic resistance patterns in initial choice of treatment.

4\. Encourage hydration with copious fluids. Instruct student to return
for re-treatment if vomiting occurs within 4 hours of any oral
medication dose.

5\. Since UTI in female students is commonly associated with sexual
activity, discuss screening for STDs as appropriate and prevention of
STDs and pregnancy (offer condoms and contraception as appropriate).

6\. Schedule repeat urine culture within one month to document sterile
urine.

WHEN TO REFER TO THE CENTER PHYSICIAN

-   If the student has a history of recurrent UTI

-   If the student has fever [\>]{.underline} 101^o^F or fever with
    chills

-   If the student has symptoms suggestive of a sexually transmitted
    infection

-   If the female student has pelvic pain suggestive of PID

-   If the student's symptoms have not resolved within 48 hours of
    initiating treatment

-   If a male student has document UTI (not urethritis)

**TREATMENT GUIDELINES FOR HEALTH STAFF**

**WARTS (COMMON)**

Authorized health and wellness staff may treat common warts on skin
surfaces as follows:

1.  Most non-genital warts eventually regress spontaneously but may
    persist for months or years.

2.  Apply a topical salicylic acid preparation according to the
    manufacturer's instructions.

3.  An alternative treatment is topical cryotherapy as directed by the
    center physician; may need to be treated weekly until resolution.

4.  The student should be instructed to soak the warts in warm water
    daily and gently debride the surface of the wart with an emery
    board.

WHEN TO REFER TO THE CENTER PHYSICIAN

-   If the student has extensive non-genital warts

-   If the student has flat warts (tretinoin therapy may be indicated)

-   If the student has not responded to topical therapy or cryotherapy
    within 4 weeks

**TREATMENT GUIDELINES FOR HEALTH STAFF**

**WARTS (EXTERNAL GENITAL)**

Authorized health and wellness staff may treat external genital warts as
follows:

1.  Student-administered imiquimod 5% cream (Aldara) applied once daily
    at bedtime three times per week for up to 16 weeks. Instruct student
    to wash treated areas with soap and water 6-10 hours after treatment
    or next morning. Instruct student to discontinue treatment and
    return for evaluation if skin irritation or rash occurs.

2.  An alternative treatment is physician-applied trichloroacetic acid
    (TCA) 80%-90%, repeated weekly as necessary.

3.  Discuss contact(s) treatment, screening for other STDs as
    appropriate, health department reporting requirements, and
    prevention of STDs and pregnancy (offer condoms and contraceptives
    as appropriate).

4.  Pregnant students with genital warts should be referred to an
    obstetrician-gynecologist for treatment, as cesarean delivery may be
    indicated.

5.  Sex partners with no visible genital warts should be counseled but
    need not be treated.

WHEN TO REFER TO THE CENTER PHYSICIAN

-   If the student has symptoms suggestive of another sexually
    transmitted infection

-   If the student has warts on the vagina, cervix, anus, rectum, or
    urethral meatus

# 

**TREATMENT GUIDELINES FOR HEALTH STAFF**

**avulsed tooth**

Authorized health and wellness staff may treat an avulsed tooth as
follows:

1.  Handle the tooth by its crown at all times. Never touch the
    periodontal root ligament.

2.  Place the tooth in a physiologic solution such as milk or 0.9%
    normal saline solution (plain water should be avoided).

3.  Evaluate the student for any attendant medical problems.

4.  Check the tooth socket for gross contamination. If the tooth socket
    has been grossly contaminated by dirt or other debris, contact the
    center physician regarding tetanus-diphtheria booster immunization
    and antibiotics.

5.  If the tooth socket is bleeding excessively, take measures to stop
    the bleeding.

WHEN TO REFER TO THE CENTER DENTIST

Immediately---If the student is transported to the dentist within 30
minutes after the tooth avulsed, there is a 90 percent chance that the
tooth can be successfully reimplanted.

**TREATMENT GUIDELINES FOR HEALTH STAFF**

**ORAL BLEEDING**

Authorized health and wellness staff may treat oral bleeding as follows:

1.  Check to see if there is a clot protruding prominently from the
    socket of a recently extracted tooth, from a wound or trauma, or
    from a gum problem. If so, instruct the student to rinse mouth or
    spit to remove clot. It may be necessary for the health staff to
    remove or wipe out the protruding clot with gauze.

2.  The health staff should make a pad with sterile gauze sponges small
    enough to fit over the bleeding area but large enough to guarantee
    pressure on biting.

3.  The health staff should place the pad in the mouth over the bleeding
    area.

4.  Instruct the student to bite, bringing his/her teeth together, and
    maintain pressure for at least 15 minutes.

5.  Remove the gauze pack, and then recheck the area for bleeding with a
    flashlight after approximately 15 minutes. If bleeding seems to have
    stopped, dismiss the student after placing a clean gauze pad in the
    mouth. Give the student instructions to maintain the pressure for an
    additional 30 minutes.

6.  Supply the student with extra gauze. Instruct the student to repeat
    the entire process; biting on the gauze pad firmly for 20-30 minute
    intervals if bleeding recurs.

7.  Advise the student to avoid strenuous work or exercise for 24 hours
    and do not rinse mouth.

WHEN TO REFER TO THE CENTER DENTIST

-   If bleeding continues

-   If trauma to jaw or teeth caused the oral bleeding

**TREATMENT GUIDELINES FOR HEALTH STAFF**

**ORAL INFECTION**

Authorized health and wellness staff may treat oral infection as
follows:

1.  If the temperature \< 100 °F, the student should be referred to the
    center dentist for an assessment during the next scheduled clinic
    session. (In such a case, the dental infection will be identified as
    a localized fluctuant swelling with or without pus oozing from the
    gingiva.)

2.  If the temperature is [\>]{.underline} 100 °F and \<102 °F and the
    student is not allergic to penicillin, administer penicillin VK 2g
    po immediately, followed by penicillin VK 500 mg po four times per
    day. If the student is allergic to penicillin, administer
    clindamycin 600 mg po immediately, followed by clindamycin 300 mg po
    four times per day.

3.  Refer any student with an oral infection, whether on antibiotics or
    not, to the center dentist for an assessment during the next
    scheduled clinic session.

4.  Observe the student on antibiotics every 2 days and continue the
    student on antibiotics for 7 days.

5.  If the student is on penicillin and there is no dramatic improvement
    in symptoms within 48-72 hours, change to clindamycin at a dosage of
    300 mg four times per day for 7 days.

6.  Follow the center dentist's dental emergency instructions and
    arrange for immediate emergency care (e.g., on-call oral surgeon or
    emergency room visit) if the student displays any or a combination
    of the following symptoms:

-   fever is ≥ 102ْ F

-   dehydration occurs

-   there is a rapid progression of swelling

-   trismus is present and difficulty swallowing

-   there is marked pain

-   the tongue is elevated

-   there is swelling of soft palate

-   there is bilateral submandibular swelling

6.  Inform the student about the signs and symptoms of a worsening
    dental infection as described above. Request that the student notify
    wellness center staff or other center staff after-hours immediately
    if the oral infection becomes emergent.

> **TREATMENT GUIDELINES FOR HEALTH STAFF**

**ORAL PAIN**

Authorized health and wellness staff may treat oral pain as follows:

1.  If the student quantifies the pain as mild, bearable, or moderate,
    administer ibuprofen 400 mg po every 6 hours \[MDD 1600 mg\] or
    acetaminophen 1000 mg po every 4 hours \[MDD 4 g\] as needed for
    pain control.

2.  If the pain is quantified as severe or if the doses of ibuprofen 400
    mg are ineffective in managing the pain, increase the dosage to
    ibuprofen 600 mg every 6 hours \[MDD 2400 mg\]. If pain relief with
    ibuprofen does not occur in 2 hours, call the center dentist for
    further disposition.

WHEN TO REFER TO THE CENTER DENTIST

-   All students with oral pain

# 

# 

# TREATMENT GUIDELINES FOR HEALTH STAFF

## **ALCOHOL OR DRUG USE BEHAVIOR**

Authorized health and wellness staff may treat possible alcohol or drug
use behavior as follows:

1.  Bring the student to a private area for evaluation.

2.  Determine if the student has allegedly ingested alcohol or drugs by
    questioning staff, student, and peers.

3.  Document observed behavior.

4.  If authorized to do so, conduct an alcohol-screening test and urine
    drug screen on suspicion according to the center operating procedure
    (COP). If not authorized to perform an alcohol test, locate a staff
    who has been trained to do the test

5.  Perform an alcohol test. Follow the center physician's directions on
    the COP regarding the appropriate action to take for the blood
    alcohol level determined by the test. Perform a second alcohol test
    to determine if the level is increasing if indicated. Continue to
    test until the level begins to decrease.

6.  Any student under the influence of alcohol or drugs must be observed
    in the dormitory or the health and wellness center to ensure safety
    until symptoms have resolved and the blood alcohol level begins to
    decrease

7.  If student is incoherent, vomiting repeatedly, or losing
    consciousness, transport to emergency center immediately.

8.  If student appears hyperactive, paranoid, or hallucinating,
    transport to emergency center immediately.

9.  All documentation of observed behavior should be sent to the health
    and wellness manager and TEAP Specialist for follow-up and inclusion
    in the student's medical record. All alcohol and drug test results,
    both positive and negative, should be sent to the health and
    wellness manager and TEAP Specialist for follow-up and inclusion in
    the student's medical record. All urine drug screens should be
    collected by health and wellness center staff while maintaining
    chain-of-custody according to COP.

**WHEN TO REFER TO THE TEAP SPECIALIST**

-   All students with an alcohol incident should be referred to the TEAP
    specialist for interview and possible assessment.

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-   If student has or is suspected of having a co-occurring psychiatric
    disorder, refer to CMHC as well

TREATMENT GUIDELINES FOR HEALTH STAFF

# Anxiety Disorders (including Panic and Phobic Disorders)

Authorized health and wellness staff may treat students with general
symptoms of anxiety as follows:

1.  Evaluate symptoms of anxiety (such as excessive worry, feeling
    anxious or "antsy", unidentified fears, autonomic arousal,
    difficulty with sleep\--especially getting to sleep, etc.). Anxiety
    can be expressed in emotional feelings, thoughts and beliefs,
    physical complaints, social behaviors, reduced functioning in
    academics/vocations, etc.

2.  If sudden onset, rule out a substance-induced reaction. If substance
    related, follow the Alcohol or Drug Use Treatment Guideline.

3.  Talk with student about his/her feelings of distress. Sensitive and
    supportive exploration of these issues can often provide at least
    short-term relief/reduction of symptoms.

4.  Be sensitive to any thoughts of self-harm. If present, follow
    guideline for suicidal behavior.

5.  Apparent over-use of health services can be an indicator of the
    somatic expression of anxiety and/or help seeking.

6.  Cognitive/behavioral interventions with or without medication
    management are often effective.

7.  For specific phobias, treat the immediate symptoms by separating the
    student from the situation or object.

8.  If the triggering events are rare and unlikely to recur on the
    center, further intervention may not be required.

In addition to the above considerations, the student should not be left
alone until the acute symptoms diminish. Provide support and
acknowledgement of the distress in a quiet, non-public area.

**WHEN TO REFER TO THE CENTER PHYSICIAN OR CENTER MENTAL HEALTH
CONSULTANT**

-   If new presenting problem

-   If longer-term management is needed

-   If the triggering event is a frequent and integral part of the
    student's regular social, academic, vocational experience

-   If new anxiety disorder present

-   If student presents with panic disorder

-   If a medical evaluation is needed

**TREATMENT GUIDELINES FOR HEALTH STAFF**

**Attention-Deficit/Hyperactivity Disorder (ADHD)**

Authorized health and wellness staff may treat general symptoms of
attention-deficit/hyperactivity disorder as follows:

1\. ADHD is marked by a condition that begins in early childhood and can
continue in some individuals through adolescence and into adulthood. It
will not likely begin during a student's stay in Job Corps without prior
history, generally reflected in the academic record. If student presents
with symptoms of ADHD (e.g., pronounced problems in maintaining
attention and concentration and/or the presence of impulsivity and/or
hyperactivity) with no history in prior schooling, rule out the presence
of drug/alcohol abuse. Evaluate and, if present, treat per the Alcohol
or Drug Use Treatment Guideline.

2\. Determine if there is a history of ADHD and if student has taken
medication. If so, evaluate medication compliance or determine if
student no longer takes medication.

3.  Reasonable accommodations such as additional test taking time,
    shorter periods of study, peer mentors, or reduced social
    stimulation may improve success.

4.  Students will more likely be referred by academics, vocational
    training, or group living because of inattentive and/or disruptive
    behavior. They are unlikely to self present unless it is to resume
    prior helpful treatment. Compensatory academic and/or social skills
    can be learned and stimulant medications can be helpful.

**WHEN TO REFER TO CENTER PHYSICIAN OR CENTER MENTAL HEALTH CONSULTANT**

-   If further evaluation and intervention are necessary and/or
    medication is needed

-   If no prior diagnosis, refer to the center mental health consultant
    for structured evaluation of ADHD or other similar conditions,
    including bipolar disorder, learning disorders, depression, or
    substance withdrawal (symptoms of hyperactivity and distractibility
    can be seen in both disorders).

