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Microsoft word - standingorders2009-20101 _2_.doc

Approved by Dr. Cohen, D.O._______________________________ Description: Following a hard blow to abdomen (by rock, fist, bicycle handlebar, etc.), an Internal organ such as the spleen or liver may be ruptured and bleed into the abdominal cavity slowly but continuously, and the patient may lose enough blood to develop signs of shock. Physical findings: 1. History of blow to abdomen 2. Symptoms may appear following the blow or as late as the next day a. Possible bruise visible b. Gradual onset of apprehension c. Pain and tenderness to mild pressure d. Abdominal distention e. Vomiting f. Rapid, weak pulse with low blood pressure g. Gradual onset on shock and coma h. Blood in urine shortly after trauma or next day 1. Keep in office for 15 minutes after blow to abdomen 2. Allow to rest in position of comfort 3. Monitor pulse and blood pressure 4. If student has none of the above symptoms, may return to class. If symptoms ensue refer 1. Check on student later in the day 2. Check on student the following day 3. Inform parents if warranted 1. Check temperature 2. Check history of nausea, vomiting, diarrhea, constipation 3. Allow student to rest 4. Inform parents if warranted 1. Denuded area of skin from scrape on sidewalk, etc. 2. Bleeding correlates with layers of skin scraped 1. Wash with soap and water 2. Remove loose skin and crusts 3. Rinse well 4. Antiseptics are not necessary but may be used 5. Lubriderm may be used for minor abrasions a. Pus on abrasion itself, usually located under crusts b. Cellulitis: spreading red area immediately around abrasion c. Lymphangitis: red streaks radiating out from abrasion d. Regional lymph nodes enlarged: If abrasion on arm, nodes will be in axilla, leg- 1. Refer for follow-up care 2. For lymphangitis, refer to MD without delay ACUTE ALLERGIC REACTIONS: Respiratory Distress 1. If difficulty breathing, keep in sitting position 2. Call EMS if distress if life threatening 3. Be prepared to give Benadryl and/or Epi-Pen Jr. if under 60 lbs or under 8 years old and 4. Inform parents 5. Refer for follow-up 6. See orders for Status Asmaticus ACUTE ASTHMA ATTACK PROTOCOL (STATUS ASMATICUS) 1. Call EMS 2. If unable to use inhaler or benefit from it, give Epi-Pen Jr. or Epi-Pen, if over 60 lbs 3. Monitor BP and pulse rate 4. Advise parents 5. Exclude from school and activities until child’s PMD adjusts medical protocol 6. May be readmitted to school with medical clearance from MD and may return to physical Activities with medical clearance from attending physician ANAPHYLAXIS Description: A rare, extremely serious form of allergy that may occur in persons not previously known to be allergic or hypersensitive. The reaction ranges from mild, self-limited symptoms to rapid death. Immediate action may be required to prevent fatality. Extreme sensitivity to one or more of the following: a. Insect sting, usually bee or wasp b. Medication or immunizations, usually by injection c. Food or pollen d. Industrial or office chemicals or their vapors (spirit duplicator liquid, carbonless a. Sudden onset – symptoms beginning within 15 minutes after exposure to inciting agent usually result in the more severe type of anaphylactic reaction b. Feeling of apprehension, sweating, weakness c. Feeling of fullness in the throat d. Respiratory difficulty; change in quality of voice – these are symptoms of laryngeal edema and may signal closure of the airway e. Tingling sensation around mouth or face, nasal congestion, itching, wheezing f. Low blood pressure with weak, rapid pulse g. Loss of consciousness, shock, coma h. May be accompanied by hives a. Give Benadryl and/or Epi-Pen Jr. if under 60 lbs or under 8 years old b. Give Benadryl and/or Epi-Pen if over 60 lbs c. Contact EMS and parents. May need second dose of Epi-Pen after 15 minutes 1. Practice universal precautions 2. Wash bite with soap and water al least twice, rinse with water 3. Apply loose dressing and elevate extremity 4. Refer to ER or MD for follow-up 5. Record date of last tetanus booster 6. Report to local authorities 7. Topical antibiotics may be applied 8. Prophylactic oral antibiotics may be prescribed, especially for bites on the hand 1. Keep student in most comfortable position 2. Administer ordered medication 3. Monitor effectiveness 4. If no ordered medication is on hand, contact parent to bring in medication