SCHOOL NURSE RESOURCE MANUAL Tenth Edition: Tenth Edition: A Guide to Practice

SCHOOL HEALTH ALERT

P.O. Box 150127

Nashville, TN 37215

SCHOOL NURSE RESOURCE MANUAL 2020

Copyright 2020 © School Health Alert

NOTICES

Nursing, including school nursing, is a dynamic, constantly changing field. The publisher, editors and contributors have made a diligent effort to ensure any guidelines, procedures or recommendations outlined in this manual are accurate, based on latest evidence, and in accordance with accepted school nursing practices at the time of publication. It is, of course, necessary for readers to apply their professional judgment, experience, knowledge of the patient, and any new research to determine the best treatment for a specific case. Additionally, it is the responsibility of the school nurse to adhere to their individual state nurse practice act when administering any treatment or medication.

Several websites are included in this manual to provide additional information, resources and references on a particular topic. However, listing these websites does not imply endorsement. Note that with any internet site, addresses and content may change, and information therein updated.

Mentions of any specific products within this book are for informational purposes and also do not constitute endorsements.

ISBN-13: 978-0-9792497-5-4ISBN-10: 0-9792497-5-9

ISBN: 978-0-972497-9-2 (e-book)

Copyright © 2020 by School Health Alert. All rights reserved. This publication may not be reproduced or distributed in any form or any means, or stored in a database or retrieval system, without the prior written permission of the publisher. Permissions may be requested via email at: [email protected].

Table of contents

Introduction to the Manual

Clinical Guidelines Index

About This Manual

Student Services/Multi-Disciplinary Teams

Acknowledgements

SECTION I: CLINICAL GUIDELINES

SECTION II: CLINICAL PROCEDURES

Catheterization, Urinary

Diabetes Monitoring

Enteral Feedings (Tube Feedings)

Medication Administration

Tracheostomy Care

SECTION III: SCHOOL NURSE MANAGEMENT

Disaster Preparedness

Do Not Attempt Resuscitation (DNAR)

Emerging and Reemerging Infectious Diseases in Schools

Environmental Health

Foodborne Illness

Immunizations

Medical Devices (Visible and Implanted), Management of

Organ Transplant, Management of Students with Solid

Recess: Promoting Safe Physical Activity During the School Day

School Refusal

School Sponsored Trips

Vaping

SECTION IIV: MANAGEMENT OF VULNERABLE POPULATIONS

INTRODUCTION- Social Determinants of Health

Bullying in Schools

Child Maltreatment

Developmental Disabilities

Down Syndrome

Homelessness

Human Trafficking

Mental Health Management

Refugee and Asylee Children and Adolescents

Sexual Minority Youth

Suicide Ideation/Threats

Teen Pregnancy/Teen Pregnancy Prevention

Trauma Informed Care

APPENDIX

Cover Your Cough

Hand Hygiene: Why, How & When?

Handwashing and Hand Sanitizer Use

Stop Germs! Wash Your Hands. (For Parents)

Handwashing: Keep Your Family Healty (For Parents)

Key Steps of Standard Precautions

CLINICAL GUIDELINES INDEX

ABDOMEN--BLUNT INJURY

ABDOMINAL PAIN/APPENDICITIS

ABRASIONS

ACUTE FLACCID MYELITIS (AFM)

ADRENAL INSUFFICIENCY

ALLERGIES

ALLERGIES, LATEX

ALLERGIES, STING

ANAPHYLAXSIS

Anorexia (See EATING DISORDERS)

ANXIETY DISORDER IN CHILDREN AND ADOLESCENTS

ASTHMA/ASTHMA EMERGENCIES

ATTENTION DEFICIT HYPERACTIVITY DISORDER

AUTISM SPECTRUM DISORDER

BACK AND NECK INJURY

BED BUGS

BIPOLAR DISORDER

BITES: ANIMAL AND HUMAN

BLISTERS

Boils (See SKIN INFECTIONS) Bulimia (See EATING DISORDERS)

BURNS

Canker Sores (See STOMATITIS)

CARDIAC CONDITIONS – LIFE THREATENING

CELIAC DISEASE

CHEST PAIN

Chickenpox (See VARICELLA)

CHILDHOOD CANCER

CONCUSSION/HEAD INJURY

CONJUNCTIVITIS

CONSTIPATION

CONTACT LENS PROBLEMS

CROHN’S DISEASE

Cuts (See LACERATIONS)

CYSTIC FIBROSIS

CYTOMEGALOVIRUS (CMV)

DENTAL EMERGENCIES

DEPRESSION

DIABETES EMERGENCIES

DIABETES INSIPIDUS

DIABETES TYPE 1

DIABETES TYPE 2

DIARRHEA

DIPHTHERIA

DYSPHAGIA (SWALLOWING DISORDERS)

EAR PAIN

EATING DISORDERS--ANOREXIA AND BULIMIA

ECZEMA (ATOPIC DERMATITIS)

ENCOPRESIS

ENURESIS

Epilepsy (See SEIZURES)

EYE TRAUMA

FACTITIOUS DISORDER

Fainting (See SYNCOPE)

FEVER

FIFTH DISEASE (ERYTHEMA INFECTIOSUM)

FOOD ALLERGIES

FOREIGN BODIES: EYE, EAR, NOSE

FRACTURE

Head Injury (See CONCUSSION)

HEADACHE(S) (INCLUDES MIGRAINE)

HEART MURMURS

HEAT-RELATED ILLNESS

HEMOPHILIA

HEPATITIS A, B, C

HERPES SIMPLEX – ORAL

HIV

Hives (See URTICARIA)

HPV

HYPOTHERMIA

Illness Falsification (See FACTITIOUS DISORDERS)

IMPETIGO

INFLUENZA

KIDNEY DISEASE/CHRONIC

LACERATIONS

LEAD POISONING

LEUKEMIA

LICE (HEAD) - PEDICULOSIS CAPITIS

Lyme Disease (see TICK-BORNE DISEASES)

MEASLES AND RUBELLA

MENINGITIS

MENSTRUAL DISORDERS

MOLLUSCUM CONTAGIOUSM

MONONUCLEOSIS (GLANDULAR FEVER, MONO)

MOSQUITO-BORNE DISEASES

MRSA (See SKIN AND SOFT TISSUE INFECTION)

MUMPS

MUSCULAR DYSTROPHY

NOROVIRUS

NOSEBLEED (EPISTAXIS)

ORAL HEALTH

Oral Lesions (See STOMATITIS)

PANDAS/PANS

PERTUSSIS

Pink Eye (See CONJUNCTIVITIS)

PINWORM INFECTION

Pityriasis Rosea (See RASHES)

PNEUMONIA

POISON IVY/OAK (CONTACT DERMATITIS)

PUBERTAL GROWTH AND DEVELOPMENT

PUNCTURE WOUNDS (MINOR, FOOT)

RASHES

RINGWORM

ROTAVIRUS

Rubella (See MEASLES AND RUBELLA) Rubeloa (See MEASLES AND RUBELLA)

SCABIES

SEIZURES -- EPILEPSY

SELF-INJURIOUS/SELF-MUTILATION BEHAVIOR

SEXUALLY TRANSMITTED DISEASES

SHINGLES

SICKLE CELL DISEASE

SINUSITIS/RHINOSINUSITIS

SKIN AND SOFT TISSUE INFECTION

(CELLULITIS, MRSA AND LYMPHAGITIS)