TREATMENT GUIDELINES FOR HEALTH STAFF

# Depression/Bipolar DISORDER

Authorized health and wellness staff may treat students with depression
and bipolar disorders as follows:

1.  Evaluate symptoms of depression such as suicidal thoughts or intent,
    changes in appetite or sleep, depressed mood, crying, feelings of
    hopelessness or helplessness, lack of pleasure (anhedonia),
    decreased energy, and family history of mood disorders.

2.  If already under treatment, determine whether the student has been
    compliant with medications prescribed.

3.  If positive for suicidal thoughts or intent, follow Treatment
    Guideline for Suicidal Behavior.

4.  Evaluate symptoms of acute manic episode such as inability to sleep,
    hyper-verbal, pressured speech, grandiosity, increased energy,
    euphoria, racing thoughts, delusions, hallucinations, or
    hypersexuality.

5.  Rule out a substance-induced acute mania. If positive, then follow
    the Alcohol or Drug Use Treatment Guideline.

6.  If hallucinations or delusions are occurring, follow Psychotic
    Disorders Treatment Guideline.

7.  Discuss with the student any psychosocial difficulties he or she may
    be experiencing; often acute symptoms of depression can be
    alleviated in the short-term by the sharing of thoughts and
    feelings.

**WHEN TO REFER TO CENTER PHYSICIAN OR CENTER MENTAL HEALTH CONSULTANT**

-   If currently receiving treatment get names, addresses, and phone
    numbers of providers

-   If not receiving treatment refer for evaluation

-   If treatment has been received in the past and symptoms have
    returned

TREATMENT GUIDELINES FOR HEALTH STAFF

**Post-traumatic Stress Disorder (PTSD)**

Authorized health and wellness staff may treat acute symptoms of
post-traumatic stress disorder as follows:

1.  Provide students with social support, reassurance, and a quiet,
    stable environment during the acute episode.

2.  Talking with the students about their current feelings and reactions
    is helpful. Avoid probing for details about the prior trauma.

3.  Determine whether the student is under treatment and what timely
    arrangements can be made for the student to their therapist.

WHEN TO REFER TO THE CENTER PHYSICIAN OR CENTER MENTAL HEALTH CONSUTANT

-   If not previously evaluated by the center mental health consultant

-   If in an acute crisis, contact the center mental health consultant
    and/or physician

-   For further assessment and ongoing intervention;
    cognitive/behavioral therapy and/or medication interventions are
    often useful. CMHC may consider a referral to a local victim's
    resource center

**TREATMENT GUIDELINES FOR HEALTH STAFF**

# Psychotic Disorders

Authorized health and wellness staff may treat students with psychotic
disorders as follows:

1.  If acutely psychotic, evaluate possible substance-induced psychosis.
    If positive, then follow the Alcohol or Drug Use Treatment
    Guideline.

2.  Evaluate for danger to self and/or others. Psychotic symptoms often
    include paranoid thinking with hallucinations and delusions which
    may include other people being viewed as threats to the student and,
    therefore, at possible physical risk from the student.

3.  Evaluate for suicidal ideation or intent. If positive then follow
    Treatment Guideline for Suicidal Behavior---the presence of
    psychosis greatly increases the likelihood of a suicide attempt,
    even if there is only suicidal ideation.

# WHEN TO REFER TO CENTER PHYSICIAN OR CENTER MENTAL HEALTH CONSULTANT

-   If positive for danger to self and/or others, then arrange transport
    to a psychiatric emergency facility, per center mental health
    consultant or COP. Make sure you are not at physical risk as well;
    alert other staff to stay nearby while the student is escorted to
    the emergency evaluation.

-   If psychotic symptoms interfere with ability to complete activities
    of daily living or leave the student so confused and disorganized
    that student could become a danger to self or others (e.g., could
    accidentally walk in front of a moving vehicle), arrange transport
    to a psychiatric emergency facility, per mental health consultant
    recommendations and/or the center operating procedures.

-   If chronically symptomatic with or without medication compliance,
    refer to the center physician. A MSWR may be also be required.

-   If the student is experiencing any psychosocial difficulties which
    may exacerbate chronic psychotic symptoms.

# TREATMENT GUIDELINES FOR HEALTH STAFF

## **SUICIDAL BEHAVIOR**

Authorized health and wellness staff may treat students with suicidal
behavior as follows:

1.  Immediately assess whether self-harm has occurred and treat any
    medical emergencies per medical protocol. After medically stable,
    evaluate for suicidal ideation and intent per the following
    protocol.

2.  If suicidal ideation only (no self-harm, no threats, no intent),
    talk with the student about any psychosocial difficulties; acute
    symptoms of depression can often be alleviated in the short-term by
    sharing thoughts and feelings. Consult with the center mental health
    consultant about findings, to determine if any further immediate
    action is needed.

3.  Notify counseling and residential life to provide further
    counseling, monitoring and support until student is evaluated.

4.  Under no circumstances should students be placed on "suicide
    watches" or "bed checks." If there is such concern about a student,
    consider immediate emergency evaluation.

## **WHEN TO REFER TO CENTER MENTAL HEALTH CONSULTANT**

-   Students who are assessed to be at a high level of risk should be
    evaluated per the treatment guideline above and transported to a
    psychiatric emergency facility immediately, per center mental health
    consultant recommendations and/or center operating procedure (COP)

-   If student attempted suicide but no self-harm occurred, maintain
    constant supervision, arrange for immediate transport to a
    designated psychiatric emergency facility, per center mental health
    consultant recommendations and/or COP

-   If suicide threat but no attempt, but student has suicidal intent
    including a plan and means to carry out self-harm, maintain constant
    supervision, and arrange for transport to a psychiatric emergency
    facility, per center mental health consultant recommendations and/or
    COP

**5.0 SYMPTOMATIC MANAGEMENT GUIDELINES**

The 2004 revised format of the symptomatic management guidelines for
non-health staff are intended to assist non-health staff during hours
when no health staff are present on center. They provide guidance on how
to handle common symptoms without expecting the non-health staff to make
a definitive diagnosis.

**Always begin with the basic ABC's of first
aid---Airway/Breathing/Circulation (CPR).**

Symptomatic management guidelines also suggest parameters to follow
about when to refer the student urgently to the on-call health staff or,
if they are not reachable, to a local emergency response team or
emergency center.

At the direction of the on-call health staff, a stabilized student may
also be referred to the next open time at the health and wellness
center. If the student's condition deteriorates prior to that time, this
decision can always be changed.

Whatever action(s) is taken/not taken should be documented in writing
and forwarded to the health and wellness center the following day for
inclusion in the student's health record (date, times, symptoms, over
the counter medications given, person(s) contacted, outcome).

If the student is transported off center for care, appropriate center
staff should be notified promptly (health staff, center physician,
mental health consultant, and/or dentist). Consider notifying a family
contact with the student's permission. If it is a serious event, also
notify the center director.

SYMPTOMATIC MANAGEMENT GUIDELINES FOR NON-HEALTH STAFF

**ABDOMINAL PAIN**

Authorized non-health staff may manage abdominal pain as follows:

1.  Abdominal pain that is sudden and severe, or associated with fever
    [\>]{.underline} 101^o^F, vomiting blood, or passing blood in the
    bowel requires urgent evaluation by a clinician.

2.  Students with abdominal pain should generally avoid solid food, but
    may take small amounts of clear fluids.

3.  Do **not** offer the student treatment with acetaminophen or
    ibuprofen for abdominal pain.

4.  For mild abdominal pain caused by indigestion, offer the student an
    antacid such as TUMS-EX 500 mg, 2 tablets four times a day, **or**
    Maalox liquid, 3 teaspoons four times a day -- taken between meals
    and at bedtime.

5.  For mild abdominal pain caused by constipation, offer the student a
    single dose of milk of magnesia 2 tablespoons (30 cc or one ounce).
    Encourage fluid intake.

6.  For mild abdominal cramps caused by diarrhea, offer the student
    loperamide caplets (Imodium AD), 2 caplets initially, then 1 caplet
    with each subsequent loose stool, not to exceed 4 caplets in 24
    hours. Take caplets with 8 ounces of water.

7.  For abdominal cramps associated with menstrual bleeding, refer to
    the Symptomatic Management Guidelines for Menstrual Cramps.

8.  All students with abdominal pain should be referred for follow-up at
    the health and wellness center.

# WHEN TO CONTACT THE ON-CALL HEALTH AND WELLNESS STAFF

-   If the student experiences abdominal pain that is sudden and severe,
    or associated with fever [\>]{.underline} 101^o^F, persistent
    vomiting, vomiting of blood, or passing blood in the bowel movement

SYMPTOMATIC MANAGEMENT GUIDELINES FOR NON-HEALTH STAFF

**ASTHMA**

Authorized non-health staff may manage asthma as follows:

1.  Any student with severe wheezing, muscle retractions, gasping, blue
    color or other signs of respiratory distress requires immediate
    medical attention. Call 911 for emergency transport. Offer the
    student oxygen by facemask if available. Albuterol HFA treatments (2
    inhalations) may be offered to the student every 15-20 minutes while
    awaiting transport.

2.  Any student with wheezing who does not respond within 10-15 minutes
    to two inhalations from an albuterol HFA should be referred
    immediately to the health and wellness center.

3.  Students known to have asthma should have access to an albuterol HFA
    **at all times** on center.

**WHEN TO CONTACT THE ON-CALL HEALTH AND WELLNESS STAFF**

-   If the student's wheezing does not respond to two inhalations within
    10-15 minutes from an albuterol HFA

**SYMPTOMATIC MANAGEMENT GUIDELINES FOR NON-HEALTH STAFF**

**BURNS**

Authorized non-health staff may manage burns as follows:

1.  Remove the student from the source of the burns.

2.  Insure an open airway and proceed with CPR if indicated.

3.  Call 911 if the burn involves the face, head, neck, fingers, toes,
    genitalia or more than 25 percent of the trunk or an extremity.

4.  Irrigate the burn wound with sterile saline solution.

5.  Cover the wound with sterile gauze soaked in sterile saline
    solution. Use cling gauze to secure the saline soaked gauze. Leave
    blisters intact.

6.  Have the burns evaluated by a clinician as soon as possible.

7.  Offer the student acetaminophen 1000 mg every 4 hours \[MDD 4 g\] or
    ibuprofen 600 mg every 6 hours \[MDD 1600 mg\] for pain.

# 

# WHEN TO CONTACT THE ON-CALL HEALTH AND WELLNESS STAFF

-   If burn is other than a mild sunburn

-   If items in #3 above are present

-   If pain is not controlled by above pain medications

**Symptomatic Management GuidelineS FOR NON-HEALTH STAFF**

**COLD And SINUS CONGESTION**

Authorized non-health staff may manage a cold and sinus congestion as
follows:

1.  For fever, offer the student acetaminophen 1000 mg every 4 hours
    \[MDD 4 g\] **or** ibuprofen 400 mg every 6 hours \[MDD 1600 mg\] as
    needed. Encourage oral hydration.

2.  Students with fever [\>]{.underline}101^o^F should be referred to
    the health and wellness center for further evaluation as soon as
    possible.

3.  For severe sinus congestion, offer saline nasal spray **or** nasal
    decongestant spray **or** pseudoephedrine (Sudafed) 30 mg -- 60 mg
    every 8 hours until evaluated by health staff. Note that nasal
    decongestant spray should not be used for more than 3 days.

# WHEN TO CONTACT THE ON-CALL HEALTH AND WELLNESS STAFF

-   If the student has a persistent fever [\>]{.underline}101^o^F that
    is unresponsive to medications listed in #1

-   If the student is wheezing or has difficulty breathing

-   If the student has a headache unresponsive to medication

**SYMPTOMATIC MANAGEMENT GUIDELINES FOR NON-HEALTH STAFF**

# CONSTIPATION

Authorized non-health staff may manage constipation as follows:

1.  Offer the student milk of magnesia 2 tablespoons (30 cc or one
    ounce) orally to relieve constipation.

2.  Encourage generous intake of non-dairy fluids (8 full 8 ounce
    glasses per day).

**WHEN TO CONTACT THE ON-CALL HEALTH AND WELLNESS STAFF**

-   If constipation persists despite treatment as above

-   If constipation is associated with abdominal pain or fever
    [\>]{.underline} 101°F

-   If this is a recurrent problem

SYMPTOMATIC MANAGEMENT GUIDELINES FOR NON-HEALTH STAFF

**COUGHING and/or DIFFICULTY BREATHING**

Authorized non-health staff may manage coughs and/or difficulty
breathing as follows:

1.  Evaluate the student's ability to breathe without pain or
    respiratory distress. Noisy breathing, gasping, blue color and other
    signs of acute distress suggest that immediate attention is needed.
    Phone 911. Offer the student oxygen by facemask if available.

2.  For fever, offer the student acetaminophen 1000 mg every 4 hours
    \[MDD 4 g\] **or** ibuprofen 400 mg every 6 hours \[MDD 1600 mg\] as
    needed. Encourage oral hydration.

3.  For cough, offer the student cough syrup in a dose containing 30 mg
    of dextromethorphan, for use primarily at bedtime, but no more often
    than every 12 hours. Again, encourage oral hydration.

4.  Students whose cough is associated with fever
    [\>]{.underline}101^o^F or persists for more than 48 hours should be
    referred to the health and wellness center.