if at home 5. Allow student to sip water and to do breathing exercises 6. Utilize peak flow meter to monitor improvement or extent of distress on base line peak 7. If student worsens, contact EMS and notify parents. Contact student’s primary for stat 8. If attack is post medication, contact primary for instructions; contact parents 1. If stinger is present, remove by any means that facilitate quick removal 2. Determine history of bee stings and allergic reactions 3. If allergic, see anaphylaxis under acute allergic reactions 4. Apply ice – observe for 15 minutes 5. If no history of allergic reactions and negative for symptoms, inform student to return to the nurse if swelling occurs. If wilt is more than an inch in diameter, send home and advise medical follow-up BACK AND NECK INJURY Physical findings: 1. Pain, made worse by pressure or movement 2. Pain may radiate into arm or leg 3. Nerve involvement: weakness, tingling, numbness, or inability to move arm or leg 4. See head injury 1. DO NOT move, bend or rotate neck 2. Assess student’s ability to move extremities slowly. Assess response to finger touch or 3. If sensation is intact, pain is minimal to absent and student is able to move all extremities normally, allow student to slowly sit up and then walk 4. If pain, sensory impairment or weakness persist, have student remain lying down and call 5. If all neurologic signs are normal and patient is above to move all extremities freely, ice 1. Observe later in the day 2. Exclude from gym 1. Practice universal precautions 2. If not severe, elevate injured part above heart level if possible 3. Apply sterile dressing and pressure to bleeding point up to 15 minutes. DO NOT remove blood soaked material – add addition material if needed 4. Call EMS if tourniquet is necessary. DO NOT APPLY A TOURNIQUET 5. Contact parents if severe 1. Soak under running water for at least 15 minutes 2. Apply sterile gauze over affected area 3. Remove victims clothing from areas involved 4. Inform parents 1. Rinse affected area under cold running water – ice may be applied 2. Cover with sterile, non-stick gauze pad of Second Skin Moist Gel Squares 2. Cover area with sterile, non-stick gauze pad 3. Call EMS for transportation to nearest hospital for large area burns 4. Contact parents 1. Encourage student to cough and speak 2. If student is unable to cough and speak, perform the Heimlich maneuver 3. If necessary, call EMS 4. Contact parents – recommend medical follow-up if warranted 1. Check temperature 2. If temperature if over 100 or student is unable to function in school, contact the parent to 3. If temperature is under 100, allow student to rest 1. Help student to lie on the floor – turn on side if possible 2. Protect child during seizure 3. Make no attempt to halt seizure 4. Maintain open airway. Do not put any objects into student’s mouth 5. If suspected respiratory failure, begin artificial resuscitation 6. Loosen tight clothing around neck and waist 7. Apply O2 via mask if ordered 8. Remain with student until conscious and oriented 9. Note asymmetrical movements or weakness after seizure 10. Call 911 if seizure lasts more than 3 or 5 minutes or as ordered 11. After seizure, allow student to rest 12. Contact parents 1. Must be kept in health office 2. May take in office with note from parent Parent/guardian must contact the school nurse before any child returns to school using crutches. CUTS 1. Practice universal precautions 2. If minor, wash with soap and water. Apply Bacitracin and Band-Aid 3. If cut is deep, stop bleeding with direct pressure and non-stick sterile gauze pad 4. Refer for medical attention if necessary 5. Check last tetanus immunization DIABETES The school personnel should know children with diabetes. Consideration should be given to their lunch schedule and their specific needs. 