SORE THROAT

SPIDER BITE

SPINA BIFIDA

SPONTANEOUS PNEUMOTHORAX

SPRAIN and STRAINS

STOMATITIS

STRESS DISORDER/POST TRAUMATIC

STY

SUBSTANCE ABUSE DISORDER

Sun Exposure (See HEAT-RELATED ILLNESSES)

Swallowing Disorders (See DYSPHAGIA)

SYNCOPE

TATTOO/BODY PIERCING

TIC DISORDERS AND TOURETTE SYNDROME

TICK-BORNE DISEASES/TICK REMOVAL

Transverse Myelitis (See ACUTE FLACCID MYLETITIS)

Trisomy 21 (See DOWN SYNDROME)

TUBERCULOSIS

UPPER RESPIRATORY INFECTION

URINARY TRACT INFECTIONS

URTICARIA (HIVES)

VARICELLA (CHICKENPOX)

WARTS (VERRUCAE VULGARIS)

ABOUT THIS MANUAL

School nursing, a specialized practice of nursing, protects and promotes student health, facilitates optimal development, and advances academic success. School nurses, grounded in ethical and evidence-based practice, are the leaders who bridge health care and education, provide care coordination, advocate for quality student-centered care, and collaborate to design systems that allow individuals and communities to develop their full potential. ¹ School nursing services uniquely address health and safety needs of students individually, as a population, and as a subspecialty of community/public health nursing.

School nurses’ work is framed using five pillars of practice: standards of practice, care coordination, leadership, quality improvement, and community/public health nursing which incorporate many areas.² School nurse services require diverse knowledge including, but not limited to, pediatric and adolescent health, infectious diseases, mental health, chronic diseases, and emergency care. School nurses can influence health and safety aspects of schools and can provide leadership to a district’s or campus’ whole school, whole community, whole child (WSCC) approach that in addition to health services, health education, and the school environment addresses mental health and social services, nutrition services, physical activity, family and community involvement, and staff health promotion.

This resource serves as a quick reference for school nurses and can assist them, their administrators, and consulting physicians to develop policies and procedures for safe student care. This manual offers brief summaries of conditions that most school nurses encounter but is not intended to be a substitute for any comprehensive pediatric or emergency care textbook.

The school nurse guidelines were developed through cooperative efforts of school nurses and physicians. We strongly recommend a similar process at the district or system level with adaptations that account for state laws and regulations as well as the unique needs of students in a school district. The registered nurse plans student health services, however, vocational/practical nurses, or unlicensed staff such as office personnel or health clinic assistants may perform certain tasks within state nursing practice guidelines. The registered nurse is responsible for training persons assigned to perform a delegated nursing task, monitoring their performance, and ensuring their compliance with the procedures. State school nurse consultants are an invaluable resource regarding laws, regulations and nurse practice acts in each state.

PHYSICIAN/HEALTHCARE PROVIDER (MD or APRN) CONSULTATION

The availability of a physician’s or healthcare provider’s services to schools varies across communities. Some large districts have full-time medical advisor or consultant, while others have part-time healthcare provider services. Small districts may engage a healthcare provider to consult for a set number of hours or on-call. Some providers volunteer as a community service.

Regardless of the arrangement, it is sound medical-legal practice for the school nurse to have written guidelines to standardize assessment and management decisions. Such guidelines with input from the school healthcare provider complement professional school nursing practice standards and the nursing process and should incorporate accepted pediatric care recommendations.

We suggest that students who have conditions that are likely to require treatment or emergency care during school hours or activities, have individual written orders from their own healthcare provider. These orders should be reviewed and updated at least each school year or as necessary and incorporated into the student’s individualized healthcare plan. The most common individual orders are for students with asthma, life threatening allergies, or diabetes. Some students with seizure disorders, migraine headaches, or other chronic conditions also need individual orders each school year.

DESCRIPTION OF SCHOOL NURSE GUIDELINES

We offer an outline format so that important features of each condition and guidelines for action can be seen at a glance. Each guideline includes a definition or etiology of the disease or condition, presenting signs and symptoms, management strategies and follow- up. This format provides the registered nurse a quick reference for student care and offers information to educate and train staff who may assist the school nurse.

Registered nurses apply their professional skills and judgment in the management of each individual case, but each school and district or system should provide care for all students in a consistent manner guided by local policies and procedures, e.g., criteria for referral or exclusion and return to class.

Usual procedures, such as Standard (Universal) Precautions, parent notification, record keeping, confidentiality, etc. may not be repeated in all guidelines but is understood to be a standard practice in all aspects of care.

DESCRIPTION OF SCHOOL NURSE MANAGEMENT AND MANAGEMENT OF VULNERABLE POPULATIONS TOPICS

Like the school nurse guidelines section, we offer an outline format so that the important features and management needs of each content area can be seen at-a-glance. Each chapter begins with an overview of the topic and then discusses anticipated concerns/problems, management, follow-up and resources. These topics are not meant to provide a treatment plan for a specific condition like the guideline section; rather how the school nurse and school district manage particular vulnerable populations or population–based needs.

STANDING ORDERS

Although standing orders are not addressed in this edition, the distinction between the two types of orders should be understood.

General orders are written by a physician or consulting healthcare provider, often the identified as the school medical advisor, which apply to all students for whom the order may be applicable.

They should be reviewed annually and updated when necessary. It is not necessary for the school medical advisor to have previously examined the student. Dosage is based on weight or age. Common examples of general orders are acetaminophen for fever, ibuprofen for minor headache, etc. These orders are issued with the understanding that a registered nurse will administer these medications after an assessment of the child.

Some state boards of nursing do not allow general standing orders in school settings. Other boards may allow a physician directed nursing protocol which requires signatures of both a healthcare provider and a nurse (usually a nursing administrator or manager). If the administration of nonprescription products is permitted, the school’s policy (for discretionary medications) should be in writing and parents must be informed. Parents should sign a written request for each school year indicating that their child may receive any of the named medications in the discretionary medication policy from school personnel according to the district’s policy.

Specific orders are written and signed by a healthcare provider for an individual child. The parents should also sign a medication authorization form for school personnel to administer any medicine at school. These specific orders contain the drug or treatment, dose, route, time and duration of administration. For example, for a child with diagnosed with ADHD: Methylphenidate 20 mg (one tablet) by mouth daily between 11 A.M. and noon after lunch or with food through December 20, 2016. Most districts require that individualized orders be renewed annually.

Each school/district should have a medication policy that guides medication administration and documentation of both specific, individual orders for medication and for any discretionary medications orders by the school healthcare provided as allowed.

We welcome your suggestions for future editions and wish you success in caring for our nation’s children. You may contact us on the Internet at www.schoolnurse.com.