# WHEN TO CONTACT THE ON-CALL HEALTH AND WELLNESS STAFF

-   If the student has wheezing or other symptoms of asthma

-   If the student has a persistent cough that interferes with daily
    functioning or nighttime sleep

**SYMPTOMATIC MANAGEMENT GUIDELINES FOR NON-HEALTH STAFF**

# DIARRHEA AND NAUSEA

Authorized non-health staff may manage diarrhea, nausea, and vomiting as
follows:

1.  Ask about the frequency of nausea, vomiting and diarrhea. Also ask
    about abdominal pain, fever, or the presence of blood in the stools
    or vomitus.

2.  If the student reports abdominal pain, refer to Symptomatic
    Management Guidelines for Abdominal Pain.

3.  Check the student's temperature and if [\>]{.underline} 100°F, offer
    the student acetaminophen 1000 mg orally every 4 hours \[MDD 4 g\]
    as needed.

4.  Offer clear fluids for the student to take frequently in small
    quantities.

5.  Refer to the health and wellness center the next day.

## **WHEN TO CONTACT THE ON-CALL HEALTH AND WELLNESS STAFF**

-   If the student's temperature is [\>]{.underline}101°F

-   If the student has persistent, severe abdominal pain

-   If the student vomits more than twice

-   If the student reports having blood in the stools or vomits blood

**SYMPTOMATIC MANAGEMENT GUIDELINES FOR NON-HEALTH STAFF**

# EARACHE

Authorized non-health staff may manage earaches as follows:

1.  Ask the student about the presence of nasal congestion, a "cold," or
    recent swimming.

2.  Check the student's temperature

3.  Offer the student acetaminophen 1000 mg every 4 hours \[MDD 4 g\]
    **or** ibuprofen 400 mg every 6 hours \[MDD 1600 mg\] for ear pain

4.  Topical heat may be applied for comfort (e.g., hot pack, hot shower,
    heating pad).

5.  Refer to the health and wellness center the next day

**WHEN TO CONTACT THE ON-CALL HEALTH AND WELLNESS STAFF**

-   If student's temperature is [\>]{.underline}101°F

-   If the student's ear pain seems excessive or is not controlled by
    acetaminophen or ibuprofen

-   If there is any pus-like drainage from the ear canal

**Symptomatic Management GuidelineS for NON-HEALTH STAFF**

**Fever**

Authorized non-health staff may manage fever as follows:

1.  If fever is \< 101°F with no specific origin, offer the student
    acetaminophen 1000 mg every 4 hours \[MDD 4 g\] **or** ibuprofen 400
    mg every 6 hours \[MDD 1600 mg\] and refer to the health and
    wellness center if the fever persists beyond 24 hours. Encourage
    oral hydration.

2.  If fever is [\>]{.underline} 101°F, follow #1 and refer to the
    health and wellness center **or** contact the clinician on call for
    further disposition.

# WHEN TO CONTACT THE ON-CALL HEALTH AND WELLNESS STAFF

-   If fever \< 101°F with no specific origin persists beyond 24 hours

-   If fever is [\>]{.underline} 101°F

**SYMPTOMATIC MANAGEMENT GUIDELINES FOR NON-HEALTH STAFF**

**FRACTURES**

Authorized non-health staff may manage a possible fracture as follows:

1.  Assess the area of injury but do not move the bones. If the bone
    protrudes through the skin the fracture is compound and needs
    immediate treatment. Cover the wound loosely with a dry sterile
    dressing. For compound limb fractures, splint the extremity across
    two joints. Transport the patient to the emergency department.

2.  If the skin is not broken, but there is extensive bruising, bleeding
    under the skin or a firm, tender bulge surrounds the injury, a
    hematoma may be present. Apply ice, elevate the limb, and immobilize
    the extremity across two joints and call the clinician for further
    treatment.

3.  If the injured bone is painful, tender or associated with muscle
    spasm, with normal motion but without hematoma, immobilize by
    splinting the bone and the two joints on the either side of the
    fracture, restrict activity of the extremity and refer to the health
    and wellness center. For pain, apply ice, elevate the limb, and
    offer the student acetaminophen 1000 mg every 4 hours \[MDD 4 g\]
    **or** ibuprofen 400 mg every 6 hours \[MDD 1600 mg\].

# WHEN TO CONTACT THE ON-CALL HEALTH AND WELLNESS STAFF

-   The health and wellness staff should be contacted in all cases of
    possible fracture.

**SYMPTOMATIC MANAGEMENT GUIDELINES FOR NON-HEALTH STAFF**

**FROSTBITE**

Authorized non-health staff may treat frostbite as follows:

1.  Immediately cover the affected areas (usually toes, feet, fingers,
    nose, cheeks, and ears) with another warmer body surface and with
    warm clothing while seeking shelter.

2.  Once indoors, where there is no danger of refreezing, rapidly rewarm
    the affected areas in tepid water (105^o^ F-110^o^ F) for 20-40
    minutes. Do **not** use local dry heat as it can cause further
    tissue damage.

3.  Damaged skin should **never** be massaged, as this leads to
    mechanical trauma.

4.  Offer the student pain medication as needed, e.g., acetaminophen
    1000 mg orally every 4 hours \[MDD 4 g\] **or** ibuprofen 400 mg
    orally every 6 hours \[MDD 1600 mg\].

5.  Seek professional medical care to determine if medical and/or
    surgical intervention is necessary for prevention of infection or
    tissue debridement/amputation.

# WHEN TO CONTACT THE ON-CALL HEALTH AND WELLNESS STAFF

-   If any case of suspected frostbite

-   If pain medication in #4 does not control student's pain

**SYMPTOMATIC MANAGEMENT GUIDELINES FOR NON-HEALTH STAFF**

**HEAD INJURY**

Authorized non-health staff may manage a head injury as follows:

1.  Observation is key. Keep the student under observation for at least
    one hour after head injury and monitor for symptoms described in #2.

2.  Call 911 to immediately transport the patient to the emergency
    department if consciousness is lost or any of these findings are
    present: unsteady gait, double vision/loss of vision, progressive
    severe headache, repetitive vomiting, declining level of alertness,
    or inability to arouse, mood change, and/or increased combativeness.

3.  The use of medication is discouraged during the observation period.
    If the patient complains of severe headache requiring medications,
    refer to the clinician on call.

# WHEN TO CONTACT THE ON-CALL HEALTH AND WELLNESS STAFF

-   If the patient complains of severe headache requiring medications

-   If any of the items in #2 occur

-   If student reports no memory of the event -- amnesia may be a sign
    of concussion

**Symptomatic Management GuidelineS FOR NON-HEALTH STAFF**

**HEADACHE**

Authorized non-health staff may manage headaches as follows:

1.  Obtain a careful history. If trauma, migraine, hypertension,
    infection, or other specific problems exist, refer to health and
    wellness center. Also refer when the headache is associated with
    changes in vision or vomiting, or does not respond to the
    recommendations given below.

2.  Offer the student acetaminophen 1000 mg every 4 hours \[MDD 4 g\]
    **or** ibuprofen 400 mg every 6 hours \[MDD 1600 mg\] as needed for
    headache.

3.  Offer bed rest for 2-4 hours when headache prevents daily function.

# WHEN TO CONTACT THE ON-CALL HEALTH AND WELLNESS STAFF

-   If headache persists for more than 24 hours or frequently recurs

-   If headache does not improve with management described above

**SYMPTOMATIC MANAGEMENT GUIDELINES FOR NON-HEALTH STAFF**

**HEAT INJURIES**

Authorized non-health staff may manage heat cramps, heat exhaustion, and
heat stroke, which are progressive forms of hyperthermia, as follows:

# Management of Heat Cramps (brief muscle contractions without rigidity of skeletal and abdominal muscles)

1.  Supportive treatment includes removal to cool environment and rest
    from exercise.

2.  Gentle massage of cramping muscles.

3.  Oral replacement of water and electrolytes with an electrolyte-based
    sports drink such as Gatorade, Powerade, or equivalent.

# Heat Exhaustion (body core temperature greater than 100^ο^F but less than 104^ο^F with complaints of malaise, weakness, headache, anorexia, nausea, and/or vomiting)

1.  Supportive treatment includes removal to cool environment and rest
    from exercise.

2.  Oral replacement of water and electrolytes with an electrolyte-based
    sports drink such as Gatorade, Powerade, or equivalent.

3.  Contact health staff.

# Heat Stroke (core body temperature 104^ο^F or above with tachycardia, hypotension, and mental changes -- often incoherent and combative)

1.  Remove from source of heat and call 911 to transport for emergency
    care.

2.  Remove clothing and apply cold packs, wet sheets, or wet cold towels
    to neck, head, abdomen, and inner thighs.

3.  Use a fan or fanning motion to circulate air over the patient.

4.  Maintain airway and be alert for vomiting to prevent aspiration.

# WHEN TO CONTACT THE ON-CALL HEALTH AND WELLNESS STAFF

-   If the student is vomiting and requires intravenous replacement of
    fluid and electrolytes in the case of heat exhaustion

-   If any alteration in mental status/function

**SYMPTOMATIC MANAGEMENT GUIDELINES FOR NON-HEALTH STAFF**

**LACERATIONS**

Authorized non-health staff may manage lacerations as follows:

1.  Stop bleeding by direct compression of the wound with sterile gauze.
    Elevate the extremity with the laceration.

2.  If bleeding does not slow or stop with five minutes of direct
    pressure, call 911.

3.  For wounds with extensive bleeding on the extremities, if you are
    alone and CPR is needed, assess the airway, place a tourniquet on
    the bleeding extremity, and resume CPR.

4.  For wounds on the trunk and head, assess the airway, stop or control
    bleeding, and resume CPR.

5.  Cover the wound with clean gauze and have the student evaluated by a
    clinician as soon as possible.

# WHEN TO CONTACT THE ON-CALL HEALTH AND WELLNESS STAFF

-   If the wound appears to need suturing

SYMPTOMATIC MANAGEMENT GUIDELINES FOR NON-HEALTH STAFF

**MENSTRUAL CRAMPS**

Authorized non-health staff may manage menstrual cramps as follows:

1.  For pain associated with menstrual periods, offer female students
    either ibuprofen 400 mg every 6 hours \[MDD 1600 mg\] **or**
    naproxen sodium 440 mg every 8 hours \[MDD 1320 mg\]. Medication
    should be taken with food or fluid, and is often needed only for the
    first two or three days of menstrual bleeding.

2.  Students with fever, vomiting, unusually severe pain, or heavy
    bleeding should be referred to the health and wellness center for
    further evaluation.

3.  Students who are pregnant or concerned about possible pregnancy
    should be referred to the health and wellness center for further
    evaluation.

# WHEN TO CONTACT THE ON-CALL HEALTH AND WELLNESS STAFF

-   If the student has possible STD exposure (unprotected sexual
    activity)

-   If the student's menstrual cramps are not relieved by the
    medications in #1

**SYMPTOMATIC MANAGEMENT GUIDELINES FOR NON-HEALTH STAFF**

**MUSCLE INJURY**

Authorized non-health staff may manage muscle injury as follows:

1.  Assess the extent of muscle injury and any associated injuries.

2.  If the muscle has a firm, tender bulge indicating a possible
    hematoma or if the range of motion of adjacent joints is limited,
    then immobilize the muscle, apply an ice pack, and refer for urgent
    evaluation.

3.  If the muscle is tender or in spasm without hematoma and with full
    range of adjacent joint motion, apply an ice pack, restrict activity
    and offer ibuprofen 400 mg every 6 hours \[MDD 1600 mg\]. Refer to
    the health and wellness center for further evaluation.

# WHEN TO CONTACT THE ON-CALL HEALTH AND WELLNESS STAFF

-   If the muscle is tender or in spasm without hematoma and with full
    range of adjacent joint motion

-   If the muscle has a firm, tender bulge indicating a possible
    hematoma or if the range of motion of adjacent joints is limited

**SYMPTOMATIC MANAGEMENT GUIDELINES FOR NON-HEALTH STAFF**

**NOSEBLEED**

Authorized non-health staff may manage nosebleeds as follows:

1.  Instruct the student to sit upright and hold a clean towel or basin
    under the chin.

2.  Instruct the student to tilt the head slightly forward to prevent
    blood from pooling in the back of the throat.

3.  Instruct the student to grasp and pinch both sides of the entire
    nose, maintaining continuous pressure for at least 10 minutes.

4.  Instruct the student [not]{.underline} to blow the nose or to insert
    tissue or cotton into the nose as this will disrupt the blood clot.

5.  If bleeding is severe or causing the student to have difficulty
    breathing or maintaining an airway, call 911.

# WHEN TO CONTACT THE ON-CALL HEALTH AND WELLNESS STAFF

-   If bleeding has not stopping after 10 minutes of continuous pressure

-   If the student has a history of high blood pressure

-   If there is preceding facial trauma with concern regarding fracture

-   If there is concern regarding a foreign body in the nose

# If the student is having recurrent nosebleeds 

# SYMPTOMATIC MANAGEMENT GUIDELINES FOR NON-HEALTH STAFF

# 

# RASH

Authorized non-health staff may manage a rash as follows:

1.  Determine the extent of the rash (e.g., is it localized to one area,
    such as the left arm, or is it generalized, such as "all over the
    body").

2.  Check the student's temperature and ask about exposure to irritants.

3.  Ask the student about shortness of breath or wheezing.

4.  If the rash is localized, there is no fever and no shortness of
    breath or wheezing, reassure the student and have him/her report to
    the health and wellness center at the next open hours.

