Download Protocols

General Instructions
Please note:
The guidelines presented are intentionally brief and do not detail those services and skills
considered as part of a nurse’s armamentarium.
General Instructions
1. Record first aid treatment and disposition of every accident/illness/injury on health room
card. When signing card, use first initial and last name. If a student nurse, use their
name/your name.
2. Reassure and explain the necessary treatment to the student.
3. Report all injuries requiring further medical care to parent/guardian. Complete accident
report or medical referral form is necessary.
4. Report all injuries to the principal involving school property, school personnel or another
student. Complete accident report if necessary.
5. No ill student is sent home without supervision and notification of parent or emergency
contact.
6. Do not apply ice packs directly to skin – cover ice pack with paper towels or other
appropriate wraps to prevent tissue damage.
PR 1
Guide for Sending a Student to the Health Room
1. The primary purpose of our health room is to provide facilities to accomplish the health
services mandated by state and local regulations. In addition it is used to provide
emergency service for any injuries or sudden illness.
2. All students must have a Health Room Pass when sent to the nurse from the teacher in
charge. HEALTH ROOM PASSES SHOULD NOT BE ISSUED AT THE END OF
A CLASS, EXCEPT IN THE CASE OF AN EMERGENCY.
3. Our school nurse may never administer medication of any sort except as prescribed by a
physician, in writing, and may never exceed the administration of first aid except as
outlined in the School District of the City of Allentown’s School Health Services Manual.
4. The Health Room serves students with (but not limited to):
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
Severe pain
Bleeding
Possible fracture, dislocation – occurring in school or enroute to school
Swelling, contusion, bruise, possible sprain – occurring in school or enroute to
school.
Recognizable illness – rashes
Illness that demands that the student be sent or taken home
Cramps
Burns occurring in school or enroute to school
Bites, stings – occurring in school or enroute to school
Severe toothache
Backaches that are so severe the student should be sent home
5. One period during the class day will be designated as preparation time for the nurse.
During this time she will conduct confidential matters such as phone calls, designated
student assessments, etc. Health room personnel will be available for emergencies only
such as serious accidents, epileptic seizures or diabetic difficulties. Please do not refer
students at this time to the health room unless it is an emergency. Also, please note that
variations from the schedule may be required as emergencies may arise. If this does
occur, the nurse will reschedule her preparation time.
PR 2
Abdomen – Blunt Injury
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 by
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.
b.
c.
d.
e.
f.
g.
h.
Possible bruise visible
Gradual onset of apprehension
Pain and tenderness to mild pressure
Abdominal distention
Vomiting
Rapid, weak pulse with low blood pressure
Gradual onset of shock and coma
Blood in urine shortly after trauma or next day
Management
1.
2.
3.
4.
Keep in health room for 15 minutes after blow to abdomen
Allow to rest in position of comfort
Monitor pulse and blood pressure
If student has none of the above symptoms, may return to class. Tell student to return if
symptoms occur
5. If any symptoms ensue, refer to emergency room or physician
Follow-up
1. Advise student to return if symptoms occur
2. Notify parent
PR 3
Abrasions
Physical Findings
1. Denuded area of skin resulting from a scrape on a rough surface, e.g., sidewalk, asphalt,
or gravel
2. Amount of bleeding greater when deeper layers of skin are scraped off
3. Most often seen on knees, elbows, hands, and face
Management
1. Wash gently with soap and water
2. During wash, try to remove loose skin tags and crusts by gently rubbing with 4x4 gauze
pads
3. Rinse with COPIOUS amounts of water to remove foreign material. If feasible, allow
running stream of lukewarm water to pour over wound
4. Apply antibiotic ointment – if not allergic
5. Cover with gauze applied loosely so air can enter
Follow-up
1. Repeat above processes if necessary to keep wound clean. This should be done at home
by parents/guardians, but school nurse may need to monitor
2. Notify parent as necessary
3. Refer to physician as necessary
Complications
1. Infection:
a.
b.
c.
d.
Pus on abrasion itself, usually located under crusts
Cellulitis: spreading red area immediately around the abrasion
Lymphangitis: red streaks radiating out from abrasion
Regional lymph nodes enlarged: if abrasion on arm, nodes will be in axilla
(armpit); if on leg, nodes will be in groin
2. Scarring:
a. Minor abrasions: scar very superficial, usually regains pigmentation and blends
with surrounding skin
b. Deep abrasions: scar usually deeper and permanent. May require later
management for cosmetic reasons
PR 4
Acne
Physical Findings
1. Mild: increased number of blackheads and whiteheads, small red pimples and pustules on
face, chest, and/or back
2. Severe: larger pimples, cysts, and abscesses that often result in scarring. Synonyms: acne
vulgaris, acne conglobata
3. More common in boys coincident with rise in blood levels of male hormone
(testosterone).
Behavioral Findings
Withdrawing, school phobia, defensiveness, or depression may be present.
Management
1. Dietary: at the present time there is no good evidence to suggest that any food, even
chocolate, makes acne worse. If parents or doctor prohibit certain foods, schools should
make an effort to reinforce those wishes. If a certain food is thought to make acne worse,
student should avoid it.
2. Facial applications: liquids, special soaps, topical prescription antibiotics, an drying
lotions are commonly used. Warn against any containing mercury. Common over-thecounter medicines for mild acne are Fostex cream and shampoo, 5% benzyl peroxide,
vanoxide, Komed, and many others.
3. Internal medications: various prescription antibiotics and vitamin A derivatives (Retin-A)
for severe acne by prescription only.
4. Avoid oily or greasy hair or facial preparations. Use water-based preparations.
5. Warn against us of tretinoin during pregnancy. It is known to cause birth defects if taken
internally.
6. Counseling:
a. Should suggest periodic visits to skin clinics at the Lehigh Valley Hospital, 17th
and Chew Streets for severe cases; check on compliance with treatment and offer
support.
b. Stress that there is no magic, quick cure; it is a long-term condition that may
require care until student’s early 20’s.
c. Encourage attendance at usual school affairs, be alert for signs of withdrawal or
depression, and point out how may peers have the same problem.
d. Keep supply of reliable pamphlets in health room; they are available from many
dermatologists’ offices.
PR 5
Anaphylaxis
Definition
A rare, extremely serious form of allergic reaction. Onset is rapid, may have no previous
symptoms, and requires instant action to prevent fatality.
Causes
Extreme sensitivity to one or more of the following:
1. Sudden onset
2. Felling of apprehension, swelling and weakness
3. Shallow respirations
4. Tingling sensation around mouth or face, nasal congestion, itching wheezing
5. Low blood pressure with weak, rapid pulse
6. Loss of consciousness, shock, coma
7. May be accompanied by hives and/or laryngeal edema
Laryngospasm (closing of air passage from swelling) can occur as part of anaphylaxis or by
itself. It requires the same management as anaphylaxis and, in addition, requires establishment of
an airway.
Management
1. Immediate injection of Epi-pen as directed. Other school personnel, e.g. Health Room
Assistant, in the absence of the school nurse may administer the Epi-pen per standing
orders. Each school nurse should keep an Epi-pen in a designated place.
2. Immediate call to 911.
3. If reaction is known to follow an insect sting, see protocol “Sting”.
4. Monitor blood pressure.
5. Elevate legs if blood pressure is low.
6. Cover with blankets if necessary to keep warm but do not allow blankets to interfere with
handling or observation.
7. If student stops breathing begin CPR.
8. Refer all cases to physician
Follow-up
1. Counsel against further exposure to sensitizing agent.
2. Recommend desensitization procedure by physician
3. Suggest students keep “Bee Sting Kit” containing adrenalin near at hand.
PR 6
Anemia
Iron Deficiency
Physical Characteristics
1. Usually none except in moderate to severe cases (children with hemoglobin levels over 78 grams are usually asymptomatic).
2. Pallor, best seen inside lower eyelid and nail beds (diagnostic hint: compare to a normal
child or adult).
3. In moderate to severe cases: fatigue, irritability, poor appetite, short attention span,
learning difficulties, frequent minor illnesses.
Management
1. Refer to physician for confirmation of anemia
2. Encourage student to eat iron-containing foods: meat, fish, poultry, soybeans, and ironenriched foods.
3. Iron supplement tablets prescribed by physician.
Follow-up
1. Monitor for side effects of iron therapy:
a. It should not be necessary to give any doses at school. However, if given at
school, since iron tablets are toxic if overdose; keep in locked cabinet.
b. Iron supplements may cause upset stomach, dark stools or constipation.
PR 7
Anorexia Nervosa
Physical Characteristics
1.
2.
3.
4.
5.
6.
7.
Extreme thinness (loss of at least 25% of normal weight)
Refusal to eat
Usually, cessation of menstruation
Often associated with bulimia (binges of over-eating followed by vomiting)
Ninety-five per cent of cases are girls between 12-18
Excessive exercising
Denial of any problems, frequently antagonistic
Management
1. Initial diagnosis most important
a. Often not suspected at home because student not seen unclothed
b. May be suspected during height/weight screening
2. Refer to counseling
3. Establish liaison with parents and physician
Follow-up
1.
2.
3.
4.
Provide safe haven in health room where the student can freely discuss problems
Weight at regular intervals
Recurrence is common
Significantly mortality: exert maximum efforts to encourage resumption of normal diet
PR 8
Appendicitis
Physical Characteristics
1. Fever – usually low, between 99 and 102
2. Location of pain – begins in pit of stomach or navel and progresses to right lower
quadrant
3. Severity of pain – mild at first but always increases in severity
4. Tenderness to pressure – usually present
5. Facial expression – child looks uncomfortable, worried and apprehensive
6. Position of comfort – child prefers to lie down, usually on left side with right leg drawn
up
7. Age differences – all findings progress more rapidly in younger children
8. Vomiting – usually present
9. Diarrhea – almost never present
10. Constipation – almost always present
Management
1. If child has symptoms 1-5 of above characteristics of first evaluation, notify
parent/guardian immediately
2. Pain, low grade fever, and tenderness to pressure are the most consistent finds – if
present, keep child in health room, observe for 15 to 30 minutes
3. If symptoms persist, request parent/guardian to take child to physician
4. If parent/guardian or relative is not available, observe another 30 minutes. If symptoms
persist or get worse, sent to hospital via EMS
5. Do not give any medication unless in its prescribed by the physician for a child with a
chronic illness
Follow-up
1. See in health room at least once postoperatively and again only if necessary
2. Observe for wound infection or stitch abscesses
3. Follow physician’s orders for athletic or physical education participation
PR 9
Asphyxiation
Definition
Inability to breathe due to choking, inhalation of toxic fumes, drowning, or strangulation
Physical Findings
1.
2.
3.
4.
Student conscious and making attempts to breathe
Complete or near-complete inability to speak
Grasping of neck, usually with both hands, palms toward neck
Rapid onset of cyanosis (blueness of lips and finger tips), cessation of breathing efforts,
and loss of consciousness
Management
1. Have another person call 911
2. If student able to cough, speak, or breathe, no immediate intervention is necessary –
observe only. If student’s own efforts cease, proceed to step 3
3. If student is unable to cough, speak, or breathe:
a. If a solid object is in the throat, administer abdominal thrusts
b. If no pulse, begin CPR
Follow-up
1. Notify parent/guardian and physician referral if necessary
2. Frequent observation that day, if student remains in school
3. Variable depending on cause and severity
PR 10
Asthma
Definition
An allergic condition which causes edema, narrowing of bronchial tubes, and excess secretion.
This reaction is caused by: a response to a foreign substance (pollen, dust), virus or bacteria,
physical factors (cold, sunlight), increased physical activity, or other agents to which the student
is allergic.
History
1. Diagnosis is usually made before child starts school, but onset can be at any age
2. History of allergies in family, frequent coughing episodes, and frequent colds
Physical Findings
1.
2.
3.
4.
5.
6.
7.
8.
Rapid or sudden onset
Respiratory difficulty, with cough and/or wheeze
Prolonged expiration
High-pitched whistling wheezes heard with stethoscope on chest or by holding ear close
to patient’s mouth
Pulse rate over 150 suggests severe asthma or excess medication
No fever in typical cases
Student breathes easier sitting up
Symptoms may be initiated or made worse by exercise
Prevention
1. Avoidance of dust, molds, animals, pollens, foods, medicines, and other allergic
substances
2. Desensitization shorts by physician
3. Preventive medications in severe cases
4. Identified students who have had life-threatening attacks should have emergency
treatment and evacuation plans developed (504)
Management
1. A student suffering from an asthma attack can usually breathe more easily if he/she is in a
sitting position or leaning slightly forward with hands braced on knees. He/she should be
made as comfortable as possible and supported, where possible, in the position that gives
him/her the greatest ease of breathing
2. Reassure the student and allay his/her fears
3. Determine if he/she has his/her own medication. If there is Authorization for Medication,
administer medication as directed
4. If attack is short, he/she may return to class after rest. Notify parent/guardian. If attack is
prolonged and severe, notify parent/guardian immediately, and call 911
PR 11
5. If student begins to hyperventilate, have him/her breathe into a paper bag or their hands if
a bag is not available
6. See administration of oxygen policy
7. Limitation of exercise
a. Some students will need a graded or adapted PE program. Parents/guardians
should understand the benefits of a graded exercise program
b. Prevent over-protection as well as over-exertion
c. Maintain liaison with PE teacher
PR 12
Attention-Deficit Hyperactivity Disorder
Diagnostic Criteria
Behavior is more frequent than others of the same mental age. Onset is usually before the age of
seven. Disturbance of at least six months duration, with at least eight of the following symptoms:
1. Fidgets and squirms
9. Can’t play quietly
2. Can’t remain seated
10. Talks excessively
3. Can’t wait for turn in games,
etc.
11. Interrupts conversation
12. Doesn’t seem to listen
4. Easily distracted
13. Loses things like pencils,
assignments
5. Blurts out answers before
question is finished
14. Engages in dangerous activities
without considering the consequences
(not thrill seeking) like running in
street without looking
6. Difficulty following instruction,
fails to finish
7. Can’t sustain attention
8. Shifts from one uncompleted
activity to another
Management
1. Educational: special class placement, teacher instruction, and modification of lesson
plans. Many strategies available in educational manuals.
2. Psychological/behavioral: counseling, both group, individual and family, behavior
modification techniques.
3. Medication: stimulants, such as Ritalin, are used, as well as other psychotropic
medications; as directed by physician.
Medication Reminder
1. Dose for each child must be individualized by physician
2. All have side effects and must be monitored closely, especially early in therapy
3. Do not try to talk parent or student into taking medication
*May not require medication
PR 13
Prognosis
1. Guarded: over 50% of ADHD children develop more serious adolescent and/or young
adult psychiatric problems
2. Better prognosis associated with 44 or higher IQ scores, stable home situation, no
symptoms of aggression or anti-social behavior
Role of the Nurse
1. Independent, objective observation in classroom, playground and cafeteria
2. Help physician receive input from school: behavioral observations; medical conduit for
rating instruments such as the Conner’s Scale
3. Administer and/or monitor medication
4. Observe for adverse side effects of medication, or if dose seems to need adjustment,
inform parent/guardian and physician
PR 14
Blunt Injury to Chest
History
1. Accident
2. Sports injury
3. Child abuse
Types of Injury
1. Rib fracture or contusion. Chest wall is thin and compliant in younger children so heart or
lungs can be injured without rib fracture
2. Pneumothorax (air in chest) or hemothorax (blood in chest)
3. Bruised or lacerated lung
4. Cardiac tamponade (blood in space around heart causing compression of heart)
Physical Findings
1.
2.
3.
4.
5.
6.
7.
Symptoms such as pneumothorax can develop slowly, even over 1 or 2 days
Rapid, shallow respirations
Painful breathing
Distended neck veins
Cyanosis
Muffled heart sounds
Low blood pressure
Management
1. Following chest injury of unusual severity, have student rest in health room for 15 to 20
minutes
2. Do not use elastic bandage to wrap chest
3. If no pain or other symptoms, allow to return to class. Notify parent/guardian of episode
4. If any symptoms persist, refer to physician
PR 15
Bites
Dog Bites
1.
2.
3.
4.
5.
6.
Wash with copious amounts of soap and water
Apply loose dressing and elevate extremity
Refer to Emergency room or physician
Record date of last Tetanus booster
Report to Health Bureau
Prophylactic oral antibiotics may be prescribed, especially for bites on the hand
Human Bites
1.
2.
3.
4.
Highly susceptible to infection
Wash copiously
Refer to physician with date of last Tetanus booster, if skin is broken
Transmission of Hepatitis B, syphilis, and other diseases must be considered
Insect Bites
1.
2.
3.
4.
5.
6.
See “Anaphylaxis” if necessary
See “Bee Sting” below if necessary
Apply ice and Sting-Kill
Inquire about type of insect bite
Contact parent/guardian and check for allergy or sensitivity
If necessary, advise medical care
Bee Stings
1.
2.
3.
4.
5.
Remove stinger, if present, by scraping. Do not pull out
Apply Sting-Kill and cold pack to alleviate swelling
Contact parent/guardian and check for allergy or sensitivity
Administer Epi-Pen, if ordered
If any of the following symptoms develop, treat as an emergency:
a. Sudden swelling of surrounding tissues
b. Swelling of throat
c. Difficulty breathing
d. Hoarseness or thickened speech
e. Weakness
f. Blue coloration of skin
g. Disorientation/dizziness
h. nausea/vomiting/abdominal cramps
i. Multiple hives
j. Feeling of impending doom
k. Red streaking following vein
PR 16
Snake or Spider Bites
1. Symptoms: extremely painful, rapid swelling, profuse sweating, nausea, shortness of
breath
2. Immobilize the arm or leg in lowered position, keeping the involved area below the level
of the victim’s heart
3. Apply cold pack to site
4. Notify parent/guardian and physician for referral
Tick Bites
1.
2.
3.
4.
5.
Remove tick carefully with tweezers, with steady firm pressure applied upward
Cleanse area with soap and water
Notify parents that a tick was removed at school, discuss with parent disposition of tick
Ticks should be identified as to: 1. Genus and species, 2. Life stage, 3. Engorgement level
If parent/nurse sends a live or dead tick (by putting a few drops of rubbing alcohol in a
double Ziploc bag), and send, along with a contact name, address and phone number and
date removed (if possible) to:
Monroe County Vector Control
c/o Jacklyn Akim
38 N. 7th Street
Stroudsburg, PA 18360
717-420-3525
Free of charge. They will tell you answers to above identification. If the tick is the “right”
genus, species, life stage, to have possible harbored spirochete for Lyme disease. They
will recommend patient see physician who should start patient on antibiotic
prophylactically because if physician waits for serologic testing results (it takes 6-8
weeks until the body has an antibody response), this may be too late to start treatment.
6. Apparently ticks do not need oxygen enough to what they are covered with. Also,
when they bite, they inject some cement around their mouth parts which make it hard to
get them out whole. The separated mouth cannot be left in, since it will often cause n
itchy nodule and become infected. Even the cement sometimes causes this reaction and
needs to be excised with a needle.
7. Refer to “Lyme Disease” for further care.
PR 17
Back and Neck Injury
Physical Findings
1. Pain, made worse by pressure or movement (do not move)
2. Pain may radiate into arm or leg
3. Nerve involvement: weakness, tingling, numbness, or inability to move arm or leg
Management
1. Do not move, bend or rotate neck of student
2. Assess student’s ability to move extremities slowly, and only a small amount. Test
response to stimuli, such as a finger touch, check pupils.
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 if weakness persist, have student remain lying down. call
911 for additional evaluation
5. If all neurological signs are normal and student is able to move all extremities freely, ice
may be applied to relieve pain
Follow-up
1. Students with minor injuries who remain in school should be observed several times
during the school day
2. Notify parent/guardian as necessary
3. Notify PE teacher if necessary
PR 18
Blisters
Physical Findings
1. Fluid filled vesicle on skin surface secondary to friction
2. Redness of surrounding skin
Management
1. If blister is not ruptured, do not open
2. Cover site loosely with band-aid or dressing
3. Blisters from burns – refer to “Burns”
Follow-up
1. Observe for signs of infection
PR 19
Boils
Physical Findings
1.
2.
3.
4.
Skin abscess originating under the skin in a sweat gland
Pain, swelling and redness
Gets to be about the size of a marble (1-2cm)
Redness progresses to yellowish center of pus
Management
1.
2.
3.
4.
5.
Do not treat
Apply sterile dressing if three is profuse drainage
Do not open with needle or knife or other instrument
Do not squeeze hare to express “core” or “head” as most boils do not have one
Advise parent/guardian to seek medical treatment
Follow-up
1. Watch for cellulites or lymphangitis
2. Refer to physician if abscess does not continue to heal daily
3. Students with recurrent cases may harbor staphylococcus aureus in nose. Refer to
physician for culture
PR 20
Burns
Physical Findings