Robert Andrews, Publisher

School Health Alert

P.O. Box 150127, Nashville, TN 37215

(866) 370-7899

www.schoolnurse.com

¹ National Association of School Nurses. (2017). Definition of school nursing. http://www.nasn.org/RoleCareer

² National Association of School Nurses. (2016). Framework for 21st century school nursing practice: National Association of School Nurses. https://doi.org/10.1177/1942602X15618644

STUDENT SERVICES/MULTI-DISCIPLINARY TEAM

DEFINITION/ETIOLOGY:

Research has shown that a collaborative approach is essential to learning and health.¹ Student services in secondary school environments are therefore ideal settings where collaboration and multi-disciplinary team approaches can provide successful academic outcomes and support the development of the whole child.²

Student services refers to services, supports, programs and practices that assist students in achieving or enhancing their academic goals. Student services vary and are based on individual student as well as student population needs. Disciplines within school environments that provide student services include school nurses, school medical advisor (e.g., physician or advanced practice registered nurse), school psychologist, school social worker, school counselors, pupil services directors, and special education coordinators. These disciplines, using a multi-disciplinary, whole child approach, work with educational staff, students and families to ensure that each student is healthy, safe, engaged, supported, and challenged, sets the standard for comprehensive, sustainable school improvement and provides for long-term student success.³

Multi-disciplinary team refers to professionals in school communities who work collaboratively with students and their families in the decision–making and goal-setting processes toward achieving successful individual or student population outcomes. Multi-disciplinary teams rely on the expertise, knowledge and experience of individual team members to develop plans and provide effective supports that are aligned with students’ goals. School nurses, as the health experts in school environments, are therefore integral members of multi-disciplinary teams, as their perspective assists educators with better understanding the impacts of and supports that may be offered to students based on their health and medical status, conditions, concerns or diagnosis.

Multi-disciplinary Team Members

The following professionals who may be included in a multi-disciplinary team:

School Nurse

School nurses support student success. They are an integral part of school multi-disciplinary teams, bridging the gap between health and wellness, and learning. School nurses identify student health-related concerns and make accommodations and/or interventions to support learning. They also focus on early detection and correction of health problems. School nurses promote and protect the optimal health of students. They work with families, healthcare providers, and students to develop individualized healthcare plans for students with special health needs. Health counseling is provided to students and their families, as well as school staff. They identify and report school environmental concerns. The school nurse determines which nursing services can be delegated and provides supervision for the staff to whom he or she delegates.

School Psychologist

School psychologists are members of school teams whose expertise in social emotional health, mental health, and cognition, assists students in achieving their academic goals. Their collaborations with the school community, including families, teachers, administrators, school nurses, and other school staff, assists in the creation of supportive learning environments where students, with their families, can achieve life skills in- and out-side of the classroom and beyond elementary and secondary years. School psychologists provide direct support and interventions to students, consult with teachers, families, and other school-employed mental health professionals (i.e., school counselors, school social workers) to improve support strategies, work with school administrators to improve school-wide practices and policies, and collaborate with community providers to coordinate needed services.⁴ In order to improve student and school outcomes, including the use of best practices and equal opportunity for all school children, school psychologists are instrumental in the implementation of assessment and accountability systems (including standardized testing), school improvement and support systems and in improving school climate, school safety and access to high quality comprehensive learning supports.⁵

School Medical Advisors

School medical advisors support school districts’ health and wellness programs. Their expertise in pediatric practices assist local boards of education and school administration with the planning, development, review and evaluation of school health programs, policies, and procedures. Their consultation, communication and coordination with school nurse supervisors and school nurses are vital to better understanding school and district-wide student health issues, concerns and statuses. Their roles and responsibilities further include participation in school health activities, such as the school wellness committee, health council, select planning and placement team meetings and other appropriate committees or meetings.⁶

School Counselor

School counselors assists students in maximizing their academic goals in elementary and secondary and in planning for post-secondary educational and other options. Their expertise include providing: individual student academic planning and goal setting; school counseling classroom lessons based on student success standards; short-term counseling to students; referrals for long-term support; collaboration with families/teachers/ administrators/community for student success; advocacy for students at individual education plan meetings and other student-focused meetings; and data analysis to identify student issues, needs and challenges.⁷

School Social Worker

School Social Workers provide students with social and emotional supports to empower them in achieving their academic and personal goals. Through collaborations with students, families, school and community resources, school social workers assist in promoting a safe school environment where students are encouraged to advocate for themselves and others. School social workers’ foci includes student culture and character development, parent outreach, professional development to support school districts’ identified social and emotional needs, and student counseling.⁸

Pupil Services Directors

Pupil services directors are members of the education team who provide supervision and leadership for services and programs that support the needs of all students. Their work includes the coordination and monitoring of all special education programs and supporting the academic and social emotional needs of all students. Their expertise includes knowledge of: special education laws and processes; Section 504 planning; extended school year; co-teaching; gifted education; and pupil registration and enrollment policies and procedures. Most pupil services directors assume responsibilities for supervising, implementing and monitoring the following school programs: health services; speech; occupational and physical therapy; and related services.

Special Education Coordinators

Special education coordinators are focused on supporting, implementing and monitoring programs and services that provide educational assistance to students who qualify for special education. Special education coordinators are highly trained and experienced teachers with specialized certification, and who work under the direction of pupil services directors. Their roles and responsibilities include: actively facilitating the planning and placement team processes for special education; assisting special education teachers and related services professionals with technical assistance and professional development activities; and participating in the hiring processes of special education teachers, teacher assistants and related services staff.

REFERENCES

¹ Centers for Disease Control and Prevention. (2010). The association between school based physical activity, including physical education, and academic performance. US Department of Health and Human Services. https://www.cdc.gov/healthyyouth/health_and_academics/pdf/pa-pe_paper.pdf

² ASCD. (2019). Whole child. http://www.ascd.org/whole-child.aspx

³ Ibid. Page 1.

⁴ National Association of School Psychologists. (2019). About school psychology. Page 1. https://www.nasponline.org/about-school-psychology

⁵ National Association of School Psychologists. (2019). ESSA overview for school psychologists. https://www.nasponline.org/research-and-policy/policy-priorities/relevant-law/the-every-student-succeeds-act/essa-implementation-resources/essa-overview-for-school-psychologists-x34810

⁶ Connecticut State Department of Education. (2019). School medical advisors: Recommendations for the qualifications, selection process and roles in the implementation of school health services programs in Connecticut schools. Page 2. https://portal.ct.gov/-/media/SDE/School-Nursing/Publications/suggested_recommendations_for_school_medical_advisors.pdf

⁷ American School Counselor Association. (2019). Who are school counselors? Page 1. https://www.schoolcounselor.org/asca/media/asca/Careers-Roles/SCInfographic.pdf

⁸ School Social Work Association of America. (2019). School social work. Page 1.https://www.sswaa.org/

ACKNOWLEDGMENTS

This 10th Edition was edited by Vicki Taliaferro, BSN, RN, NCSN and Cheryl Resha, EdD, MSN, RN, FNASN.

CONTRIBUTORS

Andrea Adimando, DNP, MS, PMHNP-BC, BCIM

Andrea Adimando is an Assistant Professor of Nursing at Southern CT State University, teaching in the BSN and MSN programs. She has over 14 years of experience as a Board-Certified Psychiatric Nurse Practitioner, specializing in child and adolescent mental health assessment and treatment in inpatient, outpatient, community, and school settings.