**WHEN TO CONTACT THE ON-CALL HEALTH AND WELLNESS STAFF**

-   If the student has an extensive rash, has fever [\>]{.underline}
    101°F, or has problems with breathing or wheezing

-   If there are signs of secondary bacterial infection of the rash
    (redness, tenderness, drainage, fever)

**SYMPTOMATIC MANAGEMENT GUIDELINES FOR NON-HEALTH STAFF**

# SEIZURE DISORDER

Authorized non-health staff may manage seizures as follows:

1.  If a staff person is present during a seizure, remain calm and note
    the time of the start of the seizure. Do not restrain the student,
    but attempt to place the student on his/her left side in case of
    vomiting and keep student from injuring him/herself. **Do not**
    place anything in the student's mouth.

2.  Note if there is any incontinence of urine or stool or biting of the
    tongue. Note the movements that he/she is making and whether or not
    he/she is able to communicate **during** the episode. Note also
    mental status at the end of the episode.

3.  Once seizure has stopped, note the time, provide reassurance and
    check the student's temperature.

4.  Call 911 if the seizure does not stop within 5 minutes or if, at
    anytime, there appears to be difficulty breathing.

# WHEN TO CONTACT THE ON-CALL HEALTH AND WELLNESS STAFF

-   If the staff called 911 and transported the student by emergency
    services.

-   If sent to emergency department, send information with the student
    regarding any current diagnoses and/ or medications the student is
    taking, (e.g., is known seizure patient and supposed to be taking
    specific seizure medication).

-   In all cases of observed or reported seizure activity

**SYMPTOMATIC MANAGEMENT GUIDELINES FOR NON-HEALTH STAFF**

**SORE THROAT**

Authorized non-health staff may manage a sore throat as follows:

1.  Ask about the presence of other "cold" symptoms, such as cough,
    runny nose, headaches and body aches.

2.  Check the student's temperature and if \> 100°F, offer the student
    acetaminophen 1000 mg every 4 hours if needed.

3.  Also offer the student acetaminophen 1000 mg every 4 hours \[MDD 4
    g\] if there are body aches, a very sore throat, or headaches, even
    if there is no elevated temperature.

4.  Offer the student a throat lozenge or have him/her gargle with salt
    water every hour as needed.

# 

# 

# WHEN TO CONTACT THE ON-CALL HEALTH AND WELLNESS STAFF

-   If the student's temperature is \> 101°F

-   If the student is having difficulty swallowing or is drooling

**SYMPTOMATIC MANAGEMENT GUIDELINES FOR NON-HEALTH STAFF**

**SPRAIN/DISLOCATION**

Authorized non-health staff may manage sprains and dislocations as
follows:

1.  Assess the injured joint and surrounding areas for bruising,
    bleeding, and swelling. When present, apply ice and immobilize the
    joint with a splint across both sides of the joint.

2.  Gently assess joint's range of motion and if range is compromised
    immobilize the joint with a splint and refer to a clinician within
    24 hours.

3.  If joint is tender and swollen and without bleeding/bruising,
    restrict activity of the joint for three days, apply ice and offer
    ibuprofen 400 mg every 6 hours \[MDD 1600 mg\]. If pain does not
    resolve or recurs within 48 hours or fever begins post injury, refer
    to a clinician.

4.  If daily function is compromised, excuse from duty until the
    clinician evaluates the patient.

**WHEN TO CONTACT THE ON-CALL HEALTH AND WELLNESS STAFF**

-   If the injured joint and surrounding areas are bruised and there is
    bleeding

-   If the joint's range of motion is reduced

-   If the joint is tender, swollen, and without bleeding/bruising and
    the pain does not resolve or recurs within 48 hours

-   If fever begins post injury

-   If the student does not respond to symptomatic management as
    outlined above

**SYMPTOMATIC MANAGEMENT GUIDELINES FOR NON-HEALTH STAFF**

**VOMITING**

Authorized non-health staff may manage vomiting as follows:

1.  Ask about the frequency of nausea and vomiting. Also ask about
    abdominal pain, fever, or the presence of blood or bile in the
    vomitus.

2.  Check the student's temperature and if [\>]{.underline} 100°F, offer
    the student acetaminophen 1000 mg every 4 hours \[MDD 4 g\] as
    needed.

3.  Offer clear fluids for the student to take frequently in small
    quantities.  Start with an ounce of clear fluids every 15-30
    minutes. 

4.  Refer to the health and wellness center the next day.

##  

## **WHEN TO CONTACT THE ON-CALL HEALTH AND WELLNESS STAFF** 

-   If the student's temperature is [\>]{.underline}101°F

-   If the student has persistent, severe abdominal pain

-   If the student complains of headache or neck stiffness

-   If the student vomits more than twice in 30 minutes 

-   If the student is unable to keep down any fluids

-   If the student reports vomiting blood or bile

-   If the student appears dehydrated (parched lips, sunken eyes,
    lethargy or clammy skin)

-   If there is a suspicion of ingesting a toxic substance or poisoning

-   If the student is concerned that she might be pregnant

**SYMPTOMATIC MANAGEMENT GUIDELINES FOR NON-HEALTH STAFF**

**KNOCKED-OUT TOOTH**

Authorized non-health staff may manage lacerations as follows:

1.  Locate the tooth.

2.  Tell the student to pick it up carefully by the top (the crown), not
    by the delicate roots.

3.  Tell the student to gently rinse off the tooth and place it in his
    cheek, or if it is front tooth, place it in the socket. If the
    student is worried about swallowing the tooth, you can advise the
    student to put the tooth in a glass of milk. The last choices of
    media are water or in a damp towel.

# WHEN TO CONTACT THE ON-CALL HEALTH AND WELLNESS STAFF

-   Contact the on-call health and wellness staff as soon as possible.
    If the student and tooth can get to a dentist within 30 minutes,
    there is reportedly a 90 percent chance that the tooth can be
    reimplanted.

**SYMPTOMATIC MANAGEMENT GUIDELINE FOR NON-HEALTH STAFF**

**ORAL BLEEDING**

Authorized non-health staff may manage oral bleeding as follows:

1.  Check to see if there is a clot protruding prominently from the
    socket of a recently extracted tooth, from a wound or trauma, or
    from a gum problem. If so, instruct the student to rinse mouth or
    spit to remove clot. It may be necessary for the student to remove
    or wipe out the protruding clot with gauze.

2.  Instruct the student to make a pad with sterile gauze sponges small
    enough to fit over the bleeding area but large enough to guarantee
    pressure on biting.

3.  Instruct the student to place the pad in the mouth over the bleeding
    area.

4.  Instruct the student to bite, bringing his/her teeth together, and
    maintain pressure for at least 30 minutes.

5.  Instruct the student to remove the gauze pack, then recheck the area
    for bleeding with a flashlight after approximately 15 minutes. If
    bleeding seems to have stopped, dismiss the student after placing a
    clean gauze pad in the mouth. Give the student instructions to
    maintain the pressure for an additional 30 minutes.

6.  Supply the student with extra gauze. Instruct the student to repeat
    the entire process, biting on the gauze pad firmly for 20-30 minute
    interval if bleeding recurs.

7.  Advise the student to refrain from strenuous work or exercise for 24
    hours to avoid recurrence of bleeding.

# WHEN TO CONTACT THE ON-CALL HEALTH AND WELLNESS STAFF

-   If this symptomatic management guideline is followed and bleeding
    continues

-   If trauma to jaw or teeth occurred prior to the episode of bleeding

**SYMPTOMATIC MANAGEMENT GUIDELINES FOR NON-HEALTH STAFF**

**ORAL PAIN**

Authorized non-health staff may manage oral pain as follows:

1.  Show the student a pain scale and ask the student to quantify the
    pain by pointing to a category.

2.  If the pain is quantified as mild, bearable, or moderate, offer the
    student ibuprofen 400 mg every 6 hours \[MDD 1600 mg\] or
    acetaminophen 1000 mg every 4 hours \[MDD 4 g\] as needed for pain
    control.

# WHEN TO CONTACT THE ON-CALL HEALTH AND WELLNESS STAFF

-   If the pain is not relieved with ibuprofen 400 mg or acetaminophen
    1000 mg

-   If the student quantifies the pain as severe

SYMPTOMATIC MANAGEMENT GUIDELINES FOR NON-HEALTH STAFF

**ALCOHOL OR DRUG USE BEHAVIOR**

Authorized non-health staff may manage possible alcohol or drug use
behavior as follows:

1.  Bring the student to a private area for evaluation.

2.  Determine if the student has allegedly ingested alcohol or drugs by
    questioning staff, student, and peers.

3.  Document observed behavior.

4.  If authorized to do so, conduct an alcohol-screening test and urine
    drug screen on suspicion according to the center operating procedure
    (COP).

5.  Any student under the influence of alcohol or drugs must be observed
    in the dormitory or the health and wellness center to ensure safety
    until symptoms have resolved.

6.  All documentation of observed behavior should be sent to the health
    and wellness center for follow-up and inclusion in the student's
    medical record. All alcohol test results, both positive and
    negative, should be sent to the health and wellness center for
    follow-up and inclusion in the student's medical record. All urine
    drug screens should be processed by health and wellness center staff
    while maintaining chain-of-custody according to COP.

**WHEN TO CONTACT THE ON-CALL HEALTH AND WELLNESS STAFF**

-   If the student is incoherent, vomiting, or losing consciousness

-   If student has ingested unknown drugs, unknown quantity, or multiple
    drugs

-   If student appears to be hyperactive, paranoid, or hallucinating

**SYMPTOMATIC MANAGEMENT GUIDELINES FOR NON-HEALTH STAFF**

# Behavior changes/Unusual Behavior

Authorized non-health staff may manage changes in behavior or unusual
behavior as follows:

1.  If the behavior is obviously dangerous or threatening to self and/or
    others, first ensure safety. Call center security and/or local
    police. Remove the student in question or remove other students from
    the area. Follow the center operating procedure for intervening in
    dangerous behavior.

2.  If the student is socially responsive and cooperative, remove the
    student to a private area for assessment.

3.  Talk with the student about your observations and concerns. Share
    this in a supportive and concerned fashion. Talking with the student
    may clarify the situation and provide direction for what to do next.

4.  If alcohol or drug use is suspected, follow the Symptomatic
    Management Guideline for Alcohol and Drug Use Behavior.

5.  If the student expresses depression but no suicidal thoughts or
    desire, be supportive and refer to health and wellness center for
    further evaluation and intervention by the center mental health
    consultant and/or center physician.

6.  If the student expresses thoughts of harm to self and/or others or
    has made any gesture, follow Symptomatic Management Guideline for
    Suicide Attempts or Threats. Do not leave student alone.

7.  If student's thoughts are jumbled, strange, "crazy", etc. Seek
    assistance from appropriate staff to help transport student to
    health and wellness center or to emergency facility per instruction
    from on-call health staff, if after hours or on weekends.

8.  After this episode has been resolved, talk to other students who may
    have witnessed or been involved and provide limited structured
    information about the situation and its resolution. Privacy rights
    must be protected. Provide assurances about safety, both theirs and
    the student in question.

# WHEN TO CONTACT THE ON-CALL HEALTH AND WELLNESS STAFF

-   If the student exhibits depression, psychotic behavior, or expresses
    the desire to hurt self and/or others or appears severely confused

**Symptomatic Management GuidelineS For Non-Health Staff**

**Suicide Attempts or Threats**

Authorized non-health staff may manage suicide attempts or threats as
follows:

1.  Immediately assess whether self-harm has occurred and alert the
    health and wellness center or 911 if necessary for any medical
    emergencies.

2.  If the student expresses any suicidal thoughts, threats, or intent,
    talk privately with student in order to gather more information
    regarding level of risk. Talk with the student about any
    psychosocial difficulties; oftentimes acute symptoms of depression
    can be alleviated in the short-term by the sharing of thoughts and
    feelings. However, continue to monitor student's behavior and
    consult with the center mental health consultant about findings, to
    determine if any further immediate action is needed.

3.  If the student continues to have suicidal thoughts with clear intent
    to harm self or, despite denying any intent, the student seems very
    anxious or upset, contact the health and wellness manager and
    security immediately. Maintain constant supervision until health
    staff arrives. If after hours, contact the health and wellness staff
    on-call.

4.  If the student is having vague thoughts of suicide, contact the
    health and wellness staff on call.

# WHEN TO CONTACT THE ON-CALL HEALTH AND WELLNESS STAFF

-   If the student has harmed him or herself

-   If the student continues to report suicidal thoughts or seems upset
    even though denying continued suicidal thoughts

### APPENDIX A

# JOB CORPS MEDICATION LISTS

List of Preferred Prescription Medications

List of Preferred Psychotropic Medications

List of Non-Prescription Medications

**Job Corps List of Preferred Medications**

**Source:**

**Health and Human Services Supply Service Center (HHS SSC)**

**Perry Point, Maryland**

**2006 Medical Supply Catalog**

**[Notes:]{.underline}**

List limited to medications available from the **2006 Medical Supply
Catalog**.

Medications in ***italics*** are second line, generally more expensive
drugs.

List **excludes** vaccines and biologicals, psychotropic agents and
dental therapeutic agents.

