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					                                      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

   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
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.   Severe pain
       b.   Bleeding
       c.   Possible fracture, dislocation – occurring in school or enroute to school
       d.   Swelling, contusion, bruise, possible sprain – occurring in school or enroute to
       e.   Recognizable illness – rashes
       f.   Illness that demands that the student be sent or taken home
       g.   Cramps
       h.   Burns occurring in school or enroute to school
       i.   Bites, stings – occurring in school or enroute to school
       j.   Severe toothache
       k.   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


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.   Possible bruise visible
            b.   Gradual onset of apprehension
            c.   Pain and tenderness to mild pressure
            d.   Abdominal distention
            e.   Vomiting
            f.   Rapid, weak pulse with low blood pressure
            g.   Gradual onset of shock and coma
            h.   Blood in urine shortly after trauma or next day


   1. Keep in health room for 15 minutes after blow to abdomen
   2. Allow to rest in position of comfort
   3. Monitor pulse and blood pressure
   4. If student has none of the above symptoms, may return to class. Tell student to return if
      symptoms occur
   5. If any symptoms ensue, refer to emergency room or physician


   1. Advise student to return if symptoms occur
   2. Notify parent

                                                PR 3

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


   1. Wash gently with soap and water
   2. During wash, try to remove loose skin tags and crusts by gently rubbing with 4x4 gauze
   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


   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


   1. Infection:

            a.   Pus on abrasion itself, usually located under crusts
            b.   Cellulitis: spreading red area immediately around the abrasion
            c.   Lymphangitis: red streaks radiating out from abrasion
            d.   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

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

Behavioral Findings

Withdrawing, school phobia, defensiveness, or depression may be present.


   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-the-
      counter 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
   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
          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


A rare, extremely serious form of allergic reaction. Onset is rapid, may have no previous
symptoms, and requires instant action to prevent fatality.


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.


   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


   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
                                       Iron Deficiency

Physical Characteristics

   1. Usually none except in moderate to severe cases (children with hemoglobin levels over 7-
      8 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.


   1. Refer to physician for confirmation of anemia
   2. Encourage student to eat iron-containing foods: meat, fish, poultry, soybeans, and iron-
      enriched foods.
   3. Iron supplement tablets prescribed by physician.


   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.   Extreme thinness (loss of at least 25% of normal weight)
   2.   Refusal to eat
   3.   Usually, cessation of menstruation
   4.   Often associated with bulimia (binges of over-eating followed by vomiting)
   5.   Ninety-five per cent of cases are girls between 12-18
   6.   Excessive exercising
   7.   Denial of any problems, frequently antagonistic


   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


   1.   Provide safe haven in health room where the student can freely discuss problems
   2.   Weight at regular intervals
   3.   Recurrence is common
   4.   Significantly mortality: exert maximum efforts to encourage resumption of normal diet

                                             PR 8

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
   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
   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


   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


   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


Inability to breathe due to choking, inhalation of toxic fumes, drowning, or strangulation

Physical Findings

   1.   Student conscious and making attempts to breathe
   2.   Complete or near-complete inability to speak
   3.   Grasping of neck, usually with both hands, palms toward neck
   4.   Rapid onset of cyanosis (blueness of lips and finger tips), cessation of breathing efforts,
        and loss of consciousness


   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


   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


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.


   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.   Rapid or sudden onset
   2.   Respiratory difficulty, with cough and/or wheeze
   3.   Prolonged expiration
   4.   High-pitched whistling wheezes heard with stethoscope on chest or by holding ear close
        to patient’s mouth
   5.   Pulse rate over 150 suggests severe asthma or excess medication
   6.   No fever in typical cases
   7.   Student breathes easier sitting up
   8.   Symptoms may be initiated or made worse by exercise


   1. Avoidance of dust, molds, animals, pollens, foods, medicines, and other allergic
   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)


   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,               11. Interrupts conversation
                                                       12. Doesn’t seem to listen
        4. Easily distracted
                                                       13. Loses things like pencils,
        5. Blurts out answers before                       assignments
           question is finished
                                                       14. Engages in dangerous activities
        6. Difficulty following instruction,               without considering the consequences
           fails to finish                                 (not thrill seeking) like running in
                                                           street without looking
        7. Can’t sustain attention

        8. Shifts from one uncompleted
           activity to another


   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

   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


   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.   Symptoms such as pneumothorax can develop slowly, even over 1 or 2 days
   2.   Rapid, shallow respirations
   3.   Painful breathing
   4.   Distended neck veins
   5.   Cyanosis
   6.   Muffled heart sounds
   7.   Low blood pressure