Patricia K. Bednarz, RN, MN, FNASN

Patricia Bednarz is a health and education consultant. Ms. Bednarz had a 25-plus year career of diversified experience as a school nurse, project manager and nursing educator. She has managed state and federal grants that included writing and contributing to proposals as well as grant implementation, fiscal management and evaluation. In 2010, Patricia was named a Fellow in the National Academy of School Nurses. Ms. Bednarz has published articles in peer-reviewed journals, chapters in books and presented at state and national school nurse conferences. Currently, Ms. Bednarz is consulting for the Michigan Department of Health and Human Services in the School Wellness Program.

Mary Blackborow, MSN, RN, NCSN

Mary Blackborow has over 40 years’ experience as a registered nurse. Her nursing experience included public health nursing and case management with 20 years’ experience as a school nurse. Her school nursing experience includes middle and high school students as well as special needs students from 3 to 21. She has held leadership positions in school nursing organizations at the local, state and national levels. In 2015, she became a Johnson and Johnson School Health Leadership Fellow.

Kristen S. Borgognone, DNP, RN, NEA-BC, CIC

Kristen Borgognone is an Assistant Professor of Nursing at Southern Connecticut State University. She has over 33 years of experience as a registered nurse. Her nursing experience includes adult and pediatric critical care, emergency medicine and psychiatry. Her experience also includes infection prevention and patient safety. Her current research is focused on the health behaviors of college students and HPV prevention activities.

Jane Borr, BSN, RN, NCSN

Jane Borr is a school nurse and school nurse educator for a hospital funded school nurse program that partners with area school districts for nursing services in the schools. She currently serves on the Michigan Association of School Nurses board as Membership Chair and was treasurer from 2010 - 2014 and 2018-2019. She was a member of the Michigan School Nurse Task Force from 2011 - 2014 where she co-chaired the data and staffing committee. She is a nationally certified school nurse.

Jane Boyd, MSN, RN, NCSN

Jane Boyd is a retired State School Nurse Consultant with over 33 years of experience as a registered nurse and over 19 years as a school nurse. Her school nursing experiences includes elementary, middle and high school. From 2016-2019 she was the Delaware State School Nurse Consultant and participated on state-level committees and leadership positions.

Hendrina Cupery, RN, MSN, NCSN

Hendrina Cupery works as the Manager of the School Nurse and Faith Community Nurse Programs in Holland Michigan. She has worked in nursing for the past 25 years, fifteen of which have been in school nursing. She serves as the Treasurer of the Michigan Association of School Nurses. She is a nationally certified school nurse.

Sandra J. Delack, MEd, BSN, RN, NCSN, FNASN

Sandi Delack is a School Health Consultant and educator with 31 years of experience as a certified school nurse-teacher, where she served as District Coordinator for a suburban school district. She is a Past President of the National Association of School Nurses (NASN), Past President of the National Board for Certification of School Nurses (NBCSN), and former board member of ANA-RI. Sandi has also held numerous leadership positions at the state level and has been involved in policy and regulation development. She is currently a national presenter as well as an adjunct faculty member at Providence College.

Stephanie G. Denya, RN, BSN, MPH

Stephanie Denya is currently a Deputy Health Director for the city of Meriden Department of Health and Human Services in Connecticut. In addition, she supervises the school health and clinic programs. She has over 30 years of nursing experience, several of which include working as a public health nurse in a school setting. She has collaborated with state/local agencies on disaster preparedness trainings, improving immunization rates, and lead poisoning awareness for which she began a school lead screening initiative requiring all pre-K and Kindergarten students to have a lead screening prior to school entry. She is also a member of several local task forces which work together to assist children and families improve their health, access to care, and quality of life.

Bonnie Edmondson, EdD

Bonnie Edmondson is an Associate Professor and Graduate Coordinator of the School Health Education Program at Southern Connecticut State University. She has over 35 years of experience as an educator, coach, and former professional athlete. Dr. Edmondson has served on expert panels for the CDC and the U.S. Department of Health and Human Services, has written numerous documents on school health policies and practices, is a peer reviewer for numerous professional publications and journals, and is a well-known speaker on health and education policy and athletic coaching. In addition, she is a two-time national champion and former world ranked hammer thrower. She is active with USA Track and Field (USATF) serving as the head women’s coach for the 2019 IAAF World Championships, the women’s throwing events coach for the 2016 United States Olympic Team and six IAAF World Championship teams. Bonnie is Chair of the USATF Women’s Commission. She holds an EdD in Educational Leadership, an MS in School Health Education, and a BA in English.

Kimberly Lacey, DNSc, MSN, RN, CNE

Dr. Kimberly Lacey is a Certified Nurse Educator and Assistant Professor of Nursing at Southern Connecticut State University, College of Health and Human Services, where she currently serves as the Director of the RN-BSN Program. Her clinical expertise is in population/public health with interests in the health and well-being of homeless youth/college students; school health; home health care; and, infectious disease prevention. Academic/research interests include leadership; nursing education; academic integrity; clinical educator and clinical nurse leader roles, and, writing across the curriculum.

Patricia Fato, BSN, CPN

Patricia Fato is currently a Clinical Nurse at PACT. PACT is a daycare for medically fragile children and affiliated with Kennedy Krieger Institute. Patricia has over 12 years of Pediatric Nursing experience. She has a bachelor’s degree in Nursing and is also a Certified Pediatric Nurse.

Susan Hoffmann, MSN, RN, NCSN

Susan Hoffmann is currently a School Nurse Consultant with over 35 years of nursing experience and over 25 years' experience in school nursing practice. Her school nursing experience includes providing direct services for elementary general education and special needs students with severe emotional and behavioral challenges, district lead nurse, mentoring, nursing education project management and leadership positions at both the state and national levels.

Bethanne Johnston, RN, MSN, CPNP

Bethanne Johnston is currently a Nephrology Pediatric Nurse Practitioner at Riley Hospital for Children, in Indianapolis, IN, with over 30 years of experience as a registered nurse and over 10 years as a nephrology nurse practitioner. Her nursing experience includes Pediatric ICU, Pediatric Emergency Medicine, and Pediatric Dialysis nursing. She currently manages children with varying stages of chronic kidney disease in the state of Indiana including those who are pre end-stage renal disease, pre-renal transplant, and children with end stage renal disease receiving hemodialysis and peritoneal dialysis. She is actively involved with the National Kidney Foundation of Indiana including serving on their board and participating in outreach programs. She is additionally involved in a program to mentor new advanced practice nurses for the IU Health System.

Stephanie G. Knutson, EdD, RN

Stephanie G. Knutson is an accomplished leader and educator with over 22 years of experience in diverse educational settings advocating for students of all ages and their families. As the School Health Administrator and Education Consultant for School Nursing and School Health Education for Connecticut State Department of Education, she provides state-wide educational leadership and facilitate policy development in the areas of school health education, and students’ physical and mental health. Her deep understanding of the role of health in the growth and cognitive development in children, individual student achievement and closing the achievement gap, lends to her evaluation of school health services. Dr. Knutson promotes physical and mental health to maximize students’ educational opportunities within secondary and higher educational institutions in Connecticut, where she creates and provides opportunities for professional development and enhancement of school staff, including school nurses, school medical advisors, health educators, principals, teachers, pupil services directors and other school staff.