+-----------------------------------------+-----+----------------------+
| **Analgesics/Antipyretics:**            |     | acetaminophen        |
|                                         |     |                      |
| acetaminophen tablets, 500 mg           |     | ibuprofen            |
|                                         |     |                      |
| ibuprofen tablets, 200 mg/400 mg        |     | Naprosyn             |
|                                         |     |                      |
| naproxen tablets, 250 mg/500 mg         |     | Anaprox              |
|                                         |     |                      |
| naproxen sodium tablets, 275 mg/550 mg  |     |                      |
+-----------------------------------------+-----+----------------------+
|                                         |     |                      |
+-----------------------------------------+-----+----------------------+
| **Antibiotics (Oral/Injectable):**      |     | Penicillin VK        |
|                                         |     |                      |
| penicillin V potassium tablets, 250     |     | Bicillin L-A         |
| mg/500 mg                               |     |                      |
|                                         |     | amoxicillin          |
| penicillin G benzathine injection, 1.2  |     |                      |
| million units                           |     | erythromycin         |
|                                         |     |                      |
| amoxicillin capsules, 250 mg/500 mg     |     | doxycycline          |
|                                         |     |                      |
| erythromycin tablets, 250 mg            |     | Minocin              |
|                                         |     |                      |
| doxycycline hyclate capsules, 100 mg    |     | Bactrim-DS/Septra-DS |
|                                         |     |                      |
| minocycline hydrochloride capsules, 50  |     | Flagyl               |
| mg/100 mg                               |     |                      |
|                                         |     | Macrodantin          |
| sulfamethoxazole/trimethoprim,          |     |                      |
| double-strength                         |     | Keflex               |
|                                         |     |                      |
| metronidazole tablets, 250 mg           |     | clindamycin          |
|                                         |     |                      |
| nitrofurantoin capsules, 50 mg/100 mg   |     | Dynapen              |
|                                         |     |                      |
| cephalexin capsules, 250 mg/500 mg      |     | *Augmentin*          |
|                                         |     |                      |
| clindamycin capsules, 150 mg            |     | *Ceclor*             |
|                                         |     |                      |
| dicloxacillin capsules, 250 mg          |     | *Duricef, Ultracef*  |
|                                         |     |                      |
| *amoxicillin, 500 mg/875mg and          |     | *Rocephin*           |
| clavulanate, 125 mg*                    |     |                      |
|                                         |     | *Ceftin*             |
| *cefaclor, 250 mg*                      |     |                      |
|                                         |     | *Zithromax*          |
| *cefadroxil capsules, 500 mg*           |     |                      |
|                                         |     | *Biaxin*             |
| *ceftriaxone sodium injection, 250      |     |                      |
| mg/500 mg*                              |     | *Cipro*              |
|                                         |     |                      |
| *cefuroxime axetil, 250 mg/500 mg*      |     | *Floxin*             |
|                                         |     |                      |
| *azithromycin tablets, 250 mg/500 mg*   |     |                      |
|                                         |     |                      |
| *clarithromycin tablets, 250 mg/500 mg* |     |                      |
|                                         |     |                      |
| *ciprofloxacin tablets, 250 mg/500 mg*  |     |                      |
|                                         |     |                      |
| *ofloxacin tablets, 300 mg*             |     |                      |
+-----------------------------------------+-----+----------------------+
|                                         |     |                      |
+-----------------------------------------+-----+----------------------+
| **Antibiotics (Ears):**                 |     | Vosol HC             |
|                                         |     |                      |
| acetic acid 2%/hydrocortisone 1% otic   |     | Coly-Mycin S         |
| solution                                |     |                      |
|                                         |     | Cortisporin          |
| colistin/neomycin/hydrocortisone otic   |     |                      |
| suspension                              |     |                      |
|                                         |     |                      |
| neomycin/polymyxin B/hydrocortisone     |     |                      |
| solution/suspension                     |     |                      |
+-----------------------------------------+-----+----------------------+
|                                         |     |                      |
+-----------------------------------------+-----+----------------------+
| **Antibiotics (Eyes):**                 |     | Ilotycin             |
|                                         |     |                      |
| erythromycin ophthalmic ointment        |     | Tobrex               |
|                                         |     |                      |
| tobramycin ophthalmic solution          |     | Garamycin            |
|                                         |     |                      |
| gentamicin sulfate ophthalmic solution  |     | *Ciloxan*            |
|                                         |     |                      |
| *ciprofloxacin ophthalmic solution,     |     |                      |
| 0.3%*                                   |     |                      |
+-----------------------------------------+-----+----------------------+
|                                         |     |                      |
+-----------------------------------------+-----+----------------------+
| **Antibiotics (Skin):**                 |     | Bacitracin           |
|                                         |     |                      |
| bacitracin topical ointment             |     | Polysporin           |
|                                         |     |                      |
| polymixin B/bacitracin topical ointment |     | *Bactroban*          |
|                                         |     |                      |
| *mupirocin topical ointment, 2%*        |     |                      |
+-----------------------------------------+-----+----------------------+
|                                         |     |                      |
+-----------------------------------------+-----+----------------------+
| **Antibiotics (Vaginal):**              |     | Metro Gel            |
|                                         |     |                      |
| metronidazole vaginal gel, 0.75%        |     | Cleocin              |
|                                         |     |                      |
| clindamycin phosphate vaginal cream, 2% |     |                      |
+-----------------------------------------+-----+----------------------+
|                                         |     |                      |
+-----------------------------------------+-----+----------------------+
| **Antifungals (Oral, Topical,           |     | Fulvicin             |
| Vaginal):**                             |     |                      |
|                                         |     | Diflucan             |
| griseofulvin, 250 mg                    |     |                      |
|                                         |     | Nizoral              |
| fluconazole tablets, 150 mg             |     |                      |
|                                         |     | Selsun               |
| ketoconazole tablets, 200 mg            |     |                      |
|                                         |     | Mycostatin           |
| selenium sulfide topical lotion, 2.5%   |     |                      |
|                                         |     | Lotrimin/Mycelex     |
| nystatin topical cream                  |     |                      |
|                                         |     | Gyn                  |
| clotrimazole topical cream, 1%          |     | e-Lotrimin/Mycelex-G |
|                                         |     |                      |
| clotrimazole vaginal cream, 1%          |     | Monistat-7           |
|                                         |     |                      |
| miconazole nitrate vaginal cream, 2%    |     |                      |
+-----------------------------------------+-----+----------------------+
|                                         |     |                      |
+-----------------------------------------+-----+----------------------+
| **Antihelminthic:**                     |     | Vermox               |
|                                         |     |                      |
| mebendazole tablets, 100 mg             |     |                      |
+-----------------------------------------+-----+----------------------+
|                                         |     |                      |
+-----------------------------------------+-----+----------------------+
| **Antitiberculous:**                    |     | INH                  |
|                                         |     |                      |
| isoniazid tablets, 300 mg               |     | Rimactane            |
|                                         |     |                      |
| rifampin capsules, 300 mg               |     |                      |
+-----------------------------------------+-----+----------------------+
|                                         |     |                      |
+-----------------------------------------+-----+----------------------+
| **Antiviral:**                          |     | Zovirax              |
|                                         |     |                      |
| acyclovir capsules, 200 mg              |     | *Tamiflu*            |
|                                         |     |                      |
| *oseltamivir capsules, 75 mg*           |     | *Aldara*             |
|                                         |     |                      |
| *imiquimod cream, 5%*                   |     |                      |
+-----------------------------------------+-----+----------------------+
|                                         |     |                      |
+-----------------------------------------+-----+----------------------+
| **Antihistamines:**                     |     | Chlortimeton         |
|                                         |     |                      |
| chlorpheniramine maleate tablets, 4 mg  |     | Benadryl             |
|                                         |     |                      |
| diphenhydramine capsules, 25 mg/50 mg   |     | Atarax               |
|                                         |     |                      |
| hydroxyzine tablets, 10 mg/25 mg        |     | Claritin             |
|                                         |     |                      |
| loratidine tablets, 10 mg               |     | *Zyrtec*             |
|                                         |     |                      |
| *cetirizine tablets, 10 mg*             |     | *Allegra*            |
|                                         |     |                      |
| *fexofenadine tablets, 60 mg, 180 mg*   |     |                      |
+-----------------------------------------+-----+----------------------+
|                                         |     |                      |
+-----------------------------------------+-----+----------------------+
| **Decongestants:**                      |     | Sudafed              |
|                                         |     |                      |
| pseudoephedrine hydrochloride tablets,  |     | Ocean nasal spray    |
| 30 mg/60 mg                             |     |                      |
|                                         |     | Afrin nasal spray    |
| sodium chloride nasal solution,         |     |                      |
| isotonic, 0.65%                         |     |                      |
|                                         |     |                      |
| oxymetazoline hydrochloride nasal       |     |                      |
| solution                                |     |                      |
+-----------------------------------------+-----+----------------------+
|                                         |     |                      |
+-----------------------------------------+-----+----------------------+
| **Combination                           |     | Dimetapp             |
| Antihistamine/Decongestant:**           |     |                      |
|                                         |     | Deconamine SR        |
| brompheniramine/pseudoephedrine         |     |                      |
|                                         |     | Actifed              |
| chlorpheniramine                        |     |                      |
| maleate/pseudoephedrine, 8 mg/120 mg    |     | Claritin-D 12 hour   |
|                                         |     |                      |
| triprolidine/pseudoephedrine, 2.5 mg/60 |     | Allegra-D            |
| mg                                      |     |                      |
|                                         |     | Vasocon-A eye drops  |
| loratadine/pseudoephedrine, 5 mg/120 mg |     |                      |
|                                         |     |                      |
| fexofenadine/pseudoephedrine, 60mg/120  |     |                      |
| mg                                      |     |                      |
|                                         |     |                      |
| naphazoline/antazoline ophthalmic       |     |                      |
| solution                                |     |                      |
+-----------------------------------------+-----+----------------------+
|                                         |     |                      |
+-----------------------------------------+-----+----------------------+
| **Antitussives:**                       |     | Robitussin DM cough  |
|                                         |     | syrup                |
| guaifenesin/dextromethorphan syrup, 100 |     |                      |
| mg/10 mg                                |     | cough suppressant    |
|                                         |     |                      |
| dextromethorphan hydrobromide syrup     |     |                      |
+-----------------------------------------+-----+----------------------+
|                                         |     |                      |
+-----------------------------------------+-----+----------------------+
| **Throat Lozenges:**                    |     | Cepacol              |
|                                         |     |                      |
| cetylpyridinium chloride oral lozenges  |     |                      |
+-----------------------------------------+-----+----------------------+
|                                         |     |                      |
+-----------------------------------------+-----+----------------------+