First Degree
1. Begins with pain and redness as in minimal sunburn
2. Later, slight to no peeling of skin
Second Degree
1. Begins with pain, redness, and blisters as in moderate to severe sunburn
2. Later, skin peels in large pieces, scarring only if secondary infection ensues
Third Degree
1. Begins with little or no pain, with red, black, or white discoloration. Some unbroken
blisters may be present
2. Heals with moderate to severe scarring
Management
First Degree
1. Immerse the burned area in cool water or apply cool compress for 15 minutes
2. Do not apply ice
3. Apply sterile dressing if needed
4. Do not apply ointments or creams
Second Degree
1. Immerse part in cool water or apply cool compress until pain subsides
2. Treat for shock if necessary
3. Apply sterile dressing
4. Contact parent for immediate medical care
Third Degree
1.
2.
3.
4.
5.
Call 911
Remove clothing only where it is easy to do so
Lay patient flat
Do not use ice
Apply cool wet compress, but to no more than ¼ of body at a time to avoid cooling
patient too much
6. Keep patient warm
7. Notify parent/guardian
Types of Burns
Electrical
1. Disconnect poser source or separate from current using non-metal object
PR 21
2. Check vital signs
3. Call 911
4. Notify parent/guardian
Chemical
1. Consult with Poison Control Center 1-800-222-1222
2. Have product label information ready
3. Notify parent/guardian
Inhalation
1. If hot smoke or chemical fumes are inhaled, the lining of the patient’s lungs may be
burned, even if there are no visible signs
2. Call Poison Control Center and/or 911
Special Instructions
1.
2.
3.
4.
Facial burns – refer to physician in all cases
Chemical or electrical burns – refer to all cases
Send date of last tetanus booster with all physician referrals
Be alert to possible child abuse
Follow-up
1.
2.
3.
4.
Dressing changes as physician directs
Observe for secondary infection
Refer to physician if area enlarges or if no improvement
Observe for scarring, especially on flexor areas of arms, legs and neck
PR 22
Common Cold Versus Allergic Rhinitis
Physical Findings
1.
2.
3.
4.
5.
6.
Allergy
Nasal discharge remains watery
More sneezing
Little or no cough
Comes and goes during entire season
Eyes usually red
Fewer lymph nodes in neck
1.
2.
3.
4.
5.
6.
Remember
Cold
Nasal discharge gradually thickens
and crusts
Less sneezing
Cough starts dry and becomes loose.
Worse with exertion
Duration 1-3 weeks
Eyes usually not red
More neck nodes
Students with allergic rhinitis may also “catch
cold”
Management
1.
2.
3.
4.
5.
Exclude from school if student has fever greater than 100° F. or severe cough
Educate about picking and blowing nose
Encourage high fluid intake
If slight sore throat, may gargle with mouthwash or warm salt water
Do not use aspirin under age 18
Follow-up
1. Refer to physician for complications: earache, fever, vomiting, headache, loss of appetite,
sore throat
2. See in health room as necessary
Fever
Is It a Cold Or The Flu
Cold
Rare
Headache
General aches and pains
Fatigue and weakness
Prostration
Running, stuffy nose
Sneezing
Sore Throat
Chest discomfort, cough
Rare
Slight
Quite mild
Never
Common
Usual
Common
Mild to moderate
Symptoms
PR 23
Flu
High (102-104°F.)
Sudden onset 2-4 days
Prominent
Usual; often quite severe
Extreme: can last 2-3 weeks
Early and prominent
Sometimes
Sometimes
Sometimes
Common; can become
severe
Contact Lenses
Types
1. Hard, remove each night
a. Traditional: non-permeable
b. Newer: gas (oxygen) permeable. Can be worn longer each day without discomfort
2. Soft, remove each night. When wet, they are soft and supple; when dry, they are rigid and
fragile. They must be kept moist.
3. Soft, extended wear. Especially designed to be worn for one week to three months
Cleaning
Regardless of which type lens is used, cleaning and disinfecting the lenses are important. This is
done first with a salt or enzyme solution which removes impurities that build up in the lens. Unsterile, homemade solutions are very dangerous. Sterile saline can be used in the school health
rooms.
Disinfecting
Disinfection, which is usually done with a chemical solution is sufficient to kill most germs, but
may not kill all germs capable of causing a corneal infection.
Instruction for when lens is out of position
Re-centering the lens
1. A lens may be left on the white of the eye indefinitely without injury or discomfort
2. If movement of the lens seems very difficult, fold the area with a few drops of water and
roll the eye
3. The lens can be moved to different positions by manipulation through the lids
4. If you become tense, a rest will restore your coordination, and a second try will succeed
Lens under upper lid
1.
2.
3.
4.
Look down with eyes
With finger on upper lash margin, pull upper lid up and press against white of the eye
Use eye lid to push lens down to center and hold
Look straight ahead
PR 24
Lens in outside corner
1. Place thumb and first finger on lash margin near outside corner of eye
2. Spread lids apart
3. Look to your nose
4. Push lens with lids to center and hold
5. Look straight ahead
Lens in inside corner
1. Place first finger of each hand on upper and lower lash margin
2. Spread lids apart
3. Look to outside corner toward ear
4. Push lens with the lids to center and hold
5. Look straight ahead
Important Facts
Myopia is not corrected by contact lenses. The hard lenses do tend to flatten the cornea slightly
and thus improve myopic vision, but this is temporary; the cornea resumes its previous shape
after the lenses are removed.
In sports, soft contacts are safest. Hard lenses, however, pose not greater dangers than do regular
glasses.
Never sleep in lenses unless advised by the doctor (under special condition) to do so. Do not use
saliva as a “wetting” agent. The risk of bacterial contamination is great. Never rinse lenses in hot
water or store in a hot or usually cold place as lens warpage may occur.
Do not “flex” your lenses. This can also warp them. Eye makeup should be used sparingly
around the eyelids. Avoid swimming when wearing contacts as they can easily be washed out
and lost.
If at any time you stop wearing your contacts for a few days, your corneas may lose their
adaptation and you will need to restrict your wearing time for a short period. Watch your
“blinking habits”. Good blinking is essential in all forms of contact lens wear. This keeps a
constant fresh supply of oxygen to the corneas and helps to “wet” the lens surfaces.
PR 25
Dental Emergencies
Red, Swollen or Sore Gums
1. Have student rinse mouth thoroughly with a warm, salt water solution (1/4 tsp. table salt
in a 4 oz. glass of water)
2. Instruct student to repeat rinses every two hours, and after eating or tooth brushing, and
before retiring
3. If no improvement in 1-2 days, refer to doctor or dentist.
Toothache
1. Have student rinse mouth vigorously with warm, salt water. Floss gently fro trapped
debris
2. Apply Ambesol with an applicator on a tooth with a cavity. Do not apply aspirin
3. If swelling of the gum, jaw, or face occurs apply a warm compress to the cheek
4. Notify parent/guardian, dental hygienist of need to see dentist
Oral Injuries
Knocked-out tooth
1. Have the student rinse mouth gently with warm salt water
2. Find the tooth. Handle only by top, not root portion. Place the tooth in a cup of water or
milk, or wrap it in clean, wet gauze. Do Not attempt to clean the tooth as this may destroy
the re-implantation process.
3. Teeth replaced within 1 hour have a good prognosis. Phone the dentist at once. He/she
may instruct you to re-insert the tooth (and how to do this) before you transport the
student
4. Obtain immediate dental care
Chipped Tooth
1. Clean any dirt, blood, debris from the injured area with a sterile gauze pad and warm
water
2. Prevent tongue or cheek laceration by covering any sharp edges of the broken tooth with
gauze or wax and have student hold in place by keeping mouth closed. Take large
fragments to dentist
3. Apply cold compress on the fact next to the injured tooth to minimize swelling
4. Refer to dentist
Fractured Jaw
1. Immobilize jaw by placing a scarf, handkerchief, tie, or towel under the chin, tying the
ends on top of the student’s head
2. Obtain immediate dental care
PR 26
Orthodontic Emergencies
1. Protruding wire from a brace can be gently bent out of the way to relieve discomfort by
using a tongue depressor or pencil eraser. If wire cannot be bent easily, cover the end
with a piece of gauze, cotton ball, or wax to prevent irritation. Do not try to remove any
wire embedded in the cheeks, gum, or tongue
2. Obtain orthodontic care the same day
Bitten Lip or Tongue
1. Apply direct pressure to the bleeding area with a sterile gauze pad
2. If the lip is swollen, apply a cold compress
3. Obtain emergency medical care if bleeding persist or if the bite is severe
PR 27
Dislocation of Joint
Physical Findings
1. Visible lack of symmetry compared to other side, usually following trauma
2. Localized pain and swelling
3. Most common in distal phalanx (tip) of finger. Shoulder is next in frequency, followed by
elbow and knee
4. May be associated with a chip fracture, especially in finger
Management
1.
2.
3.
4.
Ice pack, applied with as little pressure as possible
Do not compress
Do not try to put back into place
Notify parent/guardian and refer to physician or emergency room
Follow-up
1. Protect from further trauma
2. Inspect any casts, splints, and dressings periodically
PR 28
Drug Abuse Suspected
Physical Findings
1. Behaves differently than normal or is brought to health room with suspicion of having a
drug reaction
2. Pinpoint pupils
3. Alcohol smell on breath, may try to mask with mints, gum
Management
1.
2.
3.
4.
5.
Assess student’s behavior and vital signs
Determine type of reaction, if possible
Call 911 or Crisis Intervention, if needed
Fill out physical assessment checklist
Notify parent/guardian and administrator
Follow-up
1. See policy for Drug Abuse
PR 29
Earache
Physical Findings
1.
2.
3.
4.
Student complains of discomfort in one or both ears
May be associated with a fever
May have drainage from ear(s)
May have reddened tympanic membrane/canal
Management
1. Otoscopic assessment may be done by the school nurse
2. If temperature is elevated above 100°F. tympanic membrane/canal is red, or there is
persistent pain, notify parent/guardian and advise medical care
Follow-up
1. Student must bring in a physician’s note if he/she is to be excluded from swimming
PR 30
Eczema
Physical Findings
1. Acute: itchy, moist, red, generalized rash, usually on front of elbows, back of knees, face,
and neck
2. Chronic: same locations, but usually dry and scaly. May be red or de-pigmented. May
also be on upper or lower eyelids
Management
1. Mild cases may be treated in health room; refer to physician if severe
2. Acute: moist cold compresses to relieve itching. Do not put powders, lotions, or
ointments on weepy skin
3. Chronic: refer to physician
4. Oral antihistamines if prescribed. Usually not helpful, but may relieve itching
Follow-up
1. Secondary infection is common, especially in younger children who scratch more
2. Secondary infection usually resembles impetigo at edges of eczema: isolated circular
crusts with moist or dried pus underneath
3. Watch for cellulites or lymphangitis
4. Observe flare-ups for possible relationships to food, clothing or other environmental
factors
PR 31
Enuresis
Causes
1.
2.
3.
4.
5.
Child is too young to be toilet-trained. Children 3-5 need a toilet in or near classroom
Meatal stenosis in boys
Boys with excessively long foreskin with poor hygiene
Chronic urinary tract infection
Small bladder capacity, irritable bladder, poor sphincter control, or other organic
conditions
6. Various emotional/psychological problems
7. Possible sexual abuse
Physical Findings
1. Urine-stained and wet clothes
2. Odor
3. Emotional/behavioral problems, but not as pervasive or common as in children with
encopresis
4. Symptoms of chronic infection: poor appetite, poor nutritional status plus anemia,
itching, foul order, low-grade fever, stained underpants from constant dribbling, redness
and/or impetigo in genital area
5. Small caliber of urinary stream in boys with meatal stenosis
6. Infection under an excessively long foreskin
Management
1.
2.
3.
4.
Protect privacy of child’s problem from other children
Make toilet and washing facilities available
Help child make pre-need trip to bathroom
Liaison with parents/guardians and physician, when necessary
PR 32
Eye Trauma
Physical Findings
1.
2.
3.
4.
History of blow or other trauma to eye
Pain in eye
Redness of conjunctiva
Eye held closed
Diagnosis
1. If student is unable to open eye to not force
2. Check for visible lacerations on lids or eyeball. A small cut may be the only external
evidence of a penetrating injury
3. Check for fluid or blood in anterior chamber (between the iris and cornea). May be
accompanied by drowsiness
4. Check for diplopia
5. Check for extra-ocular movements
6. Check for unequal or irregular pupils
7. Check vision one eye at a time, using the Snellen Chart
Management
1. Notify parent/guardian and refer to physician if there is laceration on lid or other trauma
to lid or eyeball, or if vision is impaired in any way. All chemical burns must be referred.
2. Patch both eyes with 4x4 gauze pads prior to referral to physician (this minimizes eye
movement)
3. Ice packs may be used if physician referral is not necessary
4. For chemical burns or foreign body, irrigate with copious amounts of cool water at least
ten minutes
Follow-up
1. Examine eye on following day
2. Check vision on Snellen Chart on following day and refer if not same as before the
trauma
PR 33
Faculty Presentation Protocol Guidelines
1. Universal Precautions – all people are treated the same. You should have a plastic bag
containing gloves to keep in the top drawer of your desk and sign to post in class.
Regarding nosebleeds – try to have the student contain the bleeding themselves. Make
sure you put gloves on if the student is unable to contain the bleeding. Take the gloves off
so that they turn inside out and double bag them. Obtain replacement from nurse.
2. Oxygen Tank – is wall-mounted in the Health Room. Place mask over nose and mouth
of adult. For small child, invert mask and place over nose, mouth and chin. Pull the tank
straight out from the wall from the top of the tank. This automatically starts the oxygen
flow. Place the bullet in to stop the flow until you reach your destination.
3. Abdominal Thrust – wait for universal symbol – hands to neck and can’t cough, breathe
or speak. Standing behind victim, find navel. Put fist above and do chest thrust. Do not do
back blows.
4. Asthma – attacks are triggered by allergies, such as mold, dust, ragweed, and pet dander,
and extreme cold or heat. It is marked by periods of wheezing and shortness of breath
caused by narrowing of the bronchial walls that lead to the lungs. If you have asthmatic
students in your classroom, do not have animals brought in. Even guinea pigs and gerbils
can trigger attacks. If you need to share pets, do so in an open area with good ventilation
– the student may choose to be apart or decline participation.
5. Allergies – could be life-threatening. The most common food allergies are: milk, eggs,
shellfish, peanuts, tree nuts (walnut, cashew, almond), wheat and soy. Treatment of food
allergies is to avoid the food. Allergy shorts cannot desensitize foods or drugs. Do not
confuse a food intolerance (which would probably cause a gastrointestinal problem) with
a food allergy.
Control the food and treats coming into the classroom. Students are usually aware of
severe food allergies. Parents/guardians should make student aware of their limitations.
Faculty needs to be aware of students’ limitations and help enforce them. Example:
Peanut allergy – you cannot remove a peanut from a cookie and consider the cookie safe
to eat. The oils seep into other ingredients and can trigger a reaction. Sometimes just
handling peanuts and touching the child’s skin can be life threatening.
6. In case of severe anaphylaxis - An Epi-Pen is kept in the health room. To administer
the Epi-Pen, pull off the gray safety cap. Place the black tip against the thigh, at a right
angle to the leg. Press hard into the thigh until it clicks and HOLD it in place for 10
seconds (to ensure that the medicine goes into the thigh). Call 911 anytime an Epi-Pen is
administered. Notify the parent/guardian, the school administrator and the school nurse.
PR 34
Fainting (Syncope)
Definition
A brief, partial or complete loss of consciousness due to diminished oxygen supply to the brain.
Infantile
1. Breath holding spells – crying with prolonged expiration, breathing stops, cyanosis (turns
blue), body becomes rigid. Occasional twitching of arms and legs. Child faints, becomes
limp, begins breathing, wakes up and is normal
2. Pallid attacks – following a bump on the head or other minor trauma; child starts to cry
but then becomes pale and faints. Awakening is rapid
3. Adolescents may hold breath and have another person hit on chest – this causes a “head
rush”, but also may cause student to lose consciousness. Prognosis is excellent in both
types. No treatment is necessary. If this occurs before school age may be prone to easier
fainting later in life.
Vasovagal
1. Sudden pain or an emotional reaction such as anxiety leads to over reaction of the reflex
triggered by the vagus nerve.
2. Causes marked slowing of the heart and pooling of the blood in the center of the body,
away from the brain.
3. Some students are more prone to faint 24 hours after they miss a meal
4. Symptoms are: blurred vision, light headedness, nausea, sweating, loss of consciousness
Postural Hypotension
1. Common in adolescents and older persons
2. Due to deficiency in blood pressure regulation when suddenly rising to standing position.
Symptoms same as vasovagal fainting
3. Support stockings help as a preventive
Hyperactive Carotid Sinus
1. The carotid sinus is a group of nerve endings in the large artery in the neck (carotid
artery)
2. In susceptible persons, pressure in this region causes marked slowing of the heart, low
blood pressure, and fainting
Cardiac Syncope
1. In persons with certain types of congenital heart disease, the output of blood is lower than
normal, thus the brain has a lower oxygen supply and fainting occurs easier
PR 35
Exercise-associated Fainting
1. Heat syncope – an early type of heat illness due to pooling of the blood in the skin and
center of body away from the brain. It is associated with exercise and usually occurs
while standing. The student becomes pale and has a high internal temperature. Extra fluid
intake plus some salt on food may help as preventive
2. Congenital heart disease – any student who faints during exercise may have a potentially
serious heart defect and should be referred for evaluation.
Relevance for School Nurse
1. Differentiation from seizure disorder:
a.
b.
c.
d.
e.
f.
Post seizure sleep is longer and deeper
Seizures occur with no warning except occasional aura
Seizure twitching is more severe and lasts longer
Fainters usually know when it is going to happen
Some excessively frequent fainters must be referred to physician for a diagnosis
Fainters usually remember what happened after they wake up
Management
1. Prevention – educate frequent fainters about sitting down in a chair; hanging head
between knees close to floor when they feel faint. If they are embarrassed to do this in
public, they can pretend to remove something from their shoe. Educate students with
postural hypotension about getting up slowly
2. Treatment – allow fainters time to awaken by themselves. A crushed ammonia ampule
may be held by nose. Avoid close contact with eyes. Legs can be elevated. Do not use for
children with asthma
PR 36
Fever
Physical Findings
1. Oral temperature over 100° F. A lower temperature is not considered a fever.
2. In most mild, 2-5 day childhood illnesses, fever is lowest in the morning, rises in the
afternoon, highest in the evening and night. As child begins to recover, morning
temperature will be normal with fever still present later in the day
Management
1. If illness is in first or second day, and the previous day’s fever was over 101.6° F. student
should be kept home one more day, even if no fever that morning
2. If illness is in 3rd or 4th day, and student appears to be improving, with highest fever
under 101.5°F. the previous day; student may return if feels good and has appetite
3. Students with fever one day who wake up the following morning normal and with good
appetite may return to school
4. Other symptoms should be considered: Cough, nasal congestion, stomach ache, vomiting,
or diarrhea. If present to a significant degree, advise remaining at home additional day.
5. Physician’s instructions take precedence over these guidelines
6. Low grade fever may be beneficial in counteracting the illness
PR 37
Fifth Disease (Erythema Infectiosum)
Called “Fifth Disease” because it was identified after red measles, German measles, scarlet fever,
and roseola.
Cause
1. Human Parvovirus – related to but not the same as dog parvovirus
2. Transmission – Droplets from respiratory secretions or secondarily by hands. About 50%
of adults have had the disease as children and thus are immune
3. Incubation- 1-2 weeks
Symptoms
1. About a week after exposure, the patient develops a low grade fever which lasts 5-7 days
and then recovers with no other symptoms
2. About a week after the fever goes away, a distinctive rash may appear. It resembles the
appearance of a slapped cheek and there is a pink, lacy rash on the trunk, arms and legs.
Adults, especially women, may have joint pain and swelling at this stage
3. Often there is neither fever nor rash with this disease
Infectivity
The most contagious period is just before onset of fever, gradually declining during the
following week and low to absent by the time the rash appears. This disease often occurs in small
outbreaks, usually in late winter and spring, so the diagnosis may be suspected in the pre-rash
infective stage, if it has occurred in other family members. These students should not be in
school.
Transmission is enhanced by household contact. A susceptible parent has a 50% chance of
catching the disease from the child. In contrast, during an extensive school outbreak, about 20%
of susceptible teachers can develop the infection.
Pregnancy
Pregnant women who become infected in the first 4-5 months are at risk of spontaneous abortion.
So far, no baby has been born with birth defects due to parvovirus. The risk is not high:
Available data suggests that a susceptible woman exposed to her own infected child during her
first 20 weeks of pregnancy runs an increased risk of about 1-2% of having a spontaneous
abortion. If the exposure is at school or another job site, the risk is lower.
Recommendations and School Relevance
1. Children with the rash of Fifth Disease do not need to be isolated because they are no
longer contagious by the time the diagnosis is made
2. Children with unusual long term blood diseases need special consideration
PR 38
3. Exposed pregnant women need advice from their physician or an infectious disease