Suzanne Levasseur, MSN, APRN

Suzanne Levasseur is the Supervisor of Health Services for the Westport Public Schools District in Connecticut. She is an Advanced Practice registered nurse and a Certified Pediatric Nurse Practitioner and is on staff at Danbury Hospital in Danbury, Connecticut. She is currently the President for the Association of School Nurses of Connecticut and is the editor of the texts, Pediatric Nursing Secrets and Perinatal Nursing Services.

Kristi Maynard, MSN, APRN, FNP-BC, CNE

Kristi Maynard is an assistant professor at Quinnipiac University. She is an Advanced Practice registered nurse, a Certified Family Nurse Practitioner, and a Certified Nurse Educator. She has clinical experience in primary and urgent care with patients of all ages.

Susan Nokleby, MS, RN, NCSN, FNASN

Susan Nokleby is an independent School Nurse Consultant in Minnesota. As a Licensed School Nurse, Susan has worked in a special education district and as an Administrator of Health Services. She is the past President of the School Nurse Organization of Minnesota and of the National Board for Certification of School Nurses. Sue authored a chapter on homelessness in the 2nd edition of the Individualized Healthcare Plans for the School Nurse and was a member of the working group for the revisions of ANA/NASN School Nursing: Scope and Standards (2017).

Barbara Obst, MSEd, BSN, RN, NCSN

Barbara Obst is the co- coordinator of the Specialized School Health Interagency Program at the Kennedy Krieger Institute, serving as the co- coordinator for the past 20 years. She has published articles in the NASN School Nurse and was a reviewer for the 3rd edition of School Nursing a Comprehensive Text. She has been a speaker on various topics related to children with special needs statewide, and nationally for school nurses and educators.

William (Bill) Patterson Jr., MPA, RN

Bill Patterson is a state level registered professional nurse for the State of Hawaii, Department of Education (HIDOE). Prior to joining the HIDOE, Bill worked for the State of Hawaii Department of Health as a Supervisor of the Children with Special Health Needs Program and a field public health nurse. Through public health nursing, Bill first encountered school health and school nursing issues which became his cause or passion. Professionally, Bill has twenty (20) plus years of experience in the clinical/medical and nursing fields and is a chapter contributor for Legal Resource for School Health Services. Bill is an active member of both the National Association of School Nurses (NASN) and the National Association of State School Nurse Consultants (NASSNC).

Yann B. Poncin, MD

Yann Pontin is an Assistant Professor and Vice Chairman for Safety and Quality at the Yale Child Study Center. He has administrative, supervisory, and clinical experience working across the care continuum from outpatient to inpatient care, which includes intensive outpatient, partial hospitalization, emergency services, residential care and in-home services. He has 15 years' experience consulting to public, private and therapeutic schools.

Julianna Putman, MS, CCC-SLP, TSLI

Julianna Putman is an ASHA certified speech and language pathologist. She received her Bachelor of Arts in Communicative Sciences and Disorders at Michigan State University. She then received her Master of Science in Speech and Language Pathology from The University of Tulsa. She is in her eighth year of school-based speech language pathology. Her focus is currently on students with Autism Spectrum Disorder, moderate-severe cognitive and/or physical impairments.

Cheryl Resha, EdD, MSN, RN, FNASN

Cheryl Resha is currently Department Chair and Professor of Nursing at Southern Connecticut State University (SCSU). She holds a Doctorate in Educational Leadership. Prior to joining SCSU, Dr. Resha worked for the Connecticut State Department of Education as a manager and state school nurse consultant; and for a large suburban school district as the school nurse supervisor. With over 20 years’ experience in the field of school nursing, Dr. Resha has provided leadership and advocacy for school nurses, safe school nurse practice and quality school health programs. Professionally, Dr. Resha has also been a member of ASNC and NASN since 1998. As an active member of NASN for several years, Dr. Resha was inducted as a Fellow in the National Academy of School Nursing in June 2012. Dr. Resha has co-edited, authored and contributed to articles and publications regarding school nursing, such as the Scope and Standards of Professional School Nurse Practice and the Legal Resource for School Health Services.

Megan Roesler, MSN, RN, CPN

Megan Roesler is a nurse educator with the Specialized Health Needs Interagency Collaboration (SHNIC) program at the Kennedy Krieger Institute. She is a certified pediatric nurse with over 10 years of nursing experience. She conducts training and presentations throughout Maryland and has published various articles in NASN School Nurse magazine to support students with special health care needs. Megan also maintains clinical practice as a pediatric nursing clinical instructor at a local pediatric rehab hospital.

Vicki L. Taliaferro, BSN, RN, NCSN

Vicki L. Taliaferro is a school nurse consultant and editor of School Nurse Digest and Administrator’s Risk. She is co-editor of the last 4 editions of the School Nurse Resource Manual. She has authored articles, school nurse text chapters, position papers and state and local guidelines on school health topics and initiatives. She has recently served as a consultant to the National Association of School Nurses as their coordinator of professional practice documents. As State School Nurse Consultant with the Maryland State Department of Education for 10 years, she provided technical advice to state school nursing leadership; developed state guidelines & policies and assisted with the development of Board of Nursing curriculums for delegation and medication administration. Additionally, she is a member of the National Assn. of State School Nurse Consultants having served as president and in other officer positions.

Antoinette Towle MSN, PNP BC, SNP BC

Antoinette Towle is presently an Associate Professor of Nursing at Southern Connecticut State University (SCSU) teaching across the curriculum nursing to undergraduate, RN to BSN, Accelerated and graduate nursing students. She has over 35 years’ experience as a registered nurse, and over 15 years’ experience as an Advanced Practice registered nurse. She holds a Doctorate in Nursing Education, is ANCC board certified as a Pediatric and School Health Nurse Practitioner. Dr. Towle has extensive experience working in school health, in a variety of roles, school nurse, school nurse practitioner, and the Director of Health Services.

Kara Ventura, PNP, FNP, DNP

Kara Ventura is the manager of Clinical Operations for the Adult Liver and Pediatric Liver and Kidney Transplant Programs at Yale New Haven Hospital. She is a Certified Pediatric Nurse Practitioner, a Certified Adult Nurse Practitioner and holds a Doctorate in Nursing Practice. She has practiced in transplant since 1997 and is involved Nationally and Locally on Transplant Committees. She currently is also a portfolio advisor for students enrolled in the DNP program and Columbia University School of Nursing.

Kim Walker, MSN, APRN, PMHCNS-BC

Kim Walker has been a practicing school nurse for over 20 years for the San Francisco Unified School District. She is a pediatric nurse practitioner and is board certified as a psychiatric clinical nurse specialist. She is the current secretary for the Bay Coast section of CSNO. She also has a small private practice in parent coaching.

Susan F. Zacharski, MEd, RN, FNASN

Susan Zacharski is currently a School Nurse Consultant with over 40 years of experience as a registered nurse and over 27 years’ experience as a school nurse. Her school nursing experience includes Department Head of Health Services in an urban school district, preschool – 8th grade general education with a focus on special needs students including the medically fragile, participation in state level committees and leadership positions at both the state and national level. She was a member of the Michigan School Nurse Task Force from 2011–2014 where she co-chaired the school nurse practice committee.