+-----------------------------------------+-----+----------------------+
| **Ear Agents (Topical):**               |     | Auralgan             |
|                                         |     |                      |
| antipyrine/benzocaine otic solution     |     | Cerumenex            |
|                                         |     |                      |
| triethanolamine polypeptide oleate otic |     | Debrox               |
| solution, 10%                           |     |                      |
|                                         |     |                      |
| carbamide peroxide otic solution, 6.5%  |     |                      |
+-----------------------------------------+-----+----------------------+
|                                         |     |                      |
+-----------------------------------------+-----+----------------------+
| **Anaphylaxis:**                        |     | Epi-Pen              |
|                                         |     |                      |
| epinephrine hydrochloride autoinjector, |     | Adrenalin            |
| 0.3 mg                                  |     |                      |
|                                         |     |                      |
| epinephrine hydrochloride injection,    |     |                      |
| 1:1000                                  |     |                      |
+-----------------------------------------+-----+----------------------+
|                                         |     |                      |
+-----------------------------------------+-----+----------------------+
| **Asthma:**                             |     | albuterol            |
|                                         |     |                      |
| albuterol inhalation aerosol (generic)  |     | Qvar                 |
|                                         |     |                      |
| beclomethasone dipropionate oral        |     | Flovent              |
| inhaler                                 |     |                      |
|                                         |     | *Advair diskus*      |
| fluticasone propionate oral inhaler,    |     |                      |
| 110mcg/220 mcg                          |     | *Singulair*          |
|                                         |     |                      |
| *fluticasone/salmeterol oral inhaler,   |     | theophylline         |
| 250 mcg/50 mcg*                         |     |                      |
|                                         |     |                      |
| *montelukast sodium tablets, 10 mg*     |     |                      |
|                                         |     |                      |
| theophylline tablets, extended release, |     |                      |
| 200 mg/300 mg                           |     |                      |
+-----------------------------------------+-----+----------------------+
|                                         |     |                      |
+-----------------------------------------+-----+----------------------+
| **Nasal steroids:**                     |     | Beconase AQ          |
|                                         |     |                      |
| beclomethasone dipropionate nasal       |     | Nasalide             |
| inhaler                                 |     |                      |
|                                         |     |                      |
| flunisolide nasal solution              |     |                      |
+-----------------------------------------+-----+----------------------+
|                                         |     |                      |
+-----------------------------------------+-----+----------------------+
| **Antacids:**                           |     | Maalox               |
|                                         |     |                      |
| aluminum and magnesium hydroxide oral   |     | TUMS-EX              |
| solution                                |     |                      |
|                                         |     | Pepcid               |
| calcium carbonate tablets, 500 mg       |     |                      |
|                                         |     | Zantac               |
| famotidine tablets, 20 mg/40 mg         |     |                      |
|                                         |     | Prilosec             |
| ranitidine hydrochloride tablets, 150   |     |                      |
| mg/300 mg                               |     | *Prevacid*           |
|                                         |     |                      |
| omeprazole delayed release capsules, 20 |     | *Protonix*           |
| mg                                      |     |                      |
|                                         |     |                      |
| *lansoprazole delayed release capsules, |     |                      |
| 30 mg*                                  |     |                      |
|                                         |     |                      |
| *pantoprazole delayed release tablets,  |     |                      |
| 40 mg*                                  |     |                      |
+-----------------------------------------+-----+----------------------+
|                                         |     |                      |
+-----------------------------------------+-----+----------------------+
| **Antidiarrheal:**                      |     | Imodium              |
|                                         |     |                      |
| loperamide hydrochloride capsules, 2 mg |     | Pepto Bismol         |
|                                         |     |                      |
| bismuth subsalicylate oral suspension   |     |                      |
+-----------------------------------------+-----+----------------------+
|                                         |     |                      |
+-----------------------------------------+-----+----------------------+
| **Antiemetics:**                        |     | Antivert             |
|                                         |     |                      |
| meclizine hydrochloride tablets, 25 mg  |     | Dramamine            |
|                                         |     |                      |
| dimenhydrinate tablets, 50 mg           |     | Compazine            |
|                                         |     | suppositories        |
| prochlorperazine suppositories, 25 mg   |     |                      |
|                                         |     | Phenergan            |
| promethazine suppositories, 25 mg       |     | suppositories        |
+-----------------------------------------+-----+----------------------+
|                                         |     |                      |
+-----------------------------------------+-----+----------------------+
| **Laxatives/Stool softeners:**          |     | milk of magnesia     |
|                                         |     |                      |
| milk of magnesia, oral                  |     | Dulcolax             |
|                                         |     |                      |
| bisacodyl tablets, 5 mg                 |     | Colace               |
|                                         |     |                      |
| docusate sodium capsules, 100 mg        |     | Metamucil            |
|                                         |     |                      |
| psyllium hydrophilic mucilloid          |     | Cephulac             |
|                                         |     |                      |
| lactulose oral syrup, 10 gm/15 ml       |     |                      |
+-----------------------------------------+-----+----------------------+
|                                         |     |                      |
+-----------------------------------------+-----+----------------------+
| **Anticonvulsants:**                    |     | phenobarbital        |
|                                         |     |                      |
| phenobarbital, 30 mg/60 mg              |     | Dilantin             |
|                                         |     |                      |
| phenytoin sodium capsules, 100 mg       |     | Tegretol             |
|                                         |     |                      |
| carbamazepine tablets, 200 mg           |     | Depakote             |
|                                         |     |                      |
| divalproex sodium tablets, 250 mg/500   |     |                      |
| mg                                      |     |                      |
+-----------------------------------------+-----+----------------------+
|                                         |     |                      |
+-----------------------------------------+-----+----------------------+
| **Antimigraine:**                       |     | *Imitrex*            |
|                                         |     |                      |
| *sumatriptan succinate tablets, 25 mg*  |     |                      |
+-----------------------------------------+-----+----------------------+
|                                         |     |                      |
+-----------------------------------------+-----+----------------------+
| **Anticholinergics:**                   |     | Ditropan             |
|                                         |     |                      |
| oxybutynin tablets, 5 mg                |     | Bentyl               |
|                                         |     |                      |
| dicyclomine capsules, 10 mg             |     | Levsin               |
|                                         |     |                      |
| hyoscyamine tablets, 0.375 mg           |     |                      |
+-----------------------------------------+-----+----------------------+
|                                         |     |                      |
+-----------------------------------------+-----+----------------------+
| **Skeletal muscle relaxants:**          |     | Flexaril             |
|                                         |     |                      |
| cyclobenzaprine hydrochloride tablets,  |     | Robaxin              |
| 10 mg                                   |     |                      |
|                                         |     |                      |
| methocarbamol tablets, 500 mg/750 mg    |     |                      |
+-----------------------------------------+-----+----------------------+
|                                         |     |                      |
+-----------------------------------------+-----+----------------------+
| **Antihypertensives:**                  |     | hydrochlorothiazide  |
|                                         |     |                      |
| hydrochlorothiazide, 25 mg/50 mg        |     | Tenormin             |
|                                         |     |                      |
| atenolol tablets, 50 mg                 |     | Lopressor            |
|                                         |     |                      |
| metoprolol, 50 mg/100 mg                |     | Inderal              |
|                                         |     |                      |
| propranolol, 20 mg/40 mg                |     | Vasotec              |
|                                         |     |                      |
| enalapril maleate tablets, 10 mg/20 mg  |     | Zestril/Prinivil     |
|                                         |     |                      |
| lisinopril, 10 mg/20 mg                 |     | Cardizem/SR          |
|                                         |     |                      |
| diltiazem hydrochloride capsules, 60    |     | verapamil SR         |
| mg/90 mg/120 mg                         |     |                      |
|                                         |     |                      |
| verapamil hydrochloride tablets, 180    |     |                      |
| mg/240 mg                               |     |                      |
+-----------------------------------------+-----+----------------------+
|                                         |     |                      |
+-----------------------------------------+-----+----------------------+
| **Oral hypoglycemics:**                 |     | Glucophage           |
|                                         |     |                      |
| metformin hydrochloride, 500mg/850      |     | Orinase              |
| mg/1000 mg                              |     |                      |
|                                         |     | *Avandia*            |
| tolbutamide tablets, 500 mg             |     |                      |
|                                         |     |                      |
| *rosiglitazone maleate, 4 mg*           |     |                      |
+-----------------------------------------+-----+----------------------+
|                                         |     |                      |
+-----------------------------------------+-----+----------------------+
| **Steroids (Oral):**                    |     | prednisone           |
|                                         |     |                      |
| prednisone tablets, 20 mg               |     | Decadron             |
|                                         |     |                      |
| dexamethasone tablets, 4 mg             |     |                      |
+-----------------------------------------+-----+----------------------+
|                                         |     |                      |
+-----------------------------------------+-----+----------------------+
| **Steroids (Topical):**                 |     | Valisone             |
|                                         |     |                      |
| betamethasone valerate cream, 0.1%      |     | Cortef               |
|                                         |     |                      |
| hydrocortisone cream, 1%                |     | Westcort             |
|                                         |     |                      |
| hydrocortisone valerate cream, 0.2%     |     | Anusol-HC            |
|                                         |     |                      |
| hydrocortisone acetate rectal           |     | Kenalog              |
| suppositories, 25 mg                    |     |                      |
|                                         |     |                      |
| triamcinolone acetonide cream/ointment, |     |                      |
| 0.1%                                    |     |                      |
+-----------------------------------------+-----+----------------------+
|                                         |     |                      |
+-----------------------------------------+-----+----------------------+
| **Contraceptive Hormones:**             |     | Desogen 0.15/30      |
|                                         |     |                      |
| desogestrel and ethinyl estradiol       |     | Tri-Levlin/Triphasil |
|                                         |     |                      |
| levonorgestrel and ethinyl estradiol,   |     | Loestrin Fe 1.5/30   |
| triphasic                               |     |                      |
|                                         |     | Ortho Novum 1/35     |
| norethindrone and ethinyl estradiol     |     |                      |
| with iron                               |     | Ortho Novum 7/7/7    |
|                                         |     |                      |
| norethindrone and ethinyl estradiol     |     | Ortho Tricyclen      |
|                                         |     |                      |
| norethindrone and ethinyl estradiol,    |     | Lo-Ovral 0.3/30      |
| triphasic                               |     |                      |
|                                         |     | Depro Provera        |
| norgestimate and ethinyl estradiol,     |     | injection            |
| triphasic                               |     |                      |
|                                         |     | Provera              |
| norgestrel and ethinyl estradiol        |     |                      |
|                                         |     | Plan-B               |
| medroxyprogesterone acetate suspension, |     |                      |
| 150 mg                                  |     | Ortho Evra patch     |
|                                         |     |                      |
| medroxyprogesterone acetate tablets, 10 |     |                      |
| mg                                      |     |                      |
|                                         |     |                      |
| levonorgestrel, 0.75 mg                 |     |                      |
|                                         |     |                      |
| norelgestromin/ethinyl estradiol        |     |                      |
| transdermal system                      |     |                      |
+-----------------------------------------+-----+----------------------+
|                                         |     |                      |
+-----------------------------------------+-----+----------------------+
| **Iron Supplements:**                   |     | ferrous sulfate      |
|                                         |     |                      |
| ferrous sulfate tablets, 325 mg         |     |                      |
+-----------------------------------------+-----+----------------------+
|                                         |     |                      |
+-----------------------------------------+-----+----------------------+
| **Burns:**                              |     | Silvadene            |
|                                         |     |                      |
| silver sulfadiazine topical cream, 1%   |     |                      |
+-----------------------------------------+-----+----------------------+
|                                         |     |                      |
+-----------------------------------------+-----+----------------------+
|                                         |     |                      |
+-----------------------------------------+-----+----------------------+
| **Acne agents (Topical):**              |     | Desquam-X            |
|                                         |     |                      |
| benzoyl peroxide topical gel, 5%/10%    |     | Cleocin-T            |
|                                         |     |                      |
| clindamycin phosphate topical solution, |     | Eryderm              |
| 1%                                      |     |                      |
|                                         |     | Retin-A              |
| erythromycin topical solution, 2%       |     |                      |
|                                         |     |                      |
| tretinoin topical cream, 0.05%/0.1% and |     |                      |
| gel 0.025%                              |     |                      |
+-----------------------------------------+-----+----------------------+
|                                         |     |                      |
+-----------------------------------------+-----+----------------------+
| **Skin Astringents:**                   |     | calamine             |
|                                         |     |                      |
| calamine topical lotion                 |     | Domeboro solution    |
|                                         |     |                      |
| aluminum acetate for topical solution   |     | hydrogen peroxide    |
|                                         |     |                      |
| hydrogen peroxide topical solution, 3%  |     |                      |
+-----------------------------------------+-----+----------------------+
|                                         |     |                      |
+-----------------------------------------+-----+----------------------+
| **Skin Emollients:**                    |     | Vaseline             |
|                                         |     |                      |
| petrolatum, white                       |     | Lac-Hydrin           |
|                                         |     |                      |
| ammonium lactate topical lotion, 12%    |     |                      |
+-----------------------------------------+-----+----------------------+
|                                         |     |                      |
+-----------------------------------------+-----+----------------------+
| **Pediculocide:**                       |     | Nix                  |
|                                         |     |                      |
| permethrin topical cream rinse, 1%      |     | Kwell shampoo        |
|                                         |     |                      |
| lindane shampoo, 1%                     |     |                      |
+-----------------------------------------+-----+----------------------+
|                                         |     |                      |
+-----------------------------------------+-----+----------------------+
| **Scabicide:**                          |     | Elimite              |
|                                         |     |                      |
| permethrin topical cream, 5%            |     | Kwell lotion         |
|                                         |     |                      |
| lindane lotion, 1%                      |     |                      |
+-----------------------------------------+-----+----------------------+
|                                         |     |                      |
+-----------------------------------------+-----+----------------------+
| **Urinary Anesthetic:**                 |     | Pyridium             |
|                                         |     |                      |
| phenazopyridine hydrochloride tablets,  |     |                      |
| 100 mg                                  |     |                      |
+-----------------------------------------+-----+----------------------+
|                                         |     |                      |
+-----------------------------------------+-----+----------------------+
| **Vitamins - Prenatal:**                |     | Stuartnatal          |
|                                         |     |                      |
| vitamin tablets, multiple, prenatal     |     |                      |
+-----------------------------------------+-----+----------------------+
|                                         |     |                      |
+-----------------------------------------+-----+----------------------+
| **Smoking Cessation:**                  |     | Nicorette            |
|                                         |     |                      |
| nicotine polacrilex chewing gum, 2 mg/4 |     | Commit               |
| mg                                      |     |                      |
|                                         |     | Nicoderm CQ          |
| nicotine polacrilex lozenge, 2 mg/4 mg  |     |                      |
|                                         |     |                      |
| nicotine transdermal system, 7 mg/14    |     |                      |
| mg/21 mg                                |     |                      |
+-----------------------------------------+-----+----------------------+
|                                         |     |                      |
+-----------------------------------------+-----+----------------------+

**Job Corps List of Preferred Medications**

**Psychotropic Agents**

**Source:**

**Health and Human Services**

**Supply Service Center (HHS SSC)**

**2006 Medical Supply Catalog**

# Antianxiety and Sedative Agents

+----------------------------------------+-----+----------------------+
| **Benzodiazepines**                    |     | Xanax                |
|                                        |     |                      |
| alprazolam tablets, 0.5 mg             |     | Librium              |
|                                        |     |                      |
| chlordiazepoxide capsules, 25 mg       |     | Klonopin             |
|                                        |     |                      |
| clonazepam tablets, 0.5 mg             |     | *Valium*             |
|                                        |     |                      |
| *diazepam tablets, 5 mg*               |     | *Dalmane*            |
|                                        |     |                      |
| *flurazepam capsules, 15 mg*           |     | Ativan               |
|                                        |     |                      |
| lorazepam tablets, 1.0 mg              |     | *Halcion*            |
|                                        |     |                      |
| *triazolam tablets, 0.25 mg*           |     |                      |
+----------------------------------------+-----+----------------------+
|                                        |     |                      |
+----------------------------------------+-----+----------------------+
| **Miscellaneous**                      |     | BuSpar               |
|                                        |     |                      |
| buspirone tablets, 10 mg               |     | Benadryl             |
|                                        |     |                      |
| diphenhydramine capsules, 25mg/50mg    |     | Atarax, Vistaril     |
|                                        |     |                      |
| hydroxyzine tablets, 25 mg             |     | Catapres             |
|                                        |     |                      |
| clonidine tablets, 0.1 mg              |     | Inderal              |
|                                        |     |                      |
| propranolol tablets, 20 mg             |     | Inderal LA           |
|                                        |     |                      |
| propranolol capsules, sustained        |     |                      |
| release, 80mg/120mg                    |     |                      |
+----------------------------------------+-----+----------------------+
|                                        |     |                      |
+----------------------------------------+-----+----------------------+