specialist. Testing for susceptibility may be available in selected cases through a local
health department
4. Teachers and day care workers are at increased risk of exposure, but a routine policy of
exclusion of pregnant women from these work places is not recommended at this time
5. Hand washing and proper tissue disposal should be scrupulously practiced
6. Immune Globulin is not effective in preventing infection
PR 39
Foreign Bodies
Eye, Ear (including Earwax), Nose
Physical Findings
1. Eye: pain, tearing, irritation
2. Ear: usually none of the above; student may tell you he/she has put something in ear
3. Nose: usually nose at first; student may state he/she has placed object in nose. After a few
days, a unilateral sero-purulent, foul-smelling discharge
Treatment
Eye
1. Pull down lower lid with tip of index finger. If foreign body can be seen in the sac of
lower lid, remove with cotton-tipped applicator
2. If not successful after 1-2 attempts or if foreign body is in any other location, patch eye
and refer to physician
3. Chemical foreign substances in the eye constitute serious emergency. Flush eye with
copious amounts of cool water while eye lids are held open, patch eye and send to
emergency room immediately
Ear
1. Do not try to remove unless foreign body can be easily seen and grasped with forceps or
fingers
2. Notify parent/guardian and refer to physician
3. Treat ear wax the same way
Nose
1. Do not attempt to remove unless object can be seen extruding from nose and can be
grasped with fingers or forceps
2. Try having student blow nose forcibly with unobstructed side held closed
3. Notify parent/guardian and refer to physician
Follow-up
1.
2.
3.
4.
Eye: Check with teacher to ensure that student is symptom free
Eye: For chemicals, recheck visual acuity for 3-7 days after treatment
Ear: None if foreign object removed
Nose: None if foreign object removed; check for cessation of nasal discharge
PR 40
Fractures
Physical Findings
1.
2.
3.
4.
Localized pain following trauma
Frequently, asymmetry compared to opposite side. Not always present
May be swelling and/or redness but not always present
Suspect “stress” fracture if painful from excess exercise, jogging, gymnastics, ballet
training. Produces pain without swelling at site of fracture, especially on movement
Most Frequently Missed Fractures
1.
2.
3.
4.
Ribs
Fingers and toes (especially chip fractures)
Elbows
Knees
Management
1. Ice, compression, elevation
2. Notify parent
3. Immediate evacuation to physician’s office or emergency room
Follow-up
1. Periodic inspection of casts, splints, dressings
2. Accommodations for leaving class early, use of elevator
PR 41
Frost Bite
Physical Findings
1.
2.
3.
4.
5.
6.
Cold, itchy or tingly, numb feeling
Mild: edema or mild purplish color which soon subsides
Moderate: move edema and deeper purple-blue color. Blisters appears in 24-48 hours
Severe: more edema and black color with death of tissue. Blisters do not appear
Most common on fingers, toes, nose, cheeks, and earlobes
Severity not apparent until frost-bitten area is re-warmed
Management
1.
2.
3.
4.
5.
6.
7.
8.
9.
Remove any wet clothing
Re-warm the affected area with warm (not hot) water bath for 20-30 minutes
The affected part should not be rubbed or massaged during re-warming
Check oral temperature for generalized hypothermia. If present, refer to ER
Refer to physician if beyond mild stage
Do not use ice water massage, snow massage or use of excessive dry heat
Elevate the injured extremity to minimize edema
Keep student indoors for remainder of school day
Notify parent/guardian
Prevention
1. Students with previous frostbite need to be told that they are more susceptible, and
therefore need to take precautions:
a. Bare hands can be warmed under arms or between legs
b. Adolescents should avoid alcohol and tobacco
2. Provide extra clothing for neglected for underdressed children
PR 42
Head Injury
Classification
1. Trauma to scalp: laceration, bruise, abrasion
2. Trauma to bony skull: fracture
3. Trauma to brain: concussion, contusion, laceration
Physical Findings
Scalp Injury
1. Abrasion (see protocol)
2. Laceration: more bleeding than similar cut on other parts of body because skin over the
scalp has a larger blood supply
3. Bruise: Causes mildly painful swelling (synonyms; pump-knot, goose-egg). Edges may
feel depressed but it is not to be mistaken for the depressed skull fracture described below
4. In all these conditions there is not disturbance of consciousness unless there is
accompanying injury to brain
Skull Fracture
1. Non-displaced linear fracture: no symptoms except pain unless base of skull is fractured,
X-ray required for diagnosis. Basal skull fracture usually associated with severe injury
which almost always produced disturbance of consciousness or leak of blood or spinal
fluid from mouth, nose, or ear
2. Depressed skull fracture: due to a fragment or larger piece of bone pressing down on
brain as a result of trauma. Usually cannot be felt by palpation and requires X-ray for
diagnosis
Brain Injury – Concussion
1. State of consciousness: classify the injury as mild, moderate, or severe by the following
criteria:
a. Mild – momentary clouding of consciousness or memory lapse (seeing stars,
ringing bells) and then apparent normality
b. Moderate – brief period of unconsciousness, distinct memory loss, short period of
unusual behavior. Requires 15-30 minutes to return to normal. Interview student
to check for post-traumatic amnesia, which has the same significance as
retrograde amnesia
c. Severe – deeper loss of consciousness lasting 1-2 minutes or longer, vomiting,
fast or slow pulse, irregular breathing, neurological signs such as irregular pupils
of the eye, seizure, unilateral weakness, abnormal reflexes
2. Vomiting
a. Unequal size of the pupils of the eyes
PR 43
b. Unusually rapid or slow pulse rate
3. More severe brain injury (contusion, laceration, subdural or epidural hematoma)
Management
1. Scalp Injury
a. Abrasion – wash with soap and water. Apply pressure with 4x4 gauze or other
clean cloth until bleeding stops. Dressing usually not necessary
b. Laceration – same as abrasion but apply pressure longer to make sure bleeding
stops
c. Bruise – ice to relieve pain. Do not apply pressure. Prognosis excellent if no sign
of brain injury
2. Suspected skull fracture
a. Call 911
b. Notify parents/guardians
3. Brain injury – Concussion
a. If any of the “Brain Injury” signs listed above are present, the student should be
referred to a physician or emergency room immediately
b. Check pupils initially and every 15 minutes
c. If the student is slightly woozy, but all other findings are normal, notify
parents/guardians to take to physician
d. If all findings are normal, have the student rest in the health room for 15-30
minutes, the length of time depending on the severity of the injury and appearance
of the student, and then allow student to return to class. Recheck the student at the
end of the day
e. Notify parent/guardian of any head injury, and send MHI form
Follow-up
Scalp Injury
1. Check site of injury for 1-2 days
2. Watch for pyogenic granuloma, a low-grade infection due to hair and blood clot forming
a small matted nodule that will not heal. Requires clipping of hair, gently rubbing off
granuloma with soapy gauze, and applying antibiotic ointment. Best done by physician
3. “Goose-egg” needs no treatment, it disappears in 3-7 days
Skull Fracture
1. Physician follow-up required
PR 44
Brain Injury
1. Liaison with PE teacher and coach. If a second concussion occurs that school year,
student should not participate in contact/collision sports that year, unless approved by
physician
2. Check student at the end of the day
3. Notify parents by phone and in writing of what happened, and what to watch for. While
the student was being observed at school, if the symptoms were to any degree more than
the bare minimum, the school nurse should insist that parents/guardians get follow-up
instructions from a physician
4. Alert teacher to watch for post-traumatic closed head injury – irritability, headache, poor
concentration, decreased academic ability or personality changes
PR 45
Heart Murmurs
Definition: Functional
Usually called “innocent murmur”. Unusual heart sounds, heard before, during or after the
normal lub-dub of the first and second (systole and diastole) heard sounds. They are not in any
way associated with abnormality of the heart and therefore do not signify any form of heart
disease.
Definition: Organic
Also called “anatomic”. Unusual heart sounds heard at similar times and location as innocent
murmurs, but which are associated with anatomic defects of the heart, either from a disease, such
as rheumatic fever, or from congenital heart disease.
Functional
Characteristic – highly variable
1. Low or high pitched, whooshing, humming, or whistling in nature
2. May occur at any phase of the normal heart cycle from pre-systole, the 1st sound, to after
diastole, the 2nd sound
3. May be short or long; continuous throughout the entire cycle with accentuation, usually
during systole
Prevalence
These murmurs have been reported to occur in up to 90% of school age children at some
time. By contrast, the prevalence of actual heart disease in school children is a bit less than
½ of 1%.
Diagnostic Criteria
1.
2.
3.
4.
5.
Usually quieter, with occasional exceptions
Usually disappear or change in character with change in position
Not always present from day to day
No signs or symptoms of organic heart disease
No history of organic heart disease
Types
Still’s Murmur – Most common, systolic, loudest between left lower sternal border and apex of
heart. Low pitched, does not radiate.
Pulmonary Murmur – Systolic, loudest at upper left sternal border, transmitted to axilla.
PR 46
Supra Clavicular Murmur – Systolic, just above collarbone at base of neck. Often abolished by
firm pressure of stethoscope or raising chin or hyper-extending shoulders.
Split First Heart sound – Not a true murmur. First sound is doubled, heard best apex and lower
left sternal area.
Third and Fourth Heart Sound – Often present, but hard to hear. Immediately after normal 2nd
heart sound. Usually of no significance.
Diastolic Murmur – Less than 1% of diastolic murmurs are innocent in school age children.
Venous Hum – A continuous, soft blowing murmur. Loudest at upper right sternal border.
Frequently present, usually louder when child is sitting and almost always disappears when child
lies back with chin on chest.
Mammary Soufflé – continuous or systolic, at 2nd inter-space in center of chest. Soft and
blowing, decreases on stethoscope pressure or sitting up. Heard in adolescent and young women
due to larger arteries flowing to breasts.
Relevance for School Nurse
The psychological implications of suspected heart disease for student and parent/guardian can be
severe. Most innocent murmurs can be positively identified by an experienced pediatrician using
only a stethoscope; no further tests are necessary. Occasionally, referral to a pediatric
cardiologist for ECG and/or plain X-rays is necessary. Rarely are invasive procedures required.
PR 47
Headache
Physical Findings
1.
2.
3.
4.
5.
6.
7.
Verbalizes pain, pressure or pounding
Visual disturbances
Nausea/vomiting
May be associated with other symptoms i.e. stomach ache, URI, allergies
Eye strain
Anxiety/stress
Fatigue
Management
1. Obtain history to include frequency, sleep and eating habits, visual problems and
associated emotional factors
2. Rest in health room if necessary
3. Cold pack to head may be useful
4. Notify parent/guardian and refer to physician if necessary
5. Do not give aspirin products
6. Medication may be administered if student has completed authorization for medication
during school hours and has brought in medication
7. For High School Only – Acetaminophen may be administered one time in school day if
authorization by parent is signed
Follow-up
1. Maintain communication with student and family for follow-up as necessary
PR 48
Hepatitis A and B
History
1. Increased prevalence of Hepatitis B among institutionalized mentally retarded and their
caretakers
2. Different methods of transmission of Hepatitis A (fecal, oral) versus Hepatitis B (blood
and body fluids)
Differences
Incubation period
Period of infectivity
Can be carrier
Hepatitis A
4-6 weeks
Short
No
Hepatitis B
1-6 months
May be long
Yes
Physical Findings (same for Hepatitis A & B in early stages)
1.
2.
3.
4.
5.
6.
Fever, malaise, headache, fatigue
Loss of appetite, nausea, stomach ache, vomiting
Jaundice
Dark urine, light colored stools
Mild in most cases; children are well in 7 days or less
May have all symptoms except jaundice. Usually remain undiagnosed but are just as
contagious
Management
1. Refer to physician
2. Student may return to school as physician recommends
Follow-up
1. Routine staff in-service regarding routes of transmission, infectivity, precautions and
importance of hand-washing
2. Recommend Hepatitis B vaccine for school personnel
PR 49
Herpes Simplex
Physical Findings
1.
2.
3.
4.
Small, dark to light, grayish-amber crusts around nose or lips
“Canker-sores” inside cheeks for tongue may or may not be due to Herpes Simplex virus
May come and go in susceptible students over a period of 1-3 years (unusual)
May re-appear with emotional or physical stress
Management
1. Over-the-counter topical medications do not cure local lesions
2. Glyoxide and/or Ambesol to relieve burning and itching for a short time
3. Referral and exclusion necessary only for severe and/or long-lasting cases. Newer
prescription medications are available for treatment of local lesions (Acyclovir)
Special Information
1. Only contagious when external lesions are present and visible
2. May be spread by direct (kissing) or indirect (finger or lip on drinking glass) contact
3. Genital Herpes Simplex (Type II) does not require exclusion (see SEXUALLY
TRANSMITTED DISEASES). Oral Acyclovir effective to suppress painful lesions
4. Two to five percent of healthy individuals with no visible lesions in mouth or on lips
carry Herpes Simplex virus in their saliva
PR 50
Hives (Urticaria)
History
1. A skin allergy which may be due to the following factors – in order of frequency:
a.
b.
c.
d.
e.
f.
Foods
Medications
Emotional factors
Inhalants (pollens, dust)
Contact substances (dust, plants)
Physical factors (sun, cold)
Physical Findings
1.
2.
3.
4.
5.
6.
7.
Round, reddish-pink wheals on skin surface varying in size from ½ cm. to 2-3 cm.
May become confluent and larger
Tend to be clear in center with surrounding redness
Not tender or painful, but itchy
Characteristically short-lived by re-appear, often in other parts of body
May be accompanied by swelling of lips, eyes, fingers, genitalia
LARYNGEAL EDEMA IS THE MOST SERIOUS COMPLICATIONS; hoarseness and
difficult breathing
Management
1.
2.
3.
4.
5.
6.
Notify parent – can recommend some OTC lotions
Cold compresses for itching
Refer new cases to physician
Give antihistamine or other medications prescribed by physician
Keep in health room to make sure systemic symptoms are not present
If laryngeal edema suspected, administer Epi-Pen and evacuate to medical facility
immediately – call 911. Call parent/guardian
Follow-up
1. Students to follow-up in health room if symptoms continue
PR 51
Impetigo
Physical Findings
1.
2.
3.
4.
5.
6.
7.
Primary lesion is a vesicle that rapidly becomes pustular
Honey-colored loosely adherent crusts
May have wet or crusted pustules
Most frequently found on dingers and face but may be anywhere on body
Itching
Contagious on direct or secondary contact
Deeper lesions with thick adherent crusts called ecthyma
Management
1. Bacteria live under the crusts
2. Gently wash with anti-bacterial soap and remove as much of crust as comes off easily
while washing
3. Apply direct pressure until bleeding stops after removal of crust
4. Apply antibiotic ointment prescribed
5. Cover with loose dressing or band aid
6. Keep fingernails short
7. May require oral antibiotics
Follow-up
1. Exclude from school until all sores are healed or until student returns with a physician’s
note stating the condition is under treatment
2. Remind parent of management of Impetigo
3. See in health room upon school return
4. May need additional treatment if cellulites, boils, or fever develops
PR 52
Lacerations – Cuts
Management
1. Cuts which are clean, straight, less than 1/2” long, with edges separated less than 1/8”
a.
b.
c.
d.
e.
Apply firm pressure until bleeding stops
Clean thoroughly with antiseptic soap and copious amounts of water
Dry
Apply plain or butterfly dressing, and an antibiotic ointment
If possible, elevate laceration above level of heart unless fracture suspected
2. Cuts which are contaminated, longer or wider than above, or located on face or flexor
surface (knee, elbow)
a. Apply firm pressure until bleeding stops
b. Refer to physician
3. Cuts on scalp bleed more due to large blood supply
a. Apply firm pressure until bleeding stops
b. Wash gently with soapy gauze
c. Dry
Follow-up
1. Change bandage as needed
2. Observe for appearance of puss, cellulites, or lymphangitits
3. If there are sutures, watch for swelling which causes tension on sutures. Infection is more
likely with black silk than nylon sutures. Infections first appears as tiny red circle around
each stitch
4. Watch for pyogenic granuloma (See HEAD INJURY)
5. With parental/guardian and/or physician permission, wash with soap and water as
necessary to keep clean
PR 53
Lyme Disease
Definition
Lyme Disease is a potentially serious disease carried by deer ticks. The symptoms of Lyme
Disease vary from one person to another. Usually, patients develop a rash that may have a ringshaped appearance similar to a bull’s eye, along with flu-like achiness, fatigue, and low-grade
fever. Some patients, however, never get the rash and other early symptoms, but may go on to
develop arthritis, neurological disorders, heart problems, and visual impairments.
Deer Tick
The juvenile deer tick, or nymph, is abundant in late spring and summer and is about the size of a
poppy seed. It is black in color. Adult ticks are active throughout the fall, warm winter days and
early spring and are about the size of a sesame seed. Adult females (seen much more often on
humans than males) are black toward the front and a dull red toward the rear.
Prevention
1. Talk to physician about being vaccinated against Lyme Disease
2. Wear insect repellant containing DEET; follow manufacturer’s directions
3. Be vigilant for deer ticks – frequent tick checks and a daily full-body inspection are a
must
4. Promptly remove any ticks that are attached to the body using fine-tipped tweezers; take
a pair of tweezers with you in the field
5. It takes at least 24 to 48 hours for a tick to transmit the disease infection, so early
detection and prompt, proper removal of ticks is the first prevention step
6. Always wash your hands after handling a tick
PR 54
Menstrual Disorders
Definitions
Oligomenorrhea: Infrequent, irregular episodes of bleeding, usually occurring at intervals of
more than 40 days
Polymenorhea: Frequent but regular episodes occurring at intervals of 21 days or less
Hypermenorrhea: (menorrhagia) Excessive in amount and duration, at regular intervals
Metrorrhagia: Not excessive, irregular intervals
Menometrorrhagia: Excessive, prolonged, frequent and irregular intervals
Hypomenorrhea: Regular but decreased in amount
Intermenstrual: Not excessive, occurring between otherwise regular menstrual periods
Dysmenorrhea: Painful menstruation (cramps)
Amenorrhea: Absence of menstruation
Menarche – age of onset of menses
1. Average 12-14 years, but may be 9-16
2. Often irregular periods during the first six months to two years
3. Mittleschmerz: intermenstrual pain and/or bleeding, lasting few hours to 3 days. Usually
associated with ovulation
Treatment
Dysmenorrhea
1. Heating pad to abdomen and rest for 20 minutes. Mild exercise and reassurance
2. Over-the-counter pain relievers such as Motrin, Tylenol, may be necessary. Follow
school district policy for medications
3. If no relief, call parent/guardian
Amenorrhea
1. Requires evaluation when:
a. Menarche delayed beyond 16 years
b. No secondary sexual characteristics develop by age 14 (breasts, pubic and axillary
hair)
PR 55
c. Three years after developing secondary sexual characteristics and menstruation
has not yet begun
2. Persons at risk:
a. Runners, gymnasts, ballet dancers (excessive exercise)
b. Girls with too little body fat, such as anorexia nervosa, extreme dieters (vegan
vegetarians)
c. Possible development of osteoporosis due to lack of estrogen
Premenstrual Syndrome (PMS)
Symptoms
1. Altered emotional state: Tension, anxiety, depression, irritable, hostile, sad, avoids social
contact, change in work habits, libido, efficiency, fatigue, lethargy, agitation
2. Cognitive Complaints: Decreased concentration, indecision, paranoia, suicidal thoughts
3. Physical: Backache, headache, breast swollen or tender, joint and muscle pain, nausea,
diarrhea, sweating, palpitations, altered appetite, abdominal bloat, weight gain, edema,
oliguria, changes in coordination, dizziness, tremors, paresthesia, acne, greasy or dry hair
Role of the Nurse
1.
2.
3.
4.
5.
Warn against excessive medication, especially addictive drugs such as codeine
Provide comfortable, quiet rest area
Keep supply of sanitary pads to sell to student (ordered through custodial office)
Refer to severe menstrual disorders to physician
Be on alert for amenorrhea in girls who should have passed menarche
PR 56
Mononucleosis (Glandular Fever, Mono)
Physical Findings
1.
2.
3.
4.
5.
6.
7.
Milder in young children, more severe in high school and college age
Fever, malaise, and fatigue
Sore throat and enlarged, red, exudative tonsils
Lymph nodes swollen in axilla, groin, above elbow, and especially in neck
Enlarged spleen
Maculopapular rash, jaundice (rare)
Fever may last 1-2 weeks; fatigue and malaise may last 4-6 weeks
Management
1.
2.
3.
4.
5.
Refer to parent/guardian to seek medical advice
Return to school on advice of physician
Penicillin often given but its value is questionable
Ampicillin often causes a rash
Steriods often given for severe tonsillitis but their value is questionable
Follow-up
1. Protect from contact sports (danger of ruptured spleen)
2. Complications are rare: Encephalitis, hepatitis, facial paralysis
3. Home education
a. Transmitted via: saliva (kissing), drinking glasses, handshaking
b. Virus may remain in saliva several weeks during and after convalescence
c. Inform student about “chronic infectious mononucleosis”, also known as Raggedy
Man Syndrome and Chronic Fatigue Syndrome. Bulk of evidence suggests this
disease does not exist, but that students may have emotional/psychological causes
for their symptoms
PR 57
MRSA
Methicillin-resistant Staphylococcus Aureus
Description
Staphylococcus Aureus (Staph) is found on the skin and noses of healthy people. When the
skin is penetrated the Staph can cause serious wound infections, bloodstream infections
and/or pneumonia.
60% of Staph infections are resistant to Methicillin, called MRSA. MRSA can spread by
direct physical contact or on fomites such as:







Contaminated Towels
Sheets
Wound dressings
Hands
Clothes
Computer keyboards
Sports Equipment
Any draining infection could pose a threat to others.
Management
1. Keep infections, particularly those that produce pus or drainage, covered with clean, dry
bandages. The student should follow the healthcare provider’s instructions on proper care of
the wound. Pus from infected wounds can contain bacteria, including MRSA, and spread the
bacteria to others. Bandages should be disposed of in a manner such that other people cannot
have contact with the drainage.
2. Advise those who may have contact with the infected wound to wash their hands thoroughly
with soap and warm water or with an alcohol based hand sanitizer for 15 seconds. Persons
who expect to have contact with the infected wound should wear disposable gloves, and
wash their hands after removing the gloves. Hand washing is the single most important
measure to prevent MRSA transmission.
3. Avoid sharing personal items (e.g. towels, washcloths, clothing) that may have come in
contact with the infected wound. Wash soiled linens and clothes with hot water and laundry
detergent. Drying clothes in a hot dryer, rather than air-drying, also helps kill bacteria.
4. Clean potentially contaminated surfaces carefully with a disinfectant or a bleach-water
solution (1:100 dilution of sodium hypochlorite, which is approximately ¼ cup of 5.25%
household chlorine bleach to 1 gallon of water) after caring for the wound.
Recommendations for exclusion
1. Children know to be colonized with MRSA in the nose or skin do not need to be excluded
from the “healthy” school children.
PR 58
2. School children (K-12) known to be colonized with MRSA who have draining wounds or
sores should be excluded from school if the wounds cannot be covered, contained, or
dressing maintained intact and dry.
3. Children know to be colonized with MRSA should not be placed in classrooms with children
who have severe immune system suppression.
4. More complex situations should be referred to the local or state health department.
Follow-up