1. Hypoglycemia – blood sugar less than 70 a. Symptoms - Sudden onset, skin pale, shaky, sweaty, dizzy, weak, shallow b. If above symptoms are present, give 15 grams of fast-acting carbohydrate (4oz skim milk, 4oz juice, 4oz regular soda). Re-check blood sugar in 15 minutes. If blood sugar is less than 80, repeat treatment. If blood sugar is more than 80 give a balanced snack of carbohydrate and protein or send to lunch if lunch is within 30 minutes c. If child is unconscious, administer Glucagon if ordered, contact EMS and notify a. Symptoms – Gradual onset, skin flushed and dry, increased thirst and urination, deep respirations, rapid pulse b. Check ketones c. Encourage increase water intake d. Notify parents immediately if the above symptoms are present – if blood sugar is above 400 and ketones are negative, student can say in school. If blood sugar is above 400 and ketones are positive or student unable to void to check for ketones, student must be picked up by parent/guardian e. If the child is unconscious, call EMS and follow procedures for serious DRUG ABUSE (Suspected) 1. When a pupil is suspected to be under the influence of non-therapeutic drugs, he/she would be treated as any other medical emergency 2. If pupil is semi-conscious, treat as serious emergency 3. When a pupil is not able to function in school, notify designated school administrator 4. Contact parents to come for pupil. If indicated, refer to physician and/or testing 5. When possible, identify drug ingested or used 6. Refer to board policy on drug and alcohol use DYSMENORRHEA 1. Have student rest on cot 2. May use heating pad EARACHE 1. Check for redness, wax, foreign body with otoscope 2. Check temperature 3. Check throat 4. Notify parents, if warranted 5. Refer for medical attention if necessary BENADRYL/EPI-PEN ADMINISTRATION The school nurse may administer benadryl as per weight guidlenes for severe itching or swelling of the throat and/or tongue. The school nurse is to observe for improvement and notify parent/guardian. If no improvement, the certified school nurses or trained personnel at the Millstone Township Schools may administer Epi-Pen Jr. to students (30lbs to 60 lbs) and Epi-Pen to students over 60 lbs and adults whenever respirations of the client are impaired to the point of rapid deterioration jeopardizing life. Procedure 1. Administer Epi-Pen in soft tissue on side of leg or arm 2. Activate EMS 3. Have the individual lie down to keep the blood flowing to the brain until ambulance arrives 4. Have individual transported to ER 5. Notify parent/emergency contact EYE INJURIES Symptoms that could suggest serious eye problem include reduced vision, ocular pain and photophobia Blow to the eye 1. Observe for pain in eye, redness of conjunctiva, eye held closed 2. Do not force eye open 3. Check for visible lacerations on lids or eyeball 4. Check for fluid or blood in anterior chamber (between iris and cornea). May be accompanied by drowsiness 5. Check for diplopia 6. Check for extra-ocular movements 7. Check for unequal or irregular pupils 8. Check vision one eye at a time using Snellen Chart 9. Refer to MD if there is a laceration on lid or other visible trauma to lid or eyeball or if vision is impaired in any way 10. Patch eye prior to referral using bottom half of cut off paper cup for corneal abrasion 11. Do not patch very young children – may cause amblyopia 12. Ice packs may be used if physician referral is not necessary 13. Examine eye the following day 14. Check vision on Snellen Chart on following day and refer if not same as before the trauma Chemical - a true ocular emergency, alkali more serious than acid 1. Rinse thoroughly with tap water or saline for at least 15 minutes – DO NOT USE EYE CUP 2. DO NOT cover with eye pad 3. Inform and advise parents to have injured eye checked by the ER or PMD Foreign body 1. Attempt to remove with q-tip – from inner eyelid only 2. If puncture wound is present, DO NOT remove foreign body 3. If able to remove, rinse with tap water or normal saline 4. If unable to remove, contact parent to follow-up with PMD FAINTING (dizzy spells) 1. Let student lie on cot with head low and legs elevated 2. Loosen tight clothing 3. Place cold cloth on forehead, check for adequate pulse and ventilation FEVERS Above 100.2, send home with parent or guardian FOOD ALLERGY – see Anaphylaxis FRACTURES 1. Apply temporary splint to suspected fractured fingers, arms or leg; apply cold compress; elevate 2. If injury involves head or back, DO NOT move student – keep flat on floor 3. Call EMS if injury involves head or back for transport to nearest hospital 4. Inform and advise parents HEADACHE 1. Check temperature – if no temperature, allow to rest and apply ice, return to class 2. If student returns, notify parent if warranted HEAD INJURY A serious head injury can involve one or all the elements of your head: the scalp, skull, brain, spinal fluid and blood vessels. Head injury can be external, internal or both. Even if the skull is not fractured, the brain can bang against the inside of