# 

# Antidepressant Agents

+----------------------------------------+-----+---------------------+---+
| **Selective Serotonin Reuptake         |     | Celexa              |   |
| Inhibitors (SSRI's)**                  |     |                     |   |
|                                        |     | Prozac              |   |
| citalopram tablets, 40 mg              |     |                     |   |
|                                        |     | Paxil               |   |
| fluoxetine capsules, 20 mg             |     |                     |   |
|                                        |     | Zoloft              |   |
| paroxetine tablets, 20 mg              |     |                     |   |
|                                        |     |                     |   |
| sertraline tablets, 100 mg             |     |                     |   |
+----------------------------------------+-----+---------------------+---+
|                                        |     |                     |   |
+----------------------------------------+-----+---------------------+---+
| **Cyclic Antidepressants (TCA's,       |     | Elavil              |   |
| HCA's)**                               |     |                     |   |
|                                        |     | Anafranil           |   |
| amitriptyline tablets, 25 mg           |     |                     |   |
|                                        |     | Norpramin           |   |
| clomipramine tablets, 50 mg            |     |                     |   |
|                                        |     | Sinequan            |   |
| desipramine tablets, 25 mg             |     |                     |   |
|                                        |     | Tofranil            |   |
| doxepin capsules, 25 mg                |     |                     |   |
|                                        |     | ## Aventyl          |   |
| imipramine tablets, 25 mg              |     |                     |   |
|                                        |     |                     |   |
| *nortriptyline capsules, 25 mg*        |     |                     |   |
+----------------------------------------+-----+---------------------+---+
|                                        |     |                     |   |
+----------------------------------------+-----+---------------------+---+
| **Atypical Antidepressants**           |     | Wellbutrin SR       |   |
|                                        |     |                     |   |
| buproprion tablets, sustained release, |     | Wellbutrin          |   |
| 150 mg                                 |     |                     |   |
|                                        |     | Remeron             |   |
| buproprion tablets, 100 mg             |     |                     |   |
|                                        |     | Desyrel             |   |
| mirtazapine tablets, 15mg              |     |                     |   |
|                                        |     | Effexor XR          |   |
| trazodone tablets, 50 mg               |     |                     |   |
|                                        |     |                     |   |
| venlafaxine tablets, extended release, |     |                     |   |
| 75 mg/150mg                            |     |                     |   |
+----------------------------------------+-----+---------------------+---+
| #####                                  |     |                     |   |
+----------------------------------------+-----+---------------------+---+
| ##                                     |     | Tegretol            |   |
| ### Antimanic, Mood Stabilizing Agents |     |                     |   |
|                                        |     | Depakote, Dynapen   |   |
| carbamazepine tablets, 200 mg          |     |                     |   |
|                                        |     | Neurontin           |   |
| divalproex sodium tablets, 250 mg      |     |                     |   |
|                                        |     | Lamictal            |   |
| gabapentin capsules, 300 mg            |     |                     |   |
|                                        |     | lithium carbonate   |   |
| lamotrigine capsules, 25 mg/100 mg     |     |                     |   |
|                                        |     | *Eskalith*          |   |
| lithium carbonate tablets, 300 mg      |     |                     |   |
|                                        |     | Topomax             |   |
| *lithium carbonate tablets extended    |     |                     |   |
| release, 450 mg*                       |     |                     |   |
|                                        |     |                     |   |
| topiramate tablets, 25 mg/100 mg       |     |                     |   |
+----------------------------------------+-----+---------------------+---+

# Antipsychotic Agents

+-----------------------------------------+-----+---------------------+
| **Atypical Agents**                     |     | Clozapine           |
|                                         |     |                     |
| clozapine tablets, 25mg/100mg           |     | Zyprexa             |
|                                         |     |                     |
| olanzapine tablets, 5 mg                |     | Seroquel            |
|                                         |     |                     |
| quetiapine fumarate tablets, 25 mg, 100 |     | Risperdal           |
| mg                                      |     |                     |
|                                         |     |                     |
| risperidone tablets, 1 mg               |     |                     |
+-----------------------------------------+-----+---------------------+
|                                         |     |                     |
+-----------------------------------------+-----+---------------------+
| **Typical Agents**                      |     | chlorpromazine      |
|                                         |     |                     |
| chlorpromazine tablets, 50 mg           |     | Prolixin            |
|                                         |     |                     |
| fluphenazine tablets, 1 mg              |     | Haldol              |
|                                         |     |                     |
| haloperidol tablets, 2 mg               |     | *Loxitane*          |
|                                         |     |                     |
| *loxapine capsules, 25 mg*              |     | *Trilafon*          |
|                                         |     |                     |
| *perphenazine tablets, 2 mg*            |     | *Mellaril*          |
|                                         |     |                     |
| *thioridazine tablets, 50 mg*           |     | Navane              |
|                                         |     |                     |
| thiothixene capsules, 2 mg              |     | *Stelazine*         |
|                                         |     |                     |
| *trifluoperazine tablets, 2 mg*         |     |                     |
+-----------------------------------------+-----+---------------------+
|                                         |     |                     |
+-----------------------------------------+-----+---------------------+
| **Side-Effect/Anti-Parkinsonian         |     | Cogentin            |
| Agents**                                |     |                     |
|                                         |     | Artane              |
| benztropin tablets, 1 mg                |     |                     |
|                                         |     |                     |
| trihexyphenidyl tablets, 2 mg           |     |                     |
+-----------------------------------------+-----+---------------------+
| amantadine capsules, 100mg              |     | Symmetrel           |
+-----------------------------------------+-----+---------------------+

# Psychostimulant Agents (for ADHD)

+---------------------------------------------+---+---------------------+
| amphetamine mixture tablets, 10 mg/20 mg    |   | Adderall            |
|                                             |   |                     |
| methylphenidate hydrochloride tablets,      |   | Ritalin             |
| 5mg/10 mg                                   |   |                     |
|                                             |   | Ritalin SR          |
| methylphenidate hydrochloride tablets,      |   |                     |
| sustained release, 20 mg                    |   |                     |
+---------------------------------------------+---+---------------------+

**[Notes:]{.underline}**

List limited to medications available from the 2006 Medical Supply
Catalog.

Medications in italics are second line, generally more expensive or
higher-side-effect drugs.

#### List excludes general medical and dental medications, vaccines and biologicals.

**Job Corps List of Preferred Medications**

**Dental Therapeutic Agents**

Source:

**Health and Human Services**

**Supply Service Center (HHS SSC)**

**2006 Medical Supply Catalog**

+-----------------------------------------+-----+---------------------+
| **Analgesics (Mild Pain):**             |     | ibuprofen           |
|                                         |     |                     |
| ibuprofen tablets, 400 mg               |     | acetaminophen       |
|                                         |     |                     |
| acetaminophen caplets, 500 mg           |     | Naprosyn            |
|                                         |     |                     |
| naproxen tablets, 375 mg                |     |                     |
+-----------------------------------------+-----+---------------------+
|                                         |     |                     |
+-----------------------------------------+-----+---------------------+
| **Analgesics (Moderate Pain):**         |     | ibuprofen           |
|                                         |     |                     |
| ibuprofen tablets, 600 mg               |     | \*Tylenol No. 3     |
|                                         |     |                     |
| \*acetaminophen, 300 mg + codeine, 30   |     |                     |
| mg                                      |     |                     |
+-----------------------------------------+-----+---------------------+
|                                         |     |                     |
+-----------------------------------------+-----+---------------------+
| **Anxiety:**                            |     | Valium              |
|                                         |     |                     |
| diazepam tablets, 5 mg                  |     |                     |
+-----------------------------------------+-----+---------------------+
|                                         |     |                     |
+-----------------------------------------+-----+---------------------+
| **Infection/Bacterial:**                |     | Pen Vee K           |
|                                         |     |                     |
| penicillin VK tablets, 500 mg           |     | Cleocin             |
|                                         |     |                     |
| clindamycin caplets, 150 mg             |     |                     |
+-----------------------------------------+-----+---------------------+
| clarithromycin tablets, 500 mg          |     | Biaxin              |
|                                         |     |                     |
| azithromycin tablets, 250 mg            |     | Zithromax           |
+-----------------------------------------+-----+---------------------+
| **Infection/Bacterial (Prophylactic     |     | amoxicillin         |
| Coverage)**                             |     |                     |
|                                         |     |                     |
| amoxicillin capsules, 500 mg            |     |                     |
+-----------------------------------------+-----+---------------------+
| clindamycin hydrochloride capsules, 150 |     | Cleocin             |
| mg                                      |     |                     |
+-----------------------------------------+-----+---------------------+
| **Infection/Fungal:**                   |     | Diflucan            |
|                                         |     |                     |
| fluconazole tablets, 100 mg             |     | Mycostatin          |
|                                         |     |                     |
| nystatin pastilles, 100,000 units       |     | Mycolog-11 ointment |
|                                         |     |                     |
| nystatin, 100,000 units and 1 mg        |     |                     |
| triamcinolone acetonide topical         |     |                     |
| ointment per gram---15 grams            |     |                     |
+-----------------------------------------+-----+---------------------+
| **Infection/Viral:**                    |     | Zovirax             |
|                                         |     |                     |
| acyclovir capsules, 200 mg              |     |                     |
+-----------------------------------------+-----+---------------------+
|                                         |     |                     |
+-----------------------------------------+-----+---------------------+
| **Allergy:**                            |     | Benadryl            |
|                                         |     |                     |
| diphenhydramine hydrochloride, 25 mg/50 |     |                     |
| mg                                      |     |                     |
+-----------------------------------------+-----+---------------------+
|                                         |     |                     |
+-----------------------------------------+-----+---------------------+
| **Antiseptic/Antimicrobial:**           |     | Peridex             |
|                                         |     |                     |
| chlorhexidine gluconate oral rinse,     |     | hydrogen peroxide   |
| 0.12%, 480 ml                           |     |                     |
|                                         |     |                     |
| hydrogen peroxide topical solution, 3%  |     |                     |
+-----------------------------------------+-----+---------------------+
|                                         |     |                     |
+-----------------------------------------+-----+---------------------+
| **Oral Inflammatory:**                  |     | Lidex               |
|                                         |     |                     |
| fluocinonide topical cream 0.05%        |     | Kenalog in Orabase  |
|                                         |     |                     |
| triamcinolone acetonide dental paste    |     |                     |
| 0.1%                                    |     |                     |
+-----------------------------------------+-----+---------------------+
|                                         |     |                     |
+-----------------------------------------+-----+---------------------+
| **Smoking Cessation:**                  |     | Nicorette           |
|                                         |     |                     |
| nicotine polacrilex chewing gum, 2 mg/4 |     | Nicoderm CQ         |
| mg                                      |     |                     |
|                                         |     | Commit              |
| nicotine transdermal system, 7 mg/14    |     |                     |
| mg/21 mg                                |     | Dycal               |
|                                         |     |                     |
| nicotine polacrilex lozenge, 2 mg/4 mg  |     |                     |
|                                         |     |                     |
| pulp protector                          |     |                     |
|                                         |     |                     |
| calcium hydroxide composition           |     |                     |
+-----------------------------------------+-----+---------------------+

**[Notes:]{.underline}**

\*These medications should only be prescribed after Ibuprofen has been
taken, as prescribed, and has not alleviated the pain in the given time.

List limited to medications available from the **2006** **Medical Supply
Catalog.**

Medications in ***italics*** are second line, generally more expensive
or higher-side-effect drugs.

List **excludes** general medical medications, psychotropic medications,
vaccines and biologicals.

**To obtain a copy of the Perry Point Medical Supply Catalog, write or
call:**

**Customer Service**

**U.S. Department Health and Human Services**

**Supply Service Center**

**Perry Point, MD 21902**

**(800) 642-0263 (7:30 am - 4:30 pm)**

**Job Corps List of Non-Prescription Medications**

Job Corps non-prescription medications should be made available to the
non-health residential staff in unit dosing so that Symptomatic
Management Guidelines can be implemented until the affected student
receives treatment in the Health and Wellness Center. Non-health staff
should refer to the Symptomatic Management Guidelines for ongoing care
beyond the initial medication dosing recommended below.