REVIEWERS

Andrea Adimando, DNP, PMHNP-BC, BCIM

Assistant Professor of Nursing

Southern CT State University

Connecticut

Becky Bailey, BNSc, RN, NCSN

Coordinator

Custer Health

North Dakota

Julie Bartoy, MSN, RN

Macomb Community College

Department of Health and Human Services

Nursing Faculty-Pediatrics

Michigan

Jane Boyd, MSN, RN, NCSN

Education Specialist School Support Services

Student Support Team Delaware Department of Education Delaware

Christie M. Butler, BSN, RN

School Nurse Consultant

Coordinated School Health | Whole Child Initiatives Tennessee

Joan Cagginello, MS, BSN, RN

Nurse Administrator, Retired

Milford Board of Health, Chairman

Connecticut

Elizabeth Chau, SRN (UK), RN

Past NASN Exec Board

Past PPSN Chair

School Nurse, Retired

Nevada

Ann M. Connelly, MSN, RN, LSN, NCSN

Public Health Nurse Supervisor

School Nursing and Early Childhood Health Programs Ohio Department of Health

Ohio

Michael Corjulo, APRN, CPNP, AE-C, PMHS

Clinical Director

Pediatric Resource Center

Connecticut

Linda Davis-Alldritt, MA, BSN, RN, FNASN, FASHA

Past President, National Association of School Nurses

School Nurse & School Health Services Consultant Finland

Marie DeSisto, MSN, RN

Instructor

Cambridge College

Massachusetts

Nancy Dube, MPH, RH

Retired State School Nurse Consultant Maine

Mary Freeland, RN

School Nurse

Independence High School

Arizona

Jessica Gerdes, MS, RN, NCSN, IL Licensed School Nurse

(Retired) State School Nurse Consultant, Illinois State Board of Education

(Current) adjunct faculty, Lewis University (IL) school nurse certificate program

Illinois

Kathleen A. Hassey DNP, MEd, BSN, BA, RN

Director of the School Health Academy

Northeastern University

Massachusetts

Evilia Janowski, MSA, BSN, RN

State School Nurse Consultant

Michigan Department of Education/Michigan

Department of Health and Human Services

Michigan

Linda Khalil, MSEd, BSN, RN, SNT

Director, NYS Center for School Health, Contract

Office for the NYS Education Department

State School Nurse Consultant

New York

Rebecca King, MSN, RN, NCSN

Retired Nursing Director Delaware Division of Public Health Board Member, Mom's House of Wilmington

Founding Board of Directors atTAcK addiction

Delaware

Nicole Klein, PhD, RN-BC, NCSN, AE-C

Health Services Program Supervisor

Office of Superintendent of Public Instruction

Washington

Donna Kosiorowski, MS, RN, NCSN-E

School Health Consultant

Connecticut

Pat Krin, MSN, RN, FNP-BC-Retired, NCSN-E, FNASN

School Health Consultant

School Health Consulting Services

Connecticut

Natalie A. Kwit, DVM, MPH

State Public Health Veterinarian,

Vermont Department of Health

Vermont

Victoria Ladd, MSN, RN

State School Nurse Consultant

Division of Children's Health and Perinatal Services

S.C. Dept. of Health & Environmental Control

South Carolina

Teri B. Lawler, MA, LPCMH

Education Associate

Trauma-Informed Practices and Social and

Emotional Learning

Office of Innovation and Improvement

Delaware Department of Education

Delaware

Suzanne Levasseur, MSN, APRN

Supervisor of Health Services

Westport Public Schools

Connecticut

Cheria McDonald, BSN, RN, NCSN

State School Nurse Consultant

Arkansas Department of Education

Division of Elementary and Secondary Education

School Health Services

Arkansas

Keisha Simons Major MSN-Ed, RN, NCSN

Nurse Manager, Office of School Health

Prince George's County Public Schools System

Maryland

Patricia McCain, ADN, RN, BS

Retired School Nurse

Michigan

Marques Mazyck, M.F.A.

Sickle Cell Advocate

Florida

Alicia Mezu, MSN/Ed, BSN, BS, RN

Lead Health Services Specialist

State School Nurse Consultant

Maryland State Department of Education

Maryland

Claire Molner, RN, MEd, NCSN

School Nurse/Health Educator

Proctor Junior Senior High School

Vermont

Kathy Neelon, MS, BSN

Nurse Coordinator

Wallingford Public Schools

Connecticut

Lynnette Ondeck, MEd, BSN, RN, NCSN

Vice President National Association of School Nurses

School Nurse Corps Administration

Northwest Educational Service District

Washington

Emily Poland, MPH, RN

School Nurse Consultant

Team Leader, Coordinated School Health

Maine Department of Education

Maine

Deborah Pontius, MSN, RN, NCSN, FNASN

School Nurse Consultant and CE Instructor

Nationally Certified School Nurse

Fellow, National Academy of School Nurses

Nevada

Jessica R. Porter, BSN, RN, NCSN

Nationally Certified School Nurse

SCASN Webmaster

Iowa

Suzanne Putman, R.N., B.S.N., M.Ed.

POHI Nurse

Warren Woods Tower High School

Michigan

Darla Rebowe R.N., BSN, CSN

School Nurse

School Nurse Consultant

LSNO Vice President

Louisiana

Kathy L. Reiner, MPH, BA, BSN, RN

School Nurse Specialist

Colorado Department of Education

Board of Directors

Colorado

Deb Robarge, BSN, RN, NCSN

Indiana Association of School Nurses

Executive Director

Retired Health Center Director - Indiana School for

the Deaf

Indiana

Linda M. Sawyer, Ph.D., MSN, RN, CNE

Professor of Nursing – Pediatrics

Macomb Community College

Michigan

Sally Schoessler, MSEd, BSN, RN

Director of Education, Allergy & Asthma Network

Virginia

Sharonlee Trefry, MSN, RN, NCSN

State School Nurse Consultant

Maternal and Child Health Division

Vermont Department of Health Vermont

Anita Wheeler, MSN, RN

School Health Coordinator/ School Nurse

Consultant

School Health Program

Diabetes and School Health Branch

Health Promotion and Chronic Disease Prevention

Section

Texas Department of State Health Services

Texas

Susan Zacharski, MEd, BSN, RN, FASN

School Nurse Consultant

Michigan

SECTION I

CLINICAL GUIDELINES

ABDOMEN: Blunt Injury

DEFINITION/ETIOLOGY:

Following a hard blow to abdomen (by rock, fist, bicycle handlebar, etc.), an internal organ may be ruptured and bleed into the abdominal cavity slowly but continuously. Injured abdominal organs may include the spleen, liver, retroperitoneum, small intestines, colorectal, bladder, kidney, diaphragm or pancreas. Blunt abdominal injuries become apparent within nine hours.¹

SIGNS AND SYMPTOMS:², ³

• History of blow to abdomen

• Possible bruise visible

• Pain and tenderness to mild pressure

• Abdominal distention

• Vomiting

• Rapid, weak pulse with low blood pressure

• If kidney is bruised or torn, there may be blood in urine shortly after trauma or next day (more likely, if injury is to the lumbar area of the back)

• Shoulder pain (Kehr’s sign). Kehr’s sign is pain at the tip of the shoulder due to internal bleeding in the abdominal cavity. A positive Kehr’s sign is a medical emergency. Call Emergency Medical Services (EMS) immediately! ⁴

o If spleen is ruptured there may be complaints of left shoulder pain.

o If liver is injured there may be complaints of right shoulder pain.

o If there is a small intestinal tear the pain is minimal at first but worsens steadily.