the skull and be damaged. If there is bleeding within the skull, complications may follow. Always suspect neck injury where there has been trauma to the head. If a child is up and running immediately after getting a bump on the head, serious head injury is highly unlikely. However, the child should be closely watched for the next 24 hours since sometimes signs and symptoms of head injury can be delayed. Signs and Symptoms 1. Obvious signs of trauma such as a dent or fracture in the skull, a wound in the scalp and bleeding 2. Severe headache 3. Severe or persistent vomiting 4. Dazed or confused behavior; lapses in alertness or consciousness – either immediately following the accident or developing later 5. Personality changes such as increased restlessness or irritability 6. Increased drowsiness (for example if the victim is sleepy at a time he/she normally is not) 7. Slurred speech 8. Stiff neck 9. Convulsions 10. Difficulty seeing; double vision; pupils of unequal size 11. Weakness in an arm or leg 12. Fluid draining from the ears, nose or mouth; bleeding from the nose or mouth that is not the result of a facial injury 13. Slowing of the rate of breathing If you suspect serious head injury, call EMS. If you suspect neck injury, DO NOT move the victim – keep him in the position found. If the victim is in urgent danger and you must move him/her immediately, follow directions on moving a victim with a suspected spinal injury. DO NOT let other more obvious injuries distract you from the head injury. DO NOT move the victim unless absolutely necessary. DO NOT shake the victim because he/she seems dazed. DO NOT pick up a fallen child with any sign of head injury. DO NOT remove any object sticking in a wound. Management 1. Check the victim’s ABC’s. Open the airway, check breathing and circulation. If necessary, begin rescue breathing, CPR or bleeding control. If the ABC’ are present but the victim is unconscious, care for the victim as if there is a spinal injury. Stabilize the head and neck by placing your hands on both sides of the victim’s head, keeping the head in line with the spine and preventing movement – wait for medical help 2. If the victim is conscious, keep him/her calm. Encourage the victim to lie still and not to attempt to get up. Protect the victim’s neck from activity, motion and harmful objects. Be aware that blows to the head can leave a victim disoriented, confused or combative. If the victim cannot remember all that has happened, he/she was probably briefly unconscious. Inform EMS or PMD 3. Give first aid for any obvious head injuries. If you suspect that the skull may be fractured, DO NOT apply direct pressure to the bleeding site and DO NOT remove any debris from the wound. Cover wound with sterile gauze and get help immediately. For superficial wounds, use a clean bandage and apply direct pressure. Continuous pressure will almost always stop bleeding 4. If the victim starts having seizures, protect the head by placing cushions around it - remove any harmful objects 5. Vomiting is common with head injuries – take steps to protect the airway. Children often vomit once after a head injury 6. Apply ice to areas of swelling 7. Get medical help if the victim shows any of the signs and symptoms. Refer parents to ER or PMD for follow-up HIVES Generalized of unknown origin 1. Call parent for input 2. Allow child to remain in school if comfortable 3. Observe for other signs and symptoms of allergic reaction HUMAN BITES – Broken Skin 1. Highly susceptible to infection 2. Wash copiously 3. Contact parent with date of late tetanus shot 4. Tetanus booster is not necessary is last shot was within 5 years except in unusual circumstances 5. Inform parent to follow-up with PMD regarding potential transmission of blood borne pathogens JAMMED FINGERS 1. 50% of finger tip injuries have an associated chip fracture of the bone or a torn ligament 2. If any significant disability exists, apply ice pacts and refer to PMD 3. May tape 2 fingers for comfort but finger should be moved no later than next day if no no torn ligament or chip fracture is diagnosed MANTOUX TEST (PPD) The school nurses at Millstone Township may administer the intradermal PPD test (Mantoux) to all faculty, staff, volunteers and students requiring such a test as determined by state mandates. Testing will involve the exclusive use of the Mantoux intradermal test with 5+U stabilized PPD tuberculin and each test will be recorded and maintained by the Millstone Township schools. A permission slip signed by the individual to be tested or parent/guardian of student must be received prior to testing. MEDICATION REACTION 1. If child presents with hives after being in medication, contact the parent to follow-up with PMD 2. Contact PMD if warranted 3. See anaphylaxis for serious reaction