   1. Following chest injury of unusual severity, have student rest in health room for 15 to 20
   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

Dog Bites

   1.   Wash with copious amounts of soap and water
   2.   Apply loose dressing and elevate extremity
   3.   Refer to Emergency room or physician
   4.   Record date of last Tetanus booster
   5.   Report to Health Bureau
   6.   Prophylactic oral antibiotics may be prescribed, especially for bites on the hand

Human Bites

   1.   Highly susceptible to infection
   2.   Wash copiously
   3.   Refer to physician with date of last Tetanus booster, if skin is broken
   4.   Transmission of Hepatitis B, syphilis, and other diseases must be considered

Insect Bites

   1.   See “Anaphylaxis” if necessary
   2.   See “Bee Sting” below if necessary
   3.   Apply ice and Sting-Kill
   4.   Inquire about type of insect bite
   5.   Contact parent/guardian and check for allergy or sensitivity
   6.   If necessary, advise medical care

Bee Stings

   1.   Remove stinger, if present, by scraping. Do not pull out
   2.   Apply Sting-Kill and cold pack to alleviate swelling
   3.   Contact parent/guardian and check for allergy or sensitivity
   4.   Administer Epi-Pen, if ordered
   5.   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
   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.   Remove tick carefully with tweezers, with steady firm pressure applied upward
   2.   Cleanse area with soap and water
   3.   Notify parents that a tick was removed at school, discuss with parent disposition of tick
   4.   Ticks should be identified as to: 1. Genus and species, 2. Life stage, 3. Engorgement level
   5.   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

        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


   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


   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

Physical Findings

   1. Fluid filled vesicle on skin surface secondary to friction
   2. Redness of surrounding skin


   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”


   1. Observe for signs of infection

                                             PR 19

Physical Findings

   1.   Skin abscess originating under the skin in a sweat gland
   2.   Pain, swelling and redness
   3.   Gets to be about the size of a marble (1-2cm)
   4.   Redness progresses to yellowish center of pus


   1.   Do not treat
   2.   Apply sterile dressing if three is profuse drainage
   3.   Do not open with needle or knife or other instrument
   4.   Do not squeeze hare to express “core” or “head” as most boils do not have one
   5.   Advise parent/guardian to seek medical treatment


   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

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


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. Call 911
   2. Remove clothing only where it is easy to do so
   3. Lay patient flat
   4. Do not use ice
   5. 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

   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

  1. Consult with Poison Control Center 1-800-222-1222
  2. Have product label information ready
  3. Notify parent/guardian

   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.   Facial burns – refer to physician in all cases
   2.   Chemical or electrical burns – refer to all cases
   3.   Send date of last tetanus booster with all physician referrals
   4.   Be alert to possible child abuse


   1.   Dressing changes as physician directs
   2.   Observe for secondary infection
   3.   Refer to physician if area enlarges or if no improvement
   4.   Observe for scarring, especially on flexor areas of arms, legs and neck

                                               PR 22
                            Common Cold Versus Allergic Rhinitis

Physical Findings

                     Allergy                                               Cold
   1.   Nasal discharge remains watery                    1.   Nasal discharge gradually thickens
   2.   More sneezing                                          and crusts
   3.   Little or no cough                                2.   Less sneezing
   4.   Comes and goes during entire season               3.   Cough starts dry and becomes loose.
   5.   Eyes usually red                                       Worse with exertion
   6.   Fewer lymph nodes in neck                         4.   Duration 1-3 weeks
                                                          5.   Eyes usually not red
Remember                                                  6.   More neck nodes

Students with allergic rhinitis may also “catch


   1.   Exclude from school if student has fever greater than 100° F. or severe cough
   2.   Educate about picking and blowing nose
   3.   Encourage high fluid intake
   4.   If slight sore throat, may gargle with mouthwash or warm salt water
   5.   Do not use aspirin under age 18


   1. Refer to physician for complications: earache, fever, vomiting, headache, loss of appetite,
      sore throat
   2. See in health room as necessary

                                    Is It a Cold Or The Flu
         Symptoms                             Cold                              Flu
Fever                               Rare                            High (102-104°F.)
                                                                    Sudden onset 2-4 days
Headache                            Rare                            Prominent
General aches and pains             Slight                          Usual; often quite severe
Fatigue and weakness                Quite mild                      Extreme: can last 2-3 weeks
Prostration                         Never                           Early and prominent
Running, stuffy nose                Common                          Sometimes
Sneezing                            Usual                           Sometimes
Sore Throat                         Common                          Sometimes
Chest discomfort, cough             Mild to moderate                Common; can become

                                              PR 23
                                         Contact Lenses

   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


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. Un-
sterile, homemade solutions are very dangerous. Sterile saline can be used in the school health


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.   Look down with eyes
   2.   With finger on upper lash margin, pull upper lid up and press against white of the eye
   3.   Use eye lid to push lens down to center and hold
   4.   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

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.