• Gradual onset of shock and coma.

• Symptoms may appear a day or two following the blow.

MANAGEMENT/TREATMENT:⁵

1.Identification of trauma may not be obvious with initial evaluation.

2.Assessment should include vital signs, abdominal status, visual inspection, listen for bowel sounds, palpate painful and non- painful areas, check for rebound tenderness and rigidity.

3.Do not give fluids or food until the cause of pain is determined or pain subsides.

4.Notify parent. Tell what to watch for in the next 48 hours.

5.Keep in clinic for 15 minutes after blow to abdomen.

6.Allow to rest in position of comfort.

7.Monitor pulse and blood pressure.

8.If student has none of the above symptoms, may return to class. Send a note to the teacher to have the student return to health room/clinic before close of school and sooner, if symptoms appear.

9.Reassess the student.

10.If any symptoms ensue, refer to emergency room or healthcare provider.

11.Complete injury report, including information and instructions given to parent/guardian.

FOLLOW-UP:

Check student again on following day.

POTENTIAL COMPLICATIONS:⁶

• Missed diagnosis.

• Delay in diagnosis.

• Delay in treatment.

• Ruptured spleen: can be life-threatening without immediate treatment.

• Hypovolemic shock: symptoms include rapid pulse, cold-moist-clammy skin, alteration of consciousness, low blood pressure.

NOTES:

• Anatomical differences and underdeveloped muscles in children make them more susceptible to abdominal injuries with less force. Anatomically, the abdomen begins nipple level. ⁷

• Bicycle handlebar injury: Abdominal injury may occur when handlebars are turned so they punch the abdomen with force. Bicycle handlebar injuries are often considered trivial; alarming symptoms may not develop for 24 hours. Symptoms of serious injury are severe pain, vomiting or collapse.

• Children who fall on bicycles shortly after eating are at greater risk for problems. ⁸

REFERENCES

¹ Jones, E. L., Stovall, R. T., Jones, T. S., Bensard, D.D., Cothren, C., Burlew, C. C., Johnson, J.L., Jurkovich, G.J., Barnett,C.C., Pieracci, F.M., Biffl, W.L., & Moore, E.E. (2014, April). Intra-abdominal injury following blunt trauma becomes clinically apparent within 9 hours. Journal of Trauma and Acute Care Surgery., 76(4), 1020–1023. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4091734/

² Legome, E.L., & Geibel, J. (2019). Blunt abdominal trauma. Medscape. http://emedicine.medscape.com/article/1980980-overview#a2

³ Merck Manual Professional Version. (2018). Overview of abdominal trauma. https://www.merckmanuals.com/professional/injuries-poisoning/abdominal-trauma/overview-of-abdominal-trauma?query=blunt%20abdominal%20trauma

⁴ Emergency Medical Paramedic. (n.d.). What is kehr’s sign? http://www.emergencymedicalparamedic.com/what-is-kehrs-sign/

⁵ Crosby, M.F., Lyons, E., & Prestidge, L. (2019). Students with acute illness. In Selekman, J., Adair, R., & Yonkaitis, C. (Eds.), School nursing: A comprehensive text (3rd ed., pp. 432-33). F.A. Davis.

⁶ Legome, E.L., & Geibel, J. (2019). Blunt abdominal trauma. Medscape. http://emedicine.medscape.com/article/1980980-overview#a2

⁷ Saxena, A. & Grehal, H. (2017). Pediatric abdominal trauma. https://emedicine.medscape.com/article/1984811-overview

⁸ Daley, B., Raju, R., & Lee, S. (2015). Considerations in pediatric trauma. https://emedicine.medscape.com/article/435031-overview#a3

OTHER REFERENCES CONSULTED

Daley, B., Raju, R., & Lee, S. (2015). Considerations in pediatric trauma. https://emedicine.medscape.com/article/435031-overview#a3

Bravo, A., & Lopez, H. (2017). Case report, The challenge of blunt abdominal trauma in children: Report of a case and review of management.

file:///C:/Users/Susan/AppData/Local/Packages/Microsoft.MicrosoftEdge_8wekyb3d8bbwe/TempState/Downloads/2901-17096-1-PB%20(1).pdf

Carnet, K.P., & Roswell, K. (2018). Emergencies & injuries. In W.W. Hay, M.J. Levin, R. R. Deterding, & M. J. Abzug (Eds.), Current diagnosis and treatment: Pediatrics (24th ed., pp. 309-330). McGraw Hill Education.

U.S. National Library of Medicine, National Institute of Health. (2012). Recognition and management of abdominal events at athletic events. International Journal of Sports Physical Therapy Medicine.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3414076/

ABDOMINAL PAIN/APPENDICITIS

OVERVIEW/DEFINITION:

Pain or discomfort located between the bottom of the diaphragm and the top of the pelvic region. Acute abdominal pain: short term develops in hours over weeks. Chronic recurrent abdominal pain: can be weeks, months or even years.¹

Abdominal pain may be due to a variety of conditions, including but not limited to:

Intra-abdominal causes:²,³

Gastrointestinal tract

• Dietary (excessive or inappropriate intake, food-borne pathogens)

• Constipation

• Appendicitis

• Lactose intolerance (recurrent)

• Irritable bowel syndrome (discomfort for at least 12 weeks within past 12 months plus at least two of the following: altered frequency and/or appearance of bowel movements, pain relief with bowel movement)

• Peptic ulcer (recurrent)

• Incarcerated inguinal hernia

• Celiac disease (recurrent)

Liver/Gall Bladder/Spleen

• Hepatitis

• Pancreatitis

• Cholecystitis (inflammation of the gall bladder) and cholelithiasis (gall stones)

• Contusion/rupture spleen (trauma)

• Sickle cell anemia (recurrent)

Urinary Tract

• Cystitis (inflammation or infection of the bladder)

• Glomerulonephritis

• Kidney stone

Ovaries, Fallopian Tubes and Uterus

• Dysmenorrhea (menstrual cramps) (recurrent)

• Rupture of ovarian follicle at ovulation (mittelschmerz)

• Pelvic inflammatory disease (PID)

• Complication of pregnancy (ectopic pregnancy/abortion)

• Sexual abuse

Extra-abdominal causes:

• Abdominal migraine

• Diabetic ketoacidosis

• Functional abdominal pain (emotional or psychosocial)

• Group A streptococcal pharyngitis (strep throat)

• Hypoglycemia

• Lead poisoning

• Leukemia

• Lower lobe pneumonia

• Rheumatic fever

Common causes by age of students:⁴

1.Preschool: constipation, gastroenteritis, viral infection, urinary tract infection, pneumonia, trauma, lactose intolerance, sickle cell episode.

2.School age: gastroenteritis, viral infection, constipation, appendicitis, trauma, urinary tract infection, pneumonia, lactose intolerance, sickle cell pain episode.

3.Adolescent: Early adolescence is prime time for occurrence of appendicitis, mittelschmerz (ovulation pain), pelvic inflammatory disease (PID), dysmenorrhea, complication of pregnancy.

