ALLERGY IMMUNOTHERAPY INJECTIONS - STANDARDIZED NURSING PROCEDURES

Effective Date: 
Wed, 09/01/2010
Reviewed: 
Fri, 08/19/2011
Revised: 
Thu, 10/06/2016

This procedure provides RNs at the UCSC Student Health Center (SHC)  the standards for the administration of allergy serum injections to students.

Procedure

Patients requesting allergy injections are instructed to review the UCSC Student Health Center Allergy Clinic Information Sheet (HC#891c).

Initial allergy appointments may not be made until orders have been received from prescribing allergist. Orders must be given using the UCSC Allergy clinic order form. It is the responsibility of the student to obtain the physician orders for on-going allergy injections.

Patients are scheduled with an RN as a Nurse Appointment/Allergy Clinic for an initial visit for allergy shots.
Patient support staff instruct patient to visit the Student Health Center website and complete the Initial Allergy Visit Questionnaire on-line in preparation for their appointment.

Receiving Antigens:

  • Stamp paperwork that comes with antigens as "Received" and the date; keep paperwork with antigens or create paper chart
  • Store antigens in clinic refrigerator labeled with students name and SID or date of birth
  • Make EMR chart note entry "Received antigens"

Initial Allergy Clinic Visit:

  • Review the completed Allergy Clinic Questionnaire.
  • Students who have not had initial allergy desensitization in the allergist office are not permitted to initiate therapy here.
  • Students with a history of serious reactions to allergy immunotherapy require the RN to consult with the Medical Director prior to initiating on-going therapy under this protocol.
  • Review the physician order sheet. The orders must include:

                 Diagnosis being treated

                 Antigen, dilution, dose, schedule, and expiration dates

                 Interval between injections

                 Missed dose schedule

                 Instructions regarding reactions.

                 Any additional special instructions from the allergist; for example, peak flow prior to and                                             following  injection.

  • Any incomplete or unclear orders require RN clarification with the allergist prior to initiating therapy.
  • Review with the student the policies and procedures for Allergy Clinic using the Allergy Clinic Information Sheet, including the requirement that the student wait 30 minutes after injections.
  • Review and sign the Student Agreement for Allergy Immunotherapy HC890

Initial and Subsequent Visits:

  • Review the Initial Allergy Visit Questionnaire.
  • Determine that the student is scheduled at the appropriate interval. If the student is off schedule follow the allergist instructions. Any lack of clarity in the allergist instructions requires a phone call to the allergist office to clarify instructions.
  • Determine the student is not currently ill. This does not require that the nurse take vital signs.
  • Question the patient about delayed reactions to previous antigen injection. Determine if delayed reaction was local or systemic.
  • Delayed systemic reactions require consultation with allergist for revised orders.
  • Delayed local reactions of greater than the size of a quarter require consultation with the prescribing allergist prior to continuation of injections
  • If the patient has asthma assess current status. Active wheezing is a contraindication to allergy shots and requires clinician referral.
  • Check to see if the student has taken their prescribed allergy medications that day. If not, clarify the allergist’s orders regarding instructions for pre-medication with allergy medication for allergy shot.
  • Check antigen expiration dates.  If Antigens are expiring or anticipated to be depleted within 3 weeks, students are directed to contact the prescribing allergist to obtain new antigens.  Nursing staff will assist by faxing the most current allergy shot record to the allergist office if needed
  • Using universal precautions and following the allergist orders, give the prescribed dose of allergy serum.
  • Observe the student over a 30 minutes period for local and systemic allergy shot reactions.
  • For local reactions, provide ice. (Reaction greater than the size of a quarter requires notification of the allergist.)
  • For systemic reactions (disseminating rash, peri-orbital or peri-oral rash and swelling, dyspnea, wheeze, agitation, hypoxia or hypotension) follow the UCSC Anaphylaxis Emergency Care procedures. This procedure supersedes protocols for anaphylaxis provided with some allergy office protocols. Students experiencing systemic reactions must be evaluated by their prescribing Allergist before antigens are again administered at the UCSC SHC.  Paper chart components for students experiencing systemic reactions will be scanned same day in to the EMR.
  • Local reactions over the size of a quarter and all systemic allergy shot reactions require a call to the prescribing provider’s office for revised orders.

End of the Academic School Year

  • The Student Health Center only stores antigens for students receiving their allergy injections at the Student Health Center during the summer.
  • All other antigens must be picked up by the student at the end of each academic year to be transported to the prescribing allergist
  • Any antigens left at the end of the academic year, that will not be administered during the summer are discarded as noted in HC 891c "Allergy Injection Information" . 
  • Process:  At the end of the academic year SHC nursing staff review any antigens left at the SHC.  If the student will not be receiving the antigens at the SHC, two attempts are made to contact the student (one phone attempt and one secure message).  At the end of 1 weeks time, if there is no reply by the student the antigens are discarded in the Pharmaceutical Waste containers as per policy.  This process is documented as a non-appointment chart note in the EMR.

Experience, Training and/or Education

  • Current California RN License
  • Completion of UCSC orientation specific to Allergy Clinic

Evaluation of Competency

Initial Competency

  • Observe Allergy Clinic RN for at least 10 visits.
  • Demonstrate correct application of this procedure under direct RN supervision for at least 10 visits.
  • Submit a minimum of 10 additional chart notes demonstrating correct use of the procedure to the Clinic Director for review.

On-going Competency

  • Chart reviews of this procedure occur as part of the on-going Quality Assurance program of the UCSC Student Health Center.

Scope of Supervision

  • No direct clinician supervision required.
  • No allergy shots may be given unless a clinician is present in the building.

Criteria for Provider Consultation and Referral

  • RN is to consult with Medical Director about any student who has a history of a serious reaction to allergy immunotherapy.
  • RN is to consult with Medical Director about any student who is currently on beta blocker medications.
  • RN is to consult ordering allergist to clarify any unclear orders. This includes questions about pre-medication prior to allergy shot.
  • RN is to consult with ordering allergist to obtain new orders after any significant local or systemic reaction to an allergy shot.
  • RN consults with on-site provider about any student with a systemic or possibly systemic reaction.

Documentation

  • RN documents according to the standards delineated in the UCSC Student Health Center Policy on Documentation of Care.
  • Allergy shot records are kept on the flow sheet provided by the allergist and in the EMR.