1. Practice universal precautions
2. Let student sit on chair with head tilted forward slightly
3. Apply pressure with thumb and forefinger to non-bony (cartilage) of nose
4. Refer student for definitive care (packing, cauterization) if warranted
1. Apply external pressure and ice to bridge of nose, back of neck
2. Apply gauze under upper lip
3. Refer student for definitive care if warranted

1. Notify parent
2. Child cannot ride the bus to school, must be brought in by parent/guardian
3. Check child upon return to school – must be nit free to remain in school
4. Check child after 2nd treatment in approximately two weeks
5. Child must be nit free after 2nd treatment
1. For minor punctures such as pins or paperclips, clean with soap and water
2. For nail or other sharp object, soak in warm water for 20-30 minutes, apply loose fitting
dressing and advise parent to consult PMD for follow-up
3. For pencil puncture clean and treat as minor wound – tip of pencil rarely in wound and
Unless actual pencil tip is seen, DO NOT attempt to remove
1. If associated with internal disease such as rubeola, rubella, chicken pox, scarlet fever or
impetigo, child is excluded
2. Allergic rashes like hives and eczema and not contagious and the student may remain in
3. Poison ivy and oak – student may remain in school but may be excluded from gym to
avoid sweating – calamine lotion may be applied
SORE THROAT 1. Check throat for patches, enlarged or infected tonsils 2. Check temperature 3. Gargle with salt water 4. Contact parents if warranted SPLINTERS 1. Washed affected area – apply ice for 5 minutes if sore 2. Remove only minor superficial splinters 3. Use tweezers 4. DO NOT remove deep splinters – cover with a band aid and notify parent STRAINS AND SPRAINS OF ANKLE OR KNEE 1. Observe for history of trauma, twist or snap 2. Observe for history of previous injury to same joint 3. Observe for pain 4. Swelling or redness may or may not be present 5. Ice for 20 minutes, elevate and apply ace if warranted 6. Refer to PMD is severe pain or if limp continues after first day 7. Notify parent if warranted SWALLOWED OBJECTS 1. DO NOT slap on back 2. Assess breathing, encourage coughing 3. Follow procedure for Heimlich maneuver STAPLES 1. Remove staple and clean area well 2. Inform parent of last tetanus shot TICK REMOVAL 1. Grasp the tick as close to the skin as possible and pull upward with steady, even pressure – DO NOT twist or jerk the tick as this may cause the mouth parts to break off and remain in the skin along with the cement collar 2. DO NOT squeeze, crush or puncture the body of the tick as its fluids may contain infectious agents 3. DO NOT handle the tick with bare hands as infectious agents may enter via mucous membranes or breaks in the skin 4. After removing the tick, thoroughly disinfect the bite site and wash hands with soap and water 5. DO NOT use petroleum jelly, fingernail polish, isopropyl alcohol or a hot match to make a tick back out – these methods do not work and allow the tick to remain imbedded until it is forcibly removed 6. Ticks can be safely disposed of by placing them in a container of alcohol or flushing them down the toilet. Parent may send tick dead or alive to a private lab for evaluation 7. Inform parents TOOTHACHE 1. Check mouth for source of pain 2. Inform and advise parents to seek dental care 3. Ice on outside 4. Warm water rinse TOOTH – AVULSED 1. Place in tooth preservation kit/milk or saliva 2. Seek immediate dental attention TYLENOL The school nurse, on the 6th grade Camp Fairview class trip, may administer acetaminophen 650mg or wt/age appropriate dose for a temperature of 100 degrees or above if the student’s parent or guardian has signed the permission slip. The school nurse, on the 7th grade class trip, may administer acetaminophen 650mg or wt/age appropriate dose for a temperature of 100 degrees or above if the student’s parent or guardian has signed the permission slip. The school nurse may administer Tylenol 650mg for a temperature of 100 degrees or above to the eighth grade students, while on the class