   1. Have student rinse mouth vigorously with warm, salt water. Floss gently fro trapped
   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
  4. Obtain immediate dental care

Chipped Tooth
   1. Clean any dirt, blood, debris from the injured area with a sterile gauze pad and warm
   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


   1.   Ice pack, applied with as little pressure as possible
   2.   Do not compress
   3.   Do not try to put back into place
   4.   Notify parent/guardian and refer to physician or emergency room


   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


   1.   Assess student’s behavior and vital signs
   2.   Determine type of reaction, if possible
   3.   Call 911 or Crisis Intervention, if needed
   4.   Fill out physical assessment checklist
   5.   Notify parent/guardian and administrator


   1. See policy for Drug Abuse

                                              PR 29

Physical Findings

   1.   Student complains of discomfort in one or both ears
   2.   May be associated with a fever
   3.   May have drainage from ear(s)
   4.   May have reddened tympanic membrane/canal


   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


   1. Student must bring in a physician’s note if he/she is to be excluded from swimming

                                             PR 30

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


   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


   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

                                             PR 31


   1. Child is too young to be toilet-trained. Children 3-5 need a toilet in or near classroom
   2. Meatal stenosis in boys
   3. Boys with excessively long foreskin with poor hygiene
   4. Chronic urinary tract infection
   5. Small bladder capacity, irritable bladder, poor sphincter control, or other organic
   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
   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


   1.    Protect privacy of child’s problem from other children
   2.    Make toilet and washing facilities available
   3.    Help child make pre-need trip to bathroom
   4.    Liaison with parents/guardians and physician, when necessary

                                             PR 32
                                          Eye Trauma

Physical Findings

   1.   History of blow or other trauma to eye
   2.   Pain in eye
   3.   Redness of conjunctiva
   4.   Eye held closed


   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


   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
   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


   1. Examine eye on following day
   2. Check vision on Snellen Chart on following day and refer if not same as before the

                                             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)


A brief, partial or complete loss of consciousness due to diminished oxygen supply to the brain.


   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.


   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
   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.   Post seizure sleep is longer and deeper
          b.   Seizures occur with no warning except occasional aura
          c.   Seizure twitching is more severe and lasts longer
          d.   Fainters usually know when it is going to happen
          e.   Some excessively frequent fainters must be referred to physician for a diagnosis
          f.   Fainters usually remember what happened after they wake up


   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

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


   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.


   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


   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


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

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.


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



   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


   1. Do not try to remove unless foreign body can be easily seen and grasped with forceps or
   2. Notify parent/guardian and refer to physician
   3. Treat ear wax the same way


   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


   1.   Eye: Check with teacher to ensure that student is symptom free
   2.   Eye: For chemicals, recheck visual acuity for 3-7 days after treatment
   3.   Ear: None if foreign object removed
   4.   Nose: None if foreign object removed; check for cessation of nasal discharge

                                              PR 40

Physical Findings

   1.   Localized pain following trauma
   2.   Frequently, asymmetry compared to opposite side. Not always present
   3.   May be swelling and/or redness but not always present
   4.   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.   Ribs
   2.   Fingers and toes (especially chip fractures)
   3.   Elbows
   4.   Knees


   1. Ice, compression, elevation
   2. Notify parent
   3. Immediate evacuation to physician’s office or emergency room


   1. Periodic inspection of casts, splints, dressings
   2. Accommodations for leaving class early, use of elevator

                                              PR 41
                                           Frost Bite

Physical Findings

   1.   Cold, itchy or tingly, numb feeling
   2.   Mild: edema or mild purplish color which soon subsides
   3.   Moderate: move edema and deeper purple-blue color. Blisters appears in 24-48 hours
   4.   Severe: more edema and black color with death of tissue. Blisters do not appear
   5.   Most common on fingers, toes, nose, cheeks, and earlobes
   6.   Severity not apparent until frost-bitten area is re-warmed