+-----------------------------+-------------------+-------------------+
| # Medication                | # Indications     | # Dosing          |
+-----------------------------+-------------------+-------------------+
| Acetaminophen (Tylenol^®^)  | Pain, fever       | 2 tablets every 4 |
| 500 mg                      |                   | hrs[^3]           |
+-----------------------------+-------------------+-------------------+
| Antacid liquid (Maalox^®^)  | Upset stomach     | 3 teaspoons 4     |
|                             |                   | times a day       |
+-----------------------------+-------------------+-------------------+
| Antacid tablets             | Upset stomach     | 2 tablets 4 times |
| (TUMS-EX^®^) 500 mg         |                   | a day             |
+-----------------------------+-------------------+-------------------+
| Cough drops                 | Cough             | 1 cough drop as   |
|                             |                   | needed            |
+-----------------------------+-------------------+-------------------+
| Decongestant spray          | Sinus/nasal       | 2 sprays every 12 |
| (Afrin^®^)                  | congestion        | hrs               |
+-----------------------------+-------------------+-------------------+
| Dextromethorphan cough      | Cough             | 3 teaspoons every |
| syrup 10 mg                 |                   | 6 hrs[^4]         |
+-----------------------------+-------------------+-------------------+
| Diphenhydramine             | Allergy           | 1-2 capsules      |
| (Benadryl^®^) 25 mg         |                   | every 6 hrs       |
+-----------------------------+-------------------+-------------------+
| Ibuprofen                   | Pain, fever       | 2 tablets every 6 |
| (Advil^®^/Motrin^®^) 200 mg |                   | hrs[^5]           |
+-----------------------------+-------------------+-------------------+
| Loperamide (Imodium AD^®^)  | Diarrhea          | 2 caplets         |
| 2 mg                        |                   | initially         |
+-----------------------------+-------------------+-------------------+
| Milk of magnesia            | Constipation      | 2 tablespoons     |
|                             |                   | every 12 hrs      |
+-----------------------------+-------------------+-------------------+
| Naproxen sodium (Aleve^®^)  | Menstrual cramps  | 2 tablets every 8 |
| 220 mg                      |                   | hrs[^6]           |
+-----------------------------+-------------------+-------------------+
| Pseudoephedrine             | Sinus/nasal       | 1-2 tablets every |
| (Sudafed^®^) 30 mg          | congestion        | 8 hrs             |
+-----------------------------+-------------------+-------------------+
| Saline nasal spray          | Sinus/nasal       | 2 sprays as       |
|                             | congestion        | needed            |
+-----------------------------+-------------------+-------------------+
| Sore throat lozenges        | Sore throat       | 1 lozenge as      |
|                             |                   | needed            |
+-----------------------------+-------------------+-------------------+

Maximum Daily Dose (MDD)

**APPENDIX B**

Review Package---Sample Cover Memo

to Regional Nurse Consultant

**Review Package---Sample Cover Memo to Regional Nurse Consultant**

**MEMORANDUM**

TO: Jane Nurse, RNC, Region \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

FROM: John Doe, Center Director, \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ JCC

DATE: October 1, 2003

RE: Review of Health Care Guidelines

The treatment guidelines (TGs) and symptomatic management guidelines
(SMGs) and personal authorizations for health staff have been adopted
unchanged from TAG M with the exception of the following that need
review and approval by the regional office.

Attached are copies for review:

Treatment Guidelines---TG11

Authorization for Center Nurse, RN

> Center Physician Date

##### Center Mental Health Consultant Date

##### Center Dentist Date

##### Health and Wellness Manager Date

Attachments

**APPENDIX C**

**SAMPLE PERSONAL AUTHORIZATIONS**

# PERSONAL AUTHORIZATION FOR CENTER NURSING STAFF

This authorization includes a list of patient care activities that may
be performed by the center nursing staff. This authorization is not
meant to be all-inclusive. The HWM in consultation with the center
physician should complete this personal authorization for each member of
the center nursing staff. A copy of each staff member\'s form should be
kept in the health and wellness center, the original should be filed in
the employee\'s personnel record.

The level of delegation should be determined not only by the education,
experience, and training of the nurse[^7] in question, but also by the
preferences of the center physician. All center health staff and
providers shall follow accepted professional standards of care and are
subject to prevailing state laws.

This is a recommended authorization. The physician should feel free to
make additions or revisions to this authorization if necessary.

**Personal Authorization for center nursing staff**

Under this authorization, may perform the procedures

Center Nurse

that are listed below:

### Procedures

1.  Review Health Questionnaire, Form ETA-653, in addition to other
    health information provided from other health care providers

2.  Obtain the student's medical history

3.  Complete nursing assessment on all students

4.  Obtain specimens for routine testing as required by the PRH

5.  Conduct commonly performed lab test when needed

    a.  Pregnancy test

    b.  Dipstick urinalysis

    c.  Drug screens

    d.  Throat culture

    e.  Hemoglobin or hematocrit

    f.  Leukocyte esterase

    g.  STD screens

6.  Immunize students according to Job Corps policy

7.  Provide basic first aid for minor problems (i.e., sprains,
    contusions, abrasions)

8.  Provide basic first aid for major problems (i.e., CPR, shock,
    control of bleeding)

9.  Case manage chronic medical conditions

10. Administer over-the-counter medication

11. Administer prescribed medication

12. Implement treatment guidelines

Center Physician Signature

##### Date 

**PERSONAL AUTHORIZATION FOR ADVANCED PRACTICE CLINICIANS**[^8]

This authorization includes activities for patient care that may be
performed by advanced practice clinicians. It is not meant to be
all-inclusive. The HWM in consultation with the center physician should
complete this personal authorization for each advanced practice
clinician. A copy of each advanced practice clinician's form should be
kept in the health and wellness center, the original should be filed in
the employee\'s personnel record.

The level of delegation should be determined not only by the education,
experience, and training of the advanced practice clinician in question,
but also by the preferences of the center physician. All center health
staff and providers shall follow accepted professional standards of care
and are subject to prevailing state laws.

This is a sample authorization. The physician should feel free to make
additions or revisions to this authorization if necessary.

**Personal Authorization for advanced practice clinicians**

Under this authorization, may perform

Nurse Practitioner/Physician Assistant

the procedures listed below:

# 

# 

# Procedures

1.  Take, evaluate, and record comprehensive health histories

2.  Perform comprehensive physical examinations required to evaluate
    health status and acute and/or chronic medical problems

3.  Order, conduct, and interpret appropriate screening studies, tests,
    and diagnostic procedures used to assess and diagnose problems, and
    establish management/treatment plans

4.  Diagnose, treat, and manage acute episodic and chronic illnesses,
    minor traumas, and behavioral/psychological problems

5.  Initiate consultation requests and work in collaboration with
    specialists and other health professionals as appropriate

6.  Teach, counsel, and advise students about current health status,
    illness(es), and health-promotion and disease prevention activities

7.  Prescribe non-pharmacological therapies and pharmacological agents
    to include schedule controlled substances within the scope of
    specialty of nurse practitioner/physician assistant

Center Physician

Date

## **PERSONAL AUTHORIZATION FOR NON-HEALTH STAFF**

This authorization contains a list of suggested activities for patient
care that may be performed by Job Corps non-health staff. There should
be a copy of the personal authorization on file in the health and
wellness center for each center staff member who may be called on
regularly to assist sick or injured students. The original should be
filed in the employee\'s personnel record.

Non-health staff should refer all emergency or urgent situations to
health and wellness center personnel if readily available; if
unavailable, contact an emergency rescue team. The center physician,
with the assistance of the health staff, will be asked to indicate which
tasks can be delegated to such members of the non-health staff by
checking either the YES or NO column.

The National Office realizes the level of delegation will be determined
not only by the education, experience, and training of the staff member
in question, but also by the preferences of the physician.

This is a suggested listing. The center physician should feel free to
make additions or revisions to this list if necessary.

+---+----------------------------------------------------+------+---+------+
| # |                                                    |      |   |      |
| # |                                                    |      |   |      |
| # |                                                    |      |   |      |
|   |                                                    |      |   |      |
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| s |                                                    |      |   |      |
|   |                                                    |      |   |      |
| # |                                                    |      |   |      |
| # |                                                    |      |   |      |
| # |                                                    |      |   |      |
|   |                                                    |      |   |      |
| i |                                                    |      |   |      |
| n |                                                    |      |   |      |
|   |                                                    |      |   |      |
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| s |                                                    |      |   |      |
| e |                                                    |      |   |      |
| n |                                                    |      |   |      |
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|   |                                                    |      |   |      |
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| f |                                                    |      |   |      |
|   |                                                    |      |   |      |
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| a |                                                    |      |   |      |
| l |                                                    |      |   |      |
| t |                                                    |      |   |      |
| h |                                                    |      |   |      |
|   |                                                    |      |   |      |
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| t |                                                    |      |   |      |
| a |                                                    |      |   |      |
| f |                                                    |      |   |      |
| f |                                                    |      |   |      |
|   |                                                    |      |   |      |
| M |                                                    |      |   |      |
| e |                                                    |      |   |      |
| m |                                                    |      |   |      |
| b |                                                    |      |   |      |
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| r |                                                    |      |   |      |
+---+----------------------------------------------------+------+---+------+
| # |                                                    |      |   |      |
| # |                                                    |      |   |      |
| # |                                                    |      |   |      |
|   |                                                    |      |   |      |
|   |                                                    |      |   |      |
| # |                                                    |      |   |      |
| # |                                                    |      |   |      |
| # |                                                    |      |   |      |
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| : |                                                    |      |   |      |
|   |                                                    |      |   |      |
| # |                                                    |      |   |      |
| # |                                                    |      |   |      |
| # |                                                    |      |   |      |
|   |                                                    |      |   |      |
| T |                                                    |      |   |      |
| I |                                                    |      |   |      |
| T |                                                    |      |   |      |
| L |                                                    |      |   |      |
| E |                                                    |      |   |      |
| : |                                                    |      |   |      |
+---+----------------------------------------------------+------+---+------+
| # |                                                    | **Y  |   | **   |
| # |                                                    | ES** |   | NO** |
|   |                                                    |      |   |      |
| * |                                                    |      |   |      |
| * |                                                    |      |   |      |
| F |                                                    |      |   |      |
| U |                                                    |      |   |      |
| N |                                                    |      |   |      |
| C |                                                    |      |   |      |
| T |                                                    |      |   |      |
| I |                                                    |      |   |      |
| O |                                                    |      |   |      |
| N |                                                    |      |   |      |
| S |                                                    |      |   |      |
| * |                                                    |      |   |      |
| * |                                                    |      |   |      |
+---+----------------------------------------------------+------+---+------+
| 1 | Monitor students' use of prescription medications  | □    |   | □    |
| \ |                                                    |      |   |      |
| . |                                                    |      |   |      |
+---+----------------------------------------------------+------+---+------+
| 2 | Offer over-the-counter medications and devices     | □    |   | □    |
| \ | (e.g., Tylenol, Maalox, condoms):                  |      |   |      |
| . |                                                    |      |   |      |
+---+----------------------------------------------------+------+---+------+
| 3 | Obtain and record vital signs including:           |      |   |      |
| \ |                                                    |      |   |      |
| . |                                                    |      |   |      |
+---+----------------------------------------------------+------+---+------+
|   | a.  temperature                                    | □    |   | □    |
+---+----------------------------------------------------+------+---+------+
|   | b.  pulse                                          | □    |   | □    |
+---+----------------------------------------------------+------+---+------+
|   | c.  respiration                                    | □    |   | □    |
+---+----------------------------------------------------+------+---+------+
|   | d.  blood pressure                                 | □    |   | □    |
+---+----------------------------------------------------+------+---+------+
| 4 | Implement symptomatic management guidelines (SMG)  | □    |   | □    |
| \ |                                                    |      |   |      |
| . |                                                    |      |   |      |
+---+----------------------------------------------------+------+---+------+
| 5 | Give first aid for minor problems not addressed in | □    |   | □    |
| \ | the SMGs.                                          |      |   |      |
| . |                                                    |      |   |      |
+---+----------------------------------------------------+------+---+------+
| 6 | Give basic first aid for major problems including: | □    |   | □    |
| \ |                                                    |      |   |      |
| . |                                                    |      |   |      |
+---+----------------------------------------------------+------+---+------+
|   | a.  cardio-pulmonary resuscitation                 | □    |   | □    |
+---+----------------------------------------------------+------+---+------+
|   | b.  treatment of shock                             | □    |   | □    |
+---+----------------------------------------------------+------+---+------+
|   | c.  control of bleeding                            | □    |   | □    |
+---+----------------------------------------------------+------+---+------+
|   | d.  splinting or stabilizing of fractures          | □    |   | □    |
+---+----------------------------------------------------+------+---+------+
| 7 | Conduct alcohol testing based on suspicious        | □    | □ |      |
| \ | behavior                                           |      |   |      |
| . |                                                    |      |   |      |
+---+----------------------------------------------------+------+---+------+
| 8 | Call HWM or Officer of Day, who will contact RN or | □    | □ |      |
| \ | MD                                                 |      |   |      |
| . |                                                    |      |   |      |
+---+----------------------------------------------------+------+---+------+
| 9 | Call the RN or MD directly                         | □    | □ |      |
| \ |                                                    |      |   |      |
| . |                                                    |      |   |      |
+---+----------------------------------------------------+------+---+------+
| 1 | Send the student to the ER directly                | □    | □ |      |
| 0 |                                                    |      |   |      |
| \ |                                                    |      |   |      |
| . |                                                    |      |   |      |
+---+----------------------------------------------------+------+---+------+

Center Physician

Date

[^1]: References to physician can also include the nurse practitioner,
    physician's assistant, dentist, mental health consultant, and/or
    health services administrator (for symptomatic management guidelines
    for non-health staff), as appropriate.

[^2]: See PRH-6: 6.12, R9.

[^3]: MDD = 4 g

[^4]: MDD = 120 mg

[^5]: MDD = 1600 mg

[^6]: MDD = 1320 mg

[^7]: 1 Nurse as used here includes registered nurse and licensed
    practical nurse.

[^8]: 2 Advanced practice clinicians as used here include nurse
    practitioners and physician assistants.