Schools should continue to provide general cleaning on a regular schedule
Students who are infected with MRSA should follow the healthcare provider’s treatment
plan, including completion of any antibiotics prescribed.
Health rooms should provide a clean, safe environment for student’s bandage changing.
Adapted from the PA Department of Health, Bureau of Epidemiology’s Recommendation
on Children with Meticillin-Resistant Staphylococcus Aureus (MRSA) in School Settings,
and PSEA PA School Nurse Newsletter; MRSA: The Superbug, by Carol Hackenbracht.
PR 59
Muscular Dystrophy
Physical Findings
1.
2.
3.
4.
5.
Onset occurs between 2 and 6 years of age
Slowly gets worse
Clumsiness, toe-walking, lordosis (sway back), frequent falling
Difficulty with stairs and getting up from floor
Enlargement of muscles (especially calf and thigh) due to replacement of muscle with
fatty tissue
6. Obesity, scoliosis, and mild learning difficulty are often present or develop later (30%
have associated mental retardation)
7. Eventual need for braces and wheel chair
8. Life expectancy is 10-15 years from onset
9. Constipation frequent
10. Frequent respiratory infections
Management
1.
2.
3.
4.
Liaison with physical therapist
Assist with toileting: Transfer from wheel chair to toilet
Liaison with counselor (problems associated with fatal illness)
Liaison with teacher regarding student’s need for rest, short school day, frequent
appointments with physician
5. Liaison with physician for care in school
PR 60
Nose Bleed
Management
1. Swallowing excess blood can cause vomiting. It is better to have student hold head
straight, than to hold head back with chin up, or leaning forward
2. Firmly hold bleeding nostrils closed for a minimum of 5 minutes
3. If bleeding continues, hold closed firmly another 5 minutes
4. If bleeding continues refer to physician or ER
5. Household remedies are usually ineffective, such as: cold compresses or pressure on
upper lip
Follow-up
1. Restrict excessive physical exertion remainder of that day only, especially if it is hot and
sunny
2. Watch for evidence of bleeding in other parts of body: urine or spontaneous appearance
of ecchymosed (bruising) areas under skin: refer to physician
3. Repeated nose bleeds: refer to physician
PR 61
Pink Eye or Conjunctivitis
Physical Findings
1.
2.
3.
4.
5.
Redness of whites of eyes
Purulent or watery discharge
Redness and/or swelling of eyelids
Itching and rubbing of eyes
Crusts in inner corners of eyes, especially on waking from sleep
How to Differentiate the Causes
1. Allergic: discharge remains watery without pus formation
2. Infectious (Bacterial): usually more severe with pus formation and more crusts. Requires
treatment
3. Viral: usually less severe, often with no pus, runs 3-5 day course and goes away. All
three may or may not be associated with common cold
Management
1.
2.
3.
4.
5.
6.
7.
8.
9.
Wash eye gently with cool compresses for temporary relief of symptoms
Check visual acuity. It should be unchanged or normal
Check fingers and nose for impetigo
Antibiotic drops or ointments may be prescribed by physician for infections
May or may not be contagious, so do not exclude from school if condition is:
a. Mild with no visible pus and few symptoms
b. Mild and associated with common cold
c. Allergic
d. Check student later in day or next morning if symptoms persist: refer to physician
In other cases, refer to physician and exclude until under treatment for 24 hours (see
Communicable Diseases)
If subconjunctival hemorrhage is present, and accompanied by the above symptoms, refer
to physician
Send Information for Parents – Pink Eye sheet with student
Inform student to avoid eye makeup and not to share eye makeup
PR 62
Pinworms
Physical Findings
Intense itching at anal area, especially at night
Management
1.
2.
3.
4.
5.
Seek medical attention
Instruct parent/guardian to wash bed linen and underclothes in 120°F or hotter
Change underwear at least twice per day
Vigorous hand-washing and nail care, especially upon waking
Student does not need to be excluded from school
PR 63
Poison Ivy/Oak
Contact Dermatitis
Physical Findings
1. Reaction begins 1-4 days after exposure
2. Contents of blisters and weepy skin cannot cause rash in another individual or even in
another location on student
3. Early: Itching, redness, small papules and vesicles
4. Late: Increase of all early signs plus larger blisters and generalized weeping of skin
5. Healing: dryness, crusting and gradual shedding of crusts and scabs. May take 2-3 weeks
6. Most common on hands, forearms, face and legs
7. No fever
Management
1. Wash thoroughly after exposure (usually too late when discovered at school)
2. Anti-itch medication (topical) may be applied if there is no skin interruption or anything
on face
3. May suggest over-the-counter medications to parent/guardian
4. Try to prevent scratching. Loose dressing may help
5. Cold packs for temporary relief
6. Refer to physician if severe or infected
Follow-up
1.
2.
3.
4.
Observe for infection (see Abrasions) and treat as needed
Warn against re-exposed, as the reaction will be worse next time
Educate about appearance of plant
Desensitization shots usually are not effective and may be harmful to small number of
students
PR 64
Pulse Oximetry Guidelines
The Pulse Oximetry guidelines provide information to help maintain safe quality care of the
student while increasing accurate and efficient use of pulse oximetry technology.
It is indicated for monitoring a student’s clinical status, specifically the adequacy of arterial
oxyhemoglobin saturation and to measure the change in arterial oxyhemoglobin saturation when
clinical status of a student is in question. The oximeter is also used when determining treatment
and/or transfer out of school.
Inappropriate use of pulse oximetry monitoring may result in clinical judgments based on
inaccurate readings, due to operator factors and/or malfunctioning equipment. Both components
could potentially result in unnecessary medical intervention, thus impacting quality care.
To reduce inappropriate use, reassess the need of monitoring oximetry of a student. Do not
continue pulse oximetry if clinical assessment indicates that such risk is minimized or abated.
Objectives