   1.   Remove any wet clothing
   2.   Re-warm the affected area with warm (not hot) water bath for 20-30 minutes
   3.   The affected part should not be rubbed or massaged during re-warming
   4.   Check oral temperature for generalized hypothermia. If present, refer to ER
   5.   Refer to physician if beyond mild stage
   6.   Do not use ice water massage, snow massage or use of excessive dry heat
   7.   Elevate the injured extremity to minimize edema
   8.   Keep student indoors for remainder of school day
   9.   Notify parent/guardian


   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


   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

Brain Injury – Concussion
   1. State of consciousness: classify the injury as mild, moderate, or severe by the following

           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)


   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
            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


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
   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

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.


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


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.   Usually quieter, with occasional exceptions
   2.   Usually disappear or change in character with change in position
   3.   Not always present from day to day
   4.   No signs or symptoms of organic heart disease
   5.   No history of organic heart disease


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

Physical Findings

   1.   Verbalizes pain, pressure or pounding
   2.   Visual disturbances
   3.   Nausea/vomiting
   4.   May be associated with other symptoms i.e. stomach ache, URI, allergies
   5.   Eye strain
   6.   Anxiety/stress
   7.   Fatigue


   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


   1. Maintain communication with student and family for follow-up as necessary

                                            PR 48
                                       Hepatitis A and B


   1. Increased prevalence of Hepatitis B among institutionalized mentally retarded and their
   2. Different methods of transmission of Hepatitis A (fecal, oral) versus Hepatitis B (blood
      and body fluids)

     Differences                        Hepatitis A                    Hepatitis B
     Incubation period                  4-6 weeks                      1-6 months
     Period of infectivity              Short                          May be long
     Can be carrier                     No                             Yes

Physical Findings (same for Hepatitis A & B in early stages)

   1.   Fever, malaise, headache, fatigue
   2.   Loss of appetite, nausea, stomach ache, vomiting
   3.   Jaundice
   4.   Dark urine, light colored stools
   5.   Mild in most cases; children are well in 7 days or less
   6.   May have all symptoms except jaundice. Usually remain undiagnosed but are just as


   1. Refer to physician
   2. Student may return to school as physician recommends


   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.   Small, dark to light, grayish-amber crusts around nose or lips
   2.   “Canker-sores” inside cheeks for tongue may or may not be due to Herpes Simplex virus
   3.   May come and go in susceptible students over a period of 1-3 years (unusual)
   4.   May re-appear with emotional or physical stress


   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)


   1. A skin allergy which may be due to the following factors – in order of frequency:

            a.   Foods
            b.   Medications
            c.   Emotional factors
            d.   Inhalants (pollens, dust)
            e.   Contact substances (dust, plants)
            f.   Physical factors (sun, cold)

Physical Findings

   1.   Round, reddish-pink wheals on skin surface varying in size from ½ cm. to 2-3 cm.
   2.   May become confluent and larger
   3.   Tend to be clear in center with surrounding redness
   4.   Not tender or painful, but itchy
   5.   Characteristically short-lived by re-appear, often in other parts of body
   6.   May be accompanied by swelling of lips, eyes, fingers, genitalia
        difficult breathing


   1.   Notify parent – can recommend some OTC lotions
   2.   Cold compresses for itching
   3.   Refer new cases to physician
   4.   Give antihistamine or other medications prescribed by physician
   5.   Keep in health room to make sure systemic symptoms are not present
   6.   If laryngeal edema suspected, administer Epi-Pen and evacuate to medical facility
        immediately – call 911. Call parent/guardian


   1. Students to follow-up in health room if symptoms continue

                                               PR 51

Physical Findings

   1.   Primary lesion is a vesicle that rapidly becomes pustular
   2.   Honey-colored loosely adherent crusts
   3.   May have wet or crusted pustules
   4.   Most frequently found on dingers and face but may be anywhere on body
   5.   Itching
   6.   Contagious on direct or secondary contact
   7.   Deeper lesions with thick adherent crusts called ecthyma


   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


   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


   1. Cuts which are clean, straight, less than 1/2” long, with edges separated less than 1/8”

            a.   Apply firm pressure until bleeding stops
            b.   Clean thoroughly with antiseptic soap and copious amounts of water
            c.   Dry
            d.   Apply plain or butterfly dressing, and an antibiotic ointment
            e.   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


   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


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 ring-
shaped 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.


