LVN STANDING ORDERS FOR INITIATION OF TREATMENT FOR VACCINE ADVERSE REACTIONS IN ADULTS PATIENTS

Effective Date: 
Fri, 10/09/2009
Reviewed: 
Sun, 08/28/2011
Revised: 
Mon, 08/29/2011
Policy: 

Purpose: All vaccines have the potential to cause an adverse reaction.   In order to minimize adverse reactions, patients should be carefully screened for precautions and contraindications before vaccine is administered. Even with careful screening, reactions may occur. These reactions can vary from trivial and inconvenient (e.g., soreness, itching) to severe and life threatening (e.g., anaphylaxis). If reactions occur, staff should be prepared with procedures for their management.

Policy: Under these standing orders, eligible Licensed Vocational Nurses allowed by state law andwho have demonstrated competence in administration of oral and intramuscular medications, may initiate treatment of adverse reactions to immunizations.  Sign & symptoms of adverse reactions covered under this standing order include:  Sudden or gradual onset of generalized itching, erythema (redness), or urticaria (hives); angioedema (swelling of the lips,face, or throat); bronchospasm (wheezing); shortness of breath; shock; abdominal cramping; or cardiovascular collapse. 

Procedure: 

1. If itching and swelling are confined to the injection site where the vaccination was given, observe patient closely for the development of generalized symptoms & immediately notify the UCSC Student Health Center Doctor On Call (DOC).

2. If symptoms are generalized, activate the emergency medical system (EMS; e.g., call 911) and notify the UCSC Student Health Center Doctor On Call (DOC).  This should be done by a second person, while the primary nurse assesses the airway, breathing, circulation, and level of consciousness of the patient.

3. Administer aqueous epinephrine 1:1000 dilution intramuscularly, 0.01 mL/kg/dose (adult dose ranges from 0.3 mL to 0.5 mL, with maximum single dose of 0.5 mL).

4. In addition, for systemic anaphylaxis, administer diphenhydramine either orally or by intramuscular injection; the standard dose is 1–2 mg/kg, up to 100 mg maximum single dose.

5. Monitor the patient closely until EMS arrives. Perform cardiopulmonary resuscitation (CPR), if necessary, and maintain airway. Keep patient in supine position (flat on back) unless he or she is having breathing difficulty. If breathing is difficult, patient’s head may be elevated, provided blood pressure is adequate to prevent loss of consciousness. If blood pressure is low, elevate legs. Monitor blood pressure and pulse every 5 minutes.

6. If EMS has not arrived and symptoms are still present, may repeat dose of epinephrine every 10–20 minutes for up to 3 doses, depending on patient’s response and under the direction of the UCSC Student Health Center Doctor On Call (DOC).

7. Record all vital signs, medications administered to the patient, including the time, dosage, response, and the name of the medical personnel who administered the medication, and other relevant clinical information.

This policy and procedure shall remain in effect for all patients of the UCSC Student Health Center until rescinded.

Medical Director’s signature:

Electronically signed by Dr. Drew Malloy; original signed hard copies on file in the Assistant to the Executive Directors office  10/9/09