To establish monitoring guidelines for the use of pulse oximetry.
To describe clinical criteria for determining if a student is a candidate for oximetry
monitoring.
To describe appropriate application and placement of pulse oximetry sensor.
To provide information about common problems associated with pulse oximetry and
troubleshooting strategies to remedy these problems.
To provide information about the proper care of pulse oximetry equipment.
To provide reference document for determining competence for the use of pulse
oximetry.
To achieve these objectives the school nurse should use their clinical judgment when identifying
and determining if a student needs oximetry monitoring based on the student’s clinical condition.
Definitions
Pulse oximetry (SpO2) – uses the differential light absorption of reduced and oxygenated
hemoglobin o non-invasively determine (estimate) the percentage of arterial oxyhemoglobin
saturation (SaO2). It is indicated for monitoring a student’s clinical status, specifically the
adequacy of arterial oxyhemoglobin saturation and to measure the change in arterial
oxyhemoglobin saturation.
Baseline parameters – Normal parameters established by the school nurse and/or primary
physician for individual students based on their diagnosis and any pre-existing conditions.
Stable pulse oximetry reading – Student returns to baseline SpO2 or readings = > 95 for three
consecutive readings and/or a trending pattern that indicates overall stability in readings.
PR 65
Table 4 – Pulse Oximetry: What Do the Numbers Mean?
SPO2, %
PaO2, mm Hg
Oxygenation Status
95-100
80-100
Normal
91-94
60-80
Mild hypoxia
86-90
50-60
Moderate hypoxia
Less than 85
Less than 50
Severe hypoxia
Unstable pulse oximetry (SpO2) reading – Students SpO2 levels are below baseline (or < = 95),
or there is one or more de-saturation episode(s) in three consecutive readings, or evidence of a
downward trend.
Monitoring reassessment period – Time interval during which there is an identified risk for
hypoxemia.
Oximetry monitoring – is done for the purpose of assessing the stability of oxygenation status of
students with mild-to-moderate risk of hypoxemia. It provides early warning of a constant or
transient hypoxic episode before the onset of other clinical symptoms. Monitoring serves as a
guide for clinical decisions, treatment planning and possible transfer out of school for further
medical care.
Personnel Qualifications
Pulse oximetry is a relatively easy procedure to perform. However, if the procedure is not
properly performed, or if it is performed by persons who are not adequately educated about
device limitations or application, misinterpretation of readings may lead to inappropriate
intervention.
School nurses who are trained in the technical operation of pulse oximetry, measurement of vital
signs, and record keeping, may perform and record results of pulse oximetry.
Oximetry Monitoring
Spot-check monitoring is indicated for students with a mild-to-moderate risk for hypoxemia.
Oximetry monitoring can be used as an additional tool when assessment a student’s or staff’s
clinical status.
Clinical indications for monitoring may include, but not limited to:

Respiratory infections
PR 66

Asthma

Assessing the effectiveness of a aerosol treatment or meter dose inhaler

Aspiration

Anaphylaxis

Seizures

Cardiac disorders

Tracheostomy care

Student being assessed/compared to baseline

Any reason where the student or staff member’s oxygenation may be in questions
Oximetry monitoring should continue until the student/staff is back to their baseline or . 95. If
SpO2 levels are below baseline or < = 95 then further assessment and treatment is needed. If
student’s condition worsens, call 911 and follow the emergency plan for the school.
Discontinue monitoring if there is no suspected risk for hypoxemia.
Sensor Application
Pulse oximetry reading quality is greatly dependent upon operator knowledge and technique.
Selection of the site and application technique contributes to the accuracy and reliability of
readings.
The pulse oximeter is designed for use on fingers. The index finger is the recommended site.
The oximeter contains numeric LED (Light Emitting Diode) that display blood oxygen and pulse
rate readings. A red LED indicator light provides a visual indication of pulse signal quality.
Obtaining an Oxygen Saturation Reading
1. Insert the student’s index finger, nail side up, until the fingertip touches the built-in stop
guide.
2. Make sure finger is lying flat and is centered within the machine.
3. For best results, keep oximeter at student’s chest or heart level.
4. Press power switch.
5. Indicator lights for pulse and saturation will turn on immediately. Observe for 10 seconds for
continuous red light reading.
PR 67
Student Factors That May Cause Inaccurate/Low Readings:

Inadequate pulsation

Nail Polish

Deep skin pigmentation

Student movement

Cold extremities
Troubleshooting Strategies

Reinsert finger into machine or try other hand

Warm fingers by rubbing gently

Remove fingernail polish

Encourage student to hold extremity still

Position oximeter at chest level
Maintenance and Cleaning
Wipe the surface with a damp cloth and mild detergent or isopropyl. Dry with a soft cloth, or
allow to air dry.
PR 68
Puncture Wounds
Pencil Leads, Splinters, Etc.
Physical Findings
1.
2.
3.
4.
5.
Small skin laceration, usually 1/8 to ¼ inch long
Moderately severe pain
Little to no bleeding
Pencil lead: leaves purplish “tattoo” mark, usually permanent
Buried wood splinter: quite painful. Student can feel it “stick” when gentle pressure is
applied
Management
1.
2.
3.
4.
5.
Soak foot or hand in warm water to encourage drainage
Wash gently with plain soap and water
Try to get history of what punctured the skin
Determine date of last tetanus booster
Do not try to remove a splinter or other foreign object unless it is small and obviously
visible and palpable on top of skin surface and can easily be grasped with forceps. (Do
not go digging for it with a needle)
6. Place used splinter forceps in disinfecting solution
7. Use nursing judgment regarding referral to physician. Send physician date of last tetanus
booster
8. Pencil lead itself is rarely present, on the “tattoo”
Follow-up
1. Observe for appearance of cellulites, abscess, or lymphangitis
2. Remember: Pencil lead contains no lead, only graphite, which is non-toxic
PR 69
Rashes
Different Diagnoses of Common
Childhood Diseases Associated with Rash
See Communicable Disease Policy
PLEASE SEE POLICIES
PR 70
Ringworm – Tinea
Classification
1.
2.
3.
4.
5.
Tinea Pedis: Athlete’s foot
Tinea Cruris: Jock itch
Tinea Corporis: Ringworm of body
Tinea Capitis: Ringworm of scalp
Onychomycosis: Ringworm of nails
Physical Findings
1. Tinea Pedis: Scale lesions between toes. Vesiculo-papular (tiny pimples or blisters) and
scaly lesions on sides of feet. Rare in the pre-adolescent. May become secondarily
infected due to scratching
2. Tinea Cruris: Discolored areas between upper thighs extending upward onto groin and
buttock. Rare in the pre-adolescent, more common in the obese
3. Tinea Corporis: Small (1-3) reddish lesions on body or face, which gradually spread
while clearing in center. May be single or multiple
4. Tina Capitis: Small (3-5) circle of baldness with broken off hairs in center. Not seen after
adolescence
a. Must be distinguished from alopecia areata (completely bald areas) and
trichotillomania (a condition thought to be emotional; child pulls out own hair)
b. Thick crusted, oozy secondary infection of Tinea Capitis is called kerion
5. Onychomycosis: Discolored, thick, and wrinkled nails (rarely seen in children)
6. Itching: most prevalent in Tinea Pedis and Cruris
7. “Id” reaction – secondary allergic reaction on hands; tiny follicular vesicles, intense
itching
8. Wood’s Light is unreliable for diagnosis of Tinea Capitis since some strains of fungi do
not glow
Management
1. Tinea Pedis: May suggest over the counter medications to parent, if no improvement refer
to physician
2. Tinea Cruris and Tinea Corporis – exclude from school until under treatment
3. Tinea Capitis and Onychomycosis: Physician Referral
4. Exclusion from school is necessary for Tinea Capitis. May return after 24-48 hours of
treatment with a note from physician. Students with ringworm of the scalp should be
excluded from swimming during the treatment period
Follow-up
1. Watch for secondary impetigo
PR 71
2. Refer to physician: severe cases, cases which do not improve in 2-3 days, or if secondary
infection present
3. Health education: Condition may be contracted from animals
PR 72
Scabies
Physical Findings
1. Typical lesion is a “burrow” – a tiny irregular line which marks the path of the scabies
mite
2. Rash: Tiny papules, vesicles, pustule and scabs. Sometimes with tiny, linear dark scabs
0.5-1.0mm long
3. Location: Back of hands, web of fingers, front of forearms, lower abdomen, chest, and
axilla
4. Itching is intense, especially at night
5. Frequently found in other family members
6. Impetigo frequent as a secondary infection due to scratching
7. Itching may persist 2-4 days after treatment
Management
1. Exclude from school. May return after note from physician indicates no longer
communicable
2. Antihistamine ointments or lotions not helpful
3. Steroid ointments or lotions contraindicated
4. Lindane lotion should not be used more than twice in month
5. Instruct parent/guardian to wash clothes and bed linen at 120°F or hotter
Follow-up
1. See in health room each day or two after first treatment
2. Watch for impetigo; treat accordingly
3. Check siblings in school
PR 73
Scarlet Fever
Physical Findings
Scarlet Fever, also called “scarlatina”, is one of the common contagious childhood diseases. It
usually has an infection with the Group A Streptococcus. This infection can occur anywhere in
the body, but the most common site is in the tonsils and/or pharynx, thus “Strep Throat”. This
germ produces a toxin which causes the typical scarlatiniform rash: diffuse redness of cheeks
and upper chest on a background that feels like goose flesh. Later the rash spreads to other parts
of the body and, after 5-10 days results in peeling of the skin; large sheets peel in severe cases.
Most cases are mild and the student is only ill for a few days, but rarely, severe cases may occur.
The disease itself is not cause for concern, but two major complications, acute rheumatic fever of
the joints and heart, and acute glomerulonephritis (kidney disease) can be extremely serious.
Management
1. If the Strep Throat is treated properly (10 days of antibiotics), complications do not
occur
2. Some students have low fever, mild sore throat, and are treated with OTC pain reliever,
and never seen by physician. These undiagnosed cases are the ones that could develop
complications
Infectious Period
1.
2.
3.
4.
5.
Contagious 1-2 days before rash develops, and 4-5 days after
Those students who do not develop a rash are still contagious the same time
Some 10% students are carriers of group A Strep
Students may be considered non-contagious after they have been fever free for 24 hours
Proper antibiotic treatment may shorten stay home
Role of Nurse
1. Encourage completion of a 10 day course of antibiotics (usually penicillin)
2. Suspect strep throat. Students with flaming red tonsils covered with a thin pus exudates
are the most likely to have it, but the only way to be sure is by a throat culture
PR 74
Seizures – Epilepsy
Physical Characteristics
All Types
1. Distinct beginning and rapid cessation
2. Amnesia of seizure, sometimes including events that occurred a few seconds to minutes
prior to seizure
Partial Seizures
1. Simple partial seizures: (1) with motor signs (2) with somatosensory or special sensor
(visual, auditory, olfactory, gustatory, vertiginous) symptoms (3) complex partial seizures
Generalized Seizures
a.
b.
c.
d.
Absence seizures (1) typical – petit mal (2) atypical – petit mal variant, complex petit mal
Myocolonic seizures
Atonic seizures – “drop attacks”
Tonic-clonic seizure – Grand mal, major motor seizures, generalized convulsive seizure
Physical Findings
1. Partial Seizures – numbness, tingling, or pain. May originate on one part of body, visual
images or sensations, sudden tastes or smells
2. Absence seizures – Very brief (10-20 seconds) period of cessation of motion, brief loss of
consciousness but does not fall to floor, may drop glass or pencil, occasional brief
muscular twitches, may occur several times a day (as often as 20), lack of attention
3. Tonic-Clonic seizures – Tonic – body rigid with back arched, Clonic – convulsive
shaking, may be mild or severe, begins tonic, becomes clonic, sometimes preceded by
aura of sight, sound or smell, post-convulsive state: drowsy to deep sleep, frequency
varies from daily to monthly, to annually
Management
1.
2.
3.
4.
Do not stimulate by rubbing chest, face, or arms or loosening clothing
Do not try to force mouth open in tonic phase
Do not move patient during tonic phase or early part of clonic phase
If patient is on floor, position on side with mouth toward floor so oral secretions or
vomitus flow out
PR 75
5. Loosen tight clothing around neck after tonic and early clonic phase
6. Time the seizure and record description as objectively as possible
7. Grand mal seizures lasting more than 5 minutes require emergency evacuation to hospital
unless otherwise instructed for selected student
8. Refer to Seizure Swimming Policy on secondary level
9. Notify parents and get update on medicine if possible.
10. Give to EMS the student’s medical history and list of medications and any other
impairment.
PR 76
SEIZURES
Seizures may be any of the following:
-Episodes of staring with loss of eye contact
-Staring involving twitching of the arms and legs
-Generalized jerking movements of arms and legs
Unusual behavior for that person
(e.g. running, belligerence, making strange sounds
A student with a history of seizures should be
known to appropriate staff. An emergency care
plan should be developed containing a
description of the onset, type, duration and
after effects of the seizure.
If available, refer to student’s emergency care
plan.
Observe details of the seizure for
parent/legal guardian, emergency
personnel or physician. Note:
-Duration
-Kind of movement or behavior
-Body parts involved
-Loss of consciousness, etc.
-If student seems off balance, place him/her on the
floor (on a mat) for observation & safety.
-DO NOT RESTRAIN MOVEMENTS.
-Move surrounding objects to avoid injury.
-DO NOT PLACE ANYTHING BETWEEN THE
TEETH or give anything by mouth.
-Is student having a seizure lasting longer than 5
minutes?
-Is student having seizures following one another
at short intervals?
-Is student without a known history of seizures,
having a seizure?
-Is student having any breathing difficulties after
the seizure?
After seizure, keep airway clear by
placing student on his/her side. A
pillow should not be used.
Seizures are often followed by sleep. The
student may also be confused. This may last
from 15 minutes to an hour or more. After
the sleeping period, the student should be
encouraged to participate in all normal class
activities.
Contact
responsible
school authority
& parent or
legal guardian
PR 77
CALL EMS
Sexually Transmitted Diseases
Physical Findings
1. Varies greatly with specific disease. Over 20 diseases are classified as sexually
transmitted and reportable
2. Amount of discharge varies; may be none and usually does not smell bad
3. Variety of genital lesions: genital warts, herpes type II sores, primary chancre of syphilis
4. In most cases, clothing covers areas that may have sores
Management
1. No isolation or other procedures required unless lesions are open and visible (on lip,
finger, etc)
2. Refer cases to Allentown Health Bureau or family physician
3. Work with the principal to maintain confidentiality
4. Convince named contacts to report for treatment
5. Most state family codes permit treatment of a minor without parental consent or
notification
6. Convince student to notify parent/guardian, if possible
Follow-up
1. Convince student to continue full course of prescribed treatment and obtain necessary
tests
2. Convince student to cooperate in search for contacts
3. Educate student in regard to prevention, re-infection, and possible complications
PR 78
Skin Infection:
Cellulitis and Lymphangitis
Physical Findings
1. Usually occurs as a complication of a cut, abrasion, impetigo, boil, or other skin infection
or trauma. May be spontaneous
2. Cellulitis is first seen as a tiny edge of redness encircling the primary lesion
3. Redness spreads in circular fashion; is indication that local body defenses are not limiting
infection
4. Slight pain and swelling
5. Lymphangitis: red streak leading away from primary lesion
6. Student may have fever
7. Regional lymph nodes may be enlarged or painful
Management
1. Warm compresses
2. Refer to physician if no improvement after first
3. Refer to physician immediately if circle of redness is ½ cm or larger, over a joint, or on
the face
4. Refer Lymphangitis immediately
Follow up
1. Watch carefully! Capable of rapid spread
PR 79
Sprain of Ankle or Knee
Physical Characteristics
1.
2.
3.
4.
5.
History of trauma; twist or snap
History of previous injury to same joint
Pain
Swelling – may or may not be present; compare side-by-side with opposite extremity
Redness – may or may not be present; compare side-by-side with opposite extremity
Treatment
1. Rest: If uncomfortable to walk use crutches, or injury can worsen. Give permission to use
elevator (if any). If hall traffic is unmanageable on crutches, get permission to leave a
class a few minutes early
2. Ice pack: Apply to the painful area. Remove compression bandage while using ice. Apply
no more than 20 minutes at a time. It is important to avoid heat during the first 24-72
hours when swelling is still increasing. Heat will cause more swelling and prolong
inactivity
3. Compression: A pressure bandage reduces swelling; it is important to use a compression
bandage, especially when the ankle is not elevated. A 3” elastic ACE wrap is generally
used
4. Elevate extremity: keep the foot higher than the hip especially 72 hours following injury
5. Consult athletic office when necessary
6. For severe symptoms, notify parent/guardian and physician
Follow-up
1. If limp continues after first day, be sure student has seen a physician
2. Assist with provisions for support services during school hours for classes, stairs,
elevators, crutches, etc
PR 80
Sore Throat
Physical Findings
1.
2.
3.
4.
5.
6.
7.
Difficulty swallowing
Throat pain, dryness, scratchiness
Swollen nodes
Reddened pharynx/tonsils
White patches may be present
Fever may be present
Associated URI symptoms
Management
1. May gargle with warm salt water or mouth wash
2. If temperature is over 100°F, has white patches, or symptoms are persistent, notify
parent/guardian for physician referral
3. Hard candy or cough drops may provide temporary symptomatic relief. Be sure to
monitor elementary students until candy or cough drops are consumed
PR 81
Sting
Known Hypersensitivity to Insect Bites
Extreme hypersensitivity to insect sting is a potentially life threatening
condition. Known allergic students should receive medication as soon as the
sting is reported. Do not wait to observe for any reactions.
Management
1. Keep an emergency Epi-Pen adrenalin kit in a cool place where the child and responsible
adult can reach it quickly
2. From referring physician, get short, clearly written instructions with each emergency kit.
The school nurse cannot rely on the general instructions printed on the paper inside the
kit. The physician’s order must contain the name of the medication plus the dose and
time(s) to be given and the name of the student. It must be signed and dated
3. The school nurse should review the Emergency Medication procedure with the student’s
parents/guardians and obtain their written permission to give the medication as soon as
possible before a sting occurs
4. Following the sting, do not make the decision regarding giving or withholding doses
5. The school nurse should give emergency injection and/or oral medication at school as
ordered by the physician. If someone in the school is authorized to act in the absence of
the nurse, this should be documented and signed by principal, physician and
parent/guardian
6. The child should be allowed to give own injection and/or oral medication if it has been
properly prescribed by the physician, and written consent has been obtained from the
parent/guardian and principal
7. If the student cannot self-administer the medication, it should be administered by the
designated personnel and student should be evacuated to an emergency medical facility
as soon as the sting is reported
8. Notify parent/guardian of incident and need for follow-up care
9. Replace Epi-pen
PR 82
Stomach Ache
Physical Findings
1. Organic causes of stomach ache are found in less than 10% of all cases. One in 10
students complain of stomach ache and the most common ages are 5-10 years old
2. Most common symptom is usually pain in the lower abdomen or around the umbilicus.
This pain is less likely to have an organic cause than pain that is lateral
3. Pain may be related to stressful situations or meals. It rarely awakens the student from
sleep
4. Fever may indicate an organic cause and is usually an indication for sending the student
home
5. A student who complains of a stomach ache but looks alert, does not seem worried or
does not frown as if in pain usually does not have a serious condition
Management
1. Check the temperature. If it is under 100°F, rest on the right side in the health room for a
brief period
2. If the temperature is over 100°F, or if vomiting or diarrhea is present, the parent/guardian
should be notified and the student sent home
3. Advise parent/guardian not to give any medications or laxatives until they consult with
their physician
4. A cold pack or ice may be applied to the abdomen. Do not apply heat
5. A snack may help if meal is missed
6. Antacid Chewable tablets can be given to secondary student if nurse suspects stomach
ache due to eating and student is afebrile
PR 83
Student Health Record Order List
1. Current Update
2. Physicals and Immunizations
3. Physician Orders
4. Medical Referrals
5. Returned Referral Forms
6. Necessary Medical Information
7. Development Form
8. Dental Card
9. Added Progress Notes
PR 84
Sty
Physical Findings
1. Tiny abscess (0.5-1.0mm) on edge of eyelid
2. Slight redness around abscess
3. Occasional redness and tearing of eye
Treatment
1. Warm compresses
2. Ophthalmic antibiotic drops or ointment usually necessary (must be prescribed by
physician)
3. Do not use Bacitracin or other topical ointment
4. Refer to physician if no improvement in 2-3 days
5. School exclusion not necessary
Follow-up
1. Watch for unusual spread; should heal in 3-5 days
2. If infection continues or a hordeolum (cyst) develops, refer to an ophthalmologist
PR 85
Sun Stroke
Sunburn
1. Redness and pain. In severe cases swelling of skin, blisters, fever and headaches
2. Management: Ointments for mild cases if blisters appear and do not break. If breaking
occurs, apply dry sterile dressing. Serious, extensive cases should be referred
Heat Syncope (Fainting)
1. Same as simple fainting but is associated with heat and exercise
2. Management: See Fainting
Heat Cramps
1. Painful spasms usually in muscles of legs and abdomen possible. Heavy sweating
2. Management: Firm pressure on cramping muscles, or gentle massage to relieve spasm.
Give sips of water. If nausea occurs, discontinue water
Heat Exhaustion
1. Heavy sweating, weakness, skin cold, pale, clammy. Pulse thready. Normal temperature
possible. Fainting and vomiting
2. Management: Get student out of the sun. Lie down and loosen clothing. Apply cool, wet
cloths. Fan or move student to air-conditioned room. Sips of water. If nausea occurs,
discontinue water. If vomiting continues, seek immediate medical attention
Heat Stroke
1. High body temperature (106°F or higher). Hot and dry skin. Rapid and Strong pulse.
Possible unconsciousness
2. Management: Move the student to a cooler environment. Reduce body temperature with
cold bath or sponging. Use extreme caution. Remove clothing, use fans and airconditioners. If temperature rises again, repeat. Heat stroke is a severe medical
emergency. Call 911
PR 86
Tattoo and Piercing Care Procedures
Tattoo Aftercare
1. First two days post-tattoo wipe off any excess fluids and apply A&D ointment. This
promotes healing and retention of color
2. Do not bandage
3. After two days of treatment, may switch to hypoallergenic lotion (i.e.: Eucerin)
4. If there appears to be any allergic reaction to sunlight or tattoo pigment, discontinue care
and contact the tattooist
5. For the next 5 weeks:
a. Do not have the tattoo in direct sunlight
b. No swimming pools
c. No hot tubs or bathtubs
d. Do not scratch, pick or scrub tattoo
Skin Piercing (ear, eyebrow, navel, etc)
1. Cleanse area with antibacterial soap or salt water
2. Gently pat dry with disposable gauze or tissues
3. Don’t use alcohol, peroxide, betadine, or antibiotic ointment, as they are overly strong
and dry and can hinder healing
4. Excessive pain, redness or discharge should be referred
Tongue Piercing
1. To clean area use alcohol-free mouthwash or salt water rinse
2. After initial piercing cleanse area no more than 4-5 times daily
3. May give chipped ice for 1st 3-5 days for swelling or pain
PR 87
Transportation of Medication
Management
1. When a student is receiving a physician-prescribed medication transfers between schools
in the district, the sending school nurse will ask the parent/guardian to collect the
medication from the sending school and carry it to the receiving school
2. In the event that the parent/guardian is unable to do so, or fails to comply, the nurse will
contact the Home and School Visitor (HSV) (Secondary Schools) or the Student Services
Office (Elementary Schools) for transportation
3. The physician’s order and medication log sheet must be transported immediately upon
request. A fax copy is not sufficient
4. Medications will be placed in a paper bag that is folded and sealed. The quantity of the
medication will be verified by the nurse at both the sending and receiving schools
5. Paraprofessionals will transport medication logs, physician orders, medications, and
equipment for the Elementary Schools and HSV will transport for their assigned school,
or as needed.
PR 88
Influenza-Like Illness
(ILI)
Definition
Also known as Acute Respiratory Infection (ARI) and flu-like syndrome; a medical
diagnosis of possible influenza or other illness causing a set of common symptoms.
Physical Characteristics
1. High fever (over 100°F), shivering, chills, malaise, dry cough, loss of appetite, body
aches, nausea
2. High risk populations; chronic lung disease (i.e.: asthma), cardiovascular disease, kidney,
liver or blood disorders (i.e.: sickle cell anemia), nervous system disorders, metabolic
disorders (i.e.: diabetes), suppressed immune system, pregnancy
Management
1.
2.
3.
4.
5.
Determine if student meets criteria of high fever along with other symptoms
Send home as soon as possible
Isolate students from others
If unable to isolate, have client wear surgical mask
Encourage students to stay home until there is no fever for 24 hours without the use of
medications
6. If student is in high risk population, they should seek medical attention immediately
Follow-up
1.
2.
3.
4.
5.
6.
7.
Monitor absence excuses between main office and health room staff
Encourage students to stay home when sick
Teach a good hand hygiene in the health room
Teach respiratory etiquette for coughing and sneezing
Separate the ill students from the well students and staff
Monitor cleaning of the health room and adjacent bath rooms
Use N95 masks when advised to do so.
PR 89