    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
    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


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



   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


   1. Requires evaluation when:

           a. Menarche delayed beyond 16 years
           b. No secondary sexual characteristics develop by age 14 (breasts, pubic and axillary

                                              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
           c. Possible development of osteoporosis due to lack of estrogen

Premenstrual Syndrome (PMS)


   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.   Warn against excessive medication, especially addictive drugs such as codeine
   2.   Provide comfortable, quiet rest area
   3.   Keep supply of sanitary pads to sell to student (ordered through custodial office)
   4.   Refer to severe menstrual disorders to physician
   5.   Be on alert for amenorrhea in girls who should have passed menarche

                                              PR 56
                            Mononucleosis (Glandular Fever, Mono)

Physical Findings

   1.   Milder in young children, more severe in high school and college age
   2.   Fever, malaise, and fatigue
   3.   Sore throat and enlarged, red, exudative tonsils
   4.   Lymph nodes swollen in axilla, groin, above elbow, and especially in neck
   5.   Enlarged spleen
   6.   Maculopapular rash, jaundice (rare)
   7.   Fever may last 1-2 weeks; fatigue and malaise may last 4-6 weeks


   1.   Refer to parent/guardian to seek medical advice
   2.   Return to school on advice of physician
   3.   Penicillin often given but its value is questionable
   4.   Ampicillin often causes a rash
   5.   Steriods often given for severe tonsillitis but their value is questionable


   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
                           Methicillin-resistant Staphylococcus Aureus


   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.


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.


      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.  Onset occurs between 2 and 6 years of age
   2.  Slowly gets worse
   3.  Clumsiness, toe-walking, lordosis (sway back), frequent falling
   4.  Difficulty with stairs and getting up from floor
   5.  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


   1. Liaison with physical therapist
   2. Assist with toileting: Transfer from wheel chair to toilet
   3. Liaison with counselor (problems associated with fatal illness)
   4. 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


   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


   1. Restrict excessive physical exertion remainder of that day only, especially if it is hot and
   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.   Redness of whites of eyes
   2.   Purulent or watery discharge
   3.   Redness and/or swelling of eyelids
   4.   Itching and rubbing of eyes
   5.   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
   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


   1.   Wash eye gently with cool compresses for temporary relief of symptoms
   2.   Check visual acuity. It should be unchanged or normal
   3.   Check fingers and nose for impetigo
   4.   Antibiotic drops or ointments may be prescribed by physician for infections
   5.   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
   6.   In other cases, refer to physician and exclude until under treatment for 24 hours (see
        Communicable Diseases)
   7.   If subconjunctival hemorrhage is present, and accompanied by the above symptoms, refer
        to physician
   8.   Send Information for Parents – Pink Eye sheet with student
   9.   Inform student to avoid eye makeup and not to share eye makeup

                                              PR 62

Physical Findings

Intense itching at anal area, especially at night


   1.   Seek medical attention
   2.   Instruct parent/guardian to wash bed linen and underclothes in 120°F or hotter
   3.   Change underwear at least twice per day
   4.   Vigorous hand-washing and nail care, especially upon waking
   5.   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


   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


   1.   Observe for infection (see Abrasions) and treat as needed
   2.   Warn against re-exposed, as the reaction will be worse next time
   3.   Educate about appearance of plant
   4.   Desensitization shots usually are not effective and may be harmful to small number of

                                             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.


      To establish monitoring guidelines for the use of pulse oximetry.
      To describe clinical criteria for determining if a student is a candidate for oximetry
      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

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.


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

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

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

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
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.   Small skin laceration, usually 1/8 to ¼ inch long
   2.   Moderately severe pain
   3.   Little to no bleeding
   4.   Pencil lead: leaves purplish “tattoo” mark, usually permanent
   5.   Buried wood splinter: quite painful. Student can feel it “stick” when gentle pressure is


   1. Soak foot or hand in warm water to encourage drainage
   2. Wash gently with plain soap and water
   3. Try to get history of what punctured the skin
   4. Determine date of last tetanus booster
   5. 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
   8. Pencil lead itself is rarely present, on the “tattoo”


   1. Observe for appearance of cellulites, abscess, or lymphangitis
   2. Remember: Pencil lead contains no lead, only graphite, which is non-toxic

                                              PR 69
                Different Diagnoses of Common
            Childhood Diseases Associated with Rash

               See Communicable Disease Policy


                            PR 70
                                      Ringworm – Tinea


   1.   Tinea Pedis: Athlete’s foot
   2.   Tinea Cruris: Jock itch
   3.   Tinea Corporis: Ringworm of body
   4.   Tinea Capitis: Ringworm of scalp
   5.   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
          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
   8. Wood’s Light is unreliable for diagnosis of Tinea Capitis since some strains of fungi do
      not glow


   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


   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

Physical Findings

   1. Typical lesion is a “burrow” – a tiny irregular line which marks the path of the scabies
   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
   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


   1. Exclude from school. May return after note from physician indicates no longer
   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


   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.