trip, if the student’s parent or guardian has signed a permission slip. MEDICATION/INTEVENTIONS APPROVED BY THE SCHOOL PHYSICIAN The school physician has given permission to use any of the following creams, lotions, applications, washes, etc., as seen appropriate by the school nurse. Such use shall be in conformance with the manufacturer’s recommended guidelines. STANDING PROCEDURES FOR SECRETARIES, AIDES AND TEACHERS UPDATES 11/92, 12/94, 4/95, 1/96, 1/97, 6/05 BASED ON UNIVERSAL PRECAUTIONS, GLOVES SHOULD BE WORN AS WELL AS OTHER PROTECTIVE EQUIPMENT WHEN COMING INTO CONTACT WITH BODY FLUIDS ANIMAL BITES 1. Put on gloves 2. Wash area with soap and water at least twice; rinse with peroxide; cover with sterile dressing 3. Remove gloves and wash hands 4. Inform parent/guardian 5. Inform the nurse BUMPS, BRUISES, BURNS FOR MINOR BUMPS AND BRUISES: APPLY ICE AND CONTACT THE NURSE. NOTIFY PARENT/GUARDIAN For Burns: 1. Put on gloves 2. Rinse with cool water, cover with sterile dressing 3. Remove gloves and wash hands 4. Notify the nurse, notify parent/guardian BEE STINGS 1. Remove stinger if able – speed is more important than technique 2. Apply ice 3. Check for history of allergy. If allergic, student should use his Epi-Pen. Follow-up with ER, call 911 4. Contact the nurse 5. Inform parent/guardian COLDS, COUGHS, NOT FEELING WELL 1. Check temperature 2. Notify parent/guardian CONVULSIONS 1. DO NOT move student 2. Prevent student from injuring self by clearing the area of sharp or hard objects 3. Call the nurse, notify parent/guardian CUTS AND ABRASIONS MINOR 1. Put on gloves 2. Wash with soap and water and apply Band-Aid 3. Remove gloves and wash hands 4. Inform nurse DEEP 1. Put on gloves 2. Stop bleeding by applying direct pressure 3. Call nurse, notify parent/guardian 4. Remove gloves and properly dispose of waste 5. Wash hands FRACTURE – POSSIBLE: INJURY MAY BE VERY PAINFUL. DO NOT MOVE STUDENT IF BACK, NECK OR LOWER PORTION OF BODY IS INVOLVED. CALL NURSE FROST BITE 1. Place affected part in lukewarm water, gradually making water cold 2. Call nurse, notify parent/guardian HEADACHE MINOR 1. Check temperature 2. May rest 15 to 20 minutes 3. If better and temperature is below 100, may return to class SEVERE 1. Check temperature 2. Notify nurse, call parent/guardian HEAD INJURY – CALL NURSE FOR ALL HEAD INJURIES HUMAN BITES 1. Call nurse for all human bites 2. Put on gloves and wash area well 3. Inform parent/guardian EYE – CALL NURSE FOR ALL EYE PROBLEMS. FOR CHEMICALS IN THE EYE: 1. Put student’s head back and pour cups of water to thoroughly rinse eye from inner corner to outer for 15 minutes 2. Inform parent/guardian FOREIGN BODIES – DO NOT ATTEMPT TO REMOVE – CALL NURSE LIP BLEEDING 1. Put on gloves 2. Apply pressure to stop the bleeding 3. Contact the nurse MEDICATIONS – NON-EMERGENCY 1. Doctor’s order is required to give all medications 2. Only the nurse or the parent/guardian may give medications MEDICATIONS – SELF-ADMINISTERED 1. Must have all necessary paperwork completed 2. Must report use to the nurse 3. Must keep spare in nurse’s office NOSEBLEEDS 1. Mild – have student apply pressure to nostrils, sitting in chair with head slightly forward 2. Severe – call nurse. In addition to above treatment, apply ice to back of neck and gauze under lip. Always wear gloves and wash hands after removing gloves. Notify parent/guardian PENCIL PUNCTURES 1. Soak in warm water and soap 2. Call nurse 3. Tetanus shot is recommended every ten years; every five years for puncture wounds if dirt is present under skin 4. Contact parent/guardian RASH 1. Undiagnosed – call nurse 2. Poison ivy – calamine lotion may be applied by the nurse STAPLE WOUNDS AND SPLINTERS 1. Soak in warm, soapy water 2. Call nurse to determine if splinter can be removed 3. Advise parent/guardian of last tetanus shot for staple wounds SWALLOWED OBJECTS – CALL NURSE. CALL PARENT TO FOLLOW-UP WITH PRIMARY PHYSICIAN TEETH 1. Injury – call nurse 2. Loose tooth out – give holder for tooth; rinse mouth; use gauze packing if bleeding. Wash Hands 3. Always put gloves on before coming in contact with body fluids UPSET STOMACH OR VOMITING 1. Call nurse to determine if exclusion is warranted 2. Wear gloves when coming into contact with body fluids 3. Wash hands after removing gloves 4. Check temperature 5. Inform parent/guardian DISTRICT NURSES WILL PROVIDE INSERVICES TO STAFF AS NEEDED

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