   1. If the Strep Throat is treated properly (10 days of antibiotics), complications do not
   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

Infectious Period

   1.   Contagious 1-2 days before rash develops, and 4-5 days after
   2.   Those students who do not develop a rash are still contagious the same time
   3.   Some 10% students are carriers of group A Strep
   4.   Students may be considered non-contagious after they have been fever free for 24 hours
   5.   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.   Absence seizures (1) typical – petit mal (2) atypical – petit mal variant, complex petit mal
b.   Myocolonic seizures
c.   Atonic seizures – “drop attacks”
d.   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


     1.   Do not stimulate by rubbing chest, face, or arms or loosening clothing
     2.   Do not try to force mouth open in tonic phase
     3.   Do not move patient during tonic phase or early part of clonic phase
     4.   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

                                        PR 76

Seizures may be any of the following:
-Episodes of staring with loss of eye contact               A student with a history of seizures should be
-Staring involving twitching of the arms and legs          known to appropriate staff. An emergency care
-Generalized jerking movements of arms and legs                plan should be developed containing a
Unusual behavior for that person                             description of the onset, type, duration and
(e.g. running, belligerence, making strange sounds                    after effects of the seizure.

  If available, refer to student’s emergency care                Observe details of the seizure for
  plan.                                                          parent/legal guardian, emergency
-If student seems off balance, place him/her on the              personnel or physician. Note:
floor (on a mat) for observation & safety.                       -Duration
-DO NOT RESTRAIN MOVEMENTS.                                      -Kind of movement or behavior
-Move surrounding objects to avoid injury.                       -Body parts involved
-DO NOT PLACE ANYTHING BETWEEN THE                               -Loss of consciousness, etc.
TEETH or give anything by mouth.

                                                      -Is student having a seizure lasting longer than 5
  After seizure, keep airway clear by                 -Is student having seizures following one another
  placing student on his/her side. A                  at short intervals?
      pillow should not be used.                      -Is student without a known history of seizures,
                                                      having a seizure?
                                                      -Is student having any breathing difficulties after
                                                      the seizure?

     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
                                                                           CALL EMS

                                             school authority
                                                & parent or
                                              legal guardian

                                              PR 77
                                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


   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
   6. Convince student to notify parent/guardian, if possible


   1. Convince student to continue full course of prescribed treatment and obtain necessary
   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
   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


   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.   History of trauma; twist or snap
   2.   History of previous injury to same joint
   3.   Pain
   4.   Swelling – may or may not be present; compare side-by-side with opposite extremity
   5.   Redness – may or may not be present; compare side-by-side with opposite extremity


   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
   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
   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


   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.   Difficulty swallowing
   2.   Throat pain, dryness, scratchiness
   3.   Swollen nodes
   4.   Reddened pharynx/tonsils
   5.   White patches may be present
   6.   Fever may be present
   7.   Associated URI symptoms


   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
                          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.


  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
  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
   4. Fever may indicate an organic cause and is usually an indication for sending the student
   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


   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

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


   1. Warm compresses
   2. Ophthalmic antibiotic drops or ointment usually necessary (must be prescribed by
   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


   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


   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 air-
      conditioners. 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


  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


       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


   1. Determine if student meets criteria of high fever along with other symptoms
   2. Send home as soon as possible
   3. Isolate students from others
   4. If unable to isolate, have client wear surgical mask
   5. Encourage students to stay home until there is no fever for 24 hours without the use of
   6. If student is in high risk population, they should seek medical attention immediately


   1.   Monitor absence excuses between main office and health room staff
   2.   Encourage students to stay home when sick
   3.   Teach a good hand hygiene in the health room
   4.   Teach respiratory etiquette for coughing and sneezing
   5.   Separate the ill students from the well students and staff
   6.   Monitor cleaning of the health room and adjacent bath rooms
   7.   Use N95 masks when advised to do so.

                                             PR 89

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