SIGNS AND SYMPTOMS:

Symptoms vary depending on the etiology of the pain. A good assessment will help to differentiate the cause of the abdominal pain.

• Mildly ill: pain interferes minimally with normal activities.

• Moderately ill: interferes with normal routine or signs of infection or systemic illness.

• Severely ill: signs of peritonitis or intestinal obstruction or mental change.

ASSESSMENT:

History:⁵

• Onset, location, duration, frequency, severity and pattern of the pain.

• Associated symptoms such as fever, vomiting, diarrhea, red or dark red blood in stool, urinary symptoms, weight loss, jaundice, arthritis or cough and sore throat.

• Precipitating factors including constipation, trauma, underlying diseases (sickle cell anemia), menstruation, medication and diet history.

Physical examination:⁶,⁷

• Check temperature; assess circulation and hydration status.

• Enlarged liver, spleen or abdominal mass can be identified with palpitation of the lower quadrants.

• Guarding (tensing of the abdominal muscles to guard inflamed organs within the abdomen from the pain) can be elicited with gentle palpitation and rebound without deep palpation.

• Note signs of emergency surgical conditions:

o peritonitis: includes guarding and rigidity of the abdominal muscles, rebound tenderness, decreased/absent bowel sound, abdominal distention or shock.

o intestinal obstruction: distention, hyperactive bowel sounds and persistent vomiting.

o appendicitis: ⁸, ⁹, ¹⁰

- low fever at to begin but may progress

and appendicitis progresses

- nausea, vomiting

- anorexia

- vague diffuse epigastric or periumbilical pain, over several hours pain becomes more intense and shifts to right lower quadrant, rebound tenderness, release of pressure on left lower quadrant of abdomen elicits pain in right lower quadrant of abdomen (Rovsing sign)

- decreased bowel sounds

- prefers to lie on left side/right knee flexed

- If suspect appendix, perform auscultation, percussion, followed by palpation

o complication of pregnancy (female with history of delayed menstrual period) includes lower abdominal pain, pallor or shock, abnormal vaginal bleeding.

Assess location and severity of the pain:

Potential medical conditions according to pain location (list is not inclusive):¹¹

o Diffuse abdominal pain: associated with diabetic ketoacidosis, food poisoning, gastroenteritis, intestinal obstruction, pancreatic disease, peritonitis, pharyngitis and sickle cell anemia.

o Epigastric pain: associated with duodenal/gastric/peptic ulcers, esophagitis, gastritis, gastroenteritis, GERD/hiatal hernia, myocardial infarction, irritable bowel disease, liver conditions and ulcerative colitis.

o Right lower quadrant: associated with appendicitis, ectopic pregnancy, gastroenteritis, inguinal hernia, irritable bowel syndrome (IBS), kidney stone, ovarian conditions, pelvic inflammatory disease and testicular torsion.

o Right upper quadrant: associated with acute pancreatitis, gallbladder conditions, kidney stone, duodenal ulcer, liver conditions and lower lobe pneumonia.

o Left upper quadrant: associated with bowel obstruction, constipation, IBS, kidney stone, left lower lobe pneumonia, leukemia, pyelonephritis, splenic conditions and ulcerative colitis.

o Left lower quadrant : associated with constipation, ectopic pregnancy, inguinal hernia, irritable bowel syndrome (IBS), kidney stone, ovarian conditions, pelvic inflammatory disease, sigmoid colon and testicular torsion.

o Suprapubic region: associated with dysmenorrhea, endometriosis, pelvic inflammatory disease, sexually transmitted disease, and urinary tract infection/bladder infections.

ANTICIPATED CONCERNS/PROBLEMS:

• Ruptured appendix requires surgery.

MANAGEMENT/POTENTIAL INTERVENTIONS:

• If signs of appendicitis (the most common serious condition) or moderate-severe illness notify the parent/guardian immediately and refer to the student’s healthcare provider.

• If mild, may rest for 15-30 minutes. If symptoms persist, refer for evaluation. If symptoms subside, return student to class.

• No food or drink by mouth. May sip small amount of plain water.

FOLLOW-UP:

• If student returns to classroom, re-evaluate within 2-4 hours.

• If referred to healthcare provider, verify that evening or next day students was seen. ¹²

• If student requires surgery, upon the student’s return, follow healthcare provider’s instructions regarding athletic or PE participation.

REFERENCES

¹ Mayo Clinic. (2019). Abdominal pain. https://www.mayoclinic.org/symptoms/abdominal-pain/basics/definition/sym-20050728

² Merck Manual Professional Version. (2018). Acute abdominal pain. http://www.merck.com/mmpe/sec02/ch011/ch011b.html

³ Alder, A., & Minkes, R. (2018). Pediatric appendicitis. Medscape. https://emedicine.medscape.com/article/926795-overview

⁴ Ruest, C. E., & Williams, A. (2016, May). Acute abdominal pain in children. American Family Physician, 93(10), 830-837. https://www.aafp.org/afp/2016/0515/p830.html

⁵ Merck Manual Professional Version. (2018). Acute abdominal pain. http://www.merck.com/mmpe/sec02/ch011/ch011b.html

⁶ Ruest, C E., & Williams, A. (2016, May). Acute abdominal pain in children. American Family Physician, 93(10), 830-837. https://www.aafp.org/afp/2016/0515/p830.html

⁷ Cosby, M.F., Lyons, E., & Prestidge, L. (2019). Students with acute illness and injury. In J. Selekman, R. Adair Shannon, & C. F. Yonkaitis (Eds.), School nursing: A comprehensive text (3rd ed., pp. 442-43). F.A. Davis.

⁸ Merck Manual Professional Version. (2018). Acute abdominal pain. http://www.merck.com/mmpe/sec02/ch011/ch011b.html

⁹ Alder, A., & Minkes, R. (2018). Pediatric appendicitis differential diagnosis. Medscape. https://emedicine.medscape.com/article/926795-differential

¹⁰ Mayo Clinic. (2019). Appendicitis. https://www.mayoclinic.org/diseases-conditions/appendicitis/symptoms-causes/syc-20369543

¹¹ Merck Manual Professional Version. (2018). Acute abdominal pain. http://www.merck.com/mmpe/sec02/ch011/ch011b.html

¹²Cosby, M.F., Lyons, E., & Prestidge, L. (2019). Students with acute illness and injury. In J. Selekman, R. Adair Shannon, & C. F. Yonkaitis (Eds.), School nursing: A comprehensive text (3rd ed., pp. 442-43). F.A. Davis.

ABRASIONS

DEFINITION/ETIOLOGY:

An abrasion is a denuded area of skin (epidermis) resulting from a scrape on a hard or rough surface. Abrasions can occur on any part of the body, but most often occur on bony areas, such as the hands, forearms, elbows, knees, shins, and face. Abrasions often result from falls or friction accidents.¹

SIGNS AND SYMPTOMS:

• Most abrasions are superficial (involve only the dermis layer).

• There is usually minimal bleeding and may ooze serosanguinous fluid. The amount of bleeding is greater when deeper layers of skin are scraped off.

• Abrasions can contain particles of dirt, or other foreign materials.

MANAGEMENT/TREATMENT:

• Wash gently under running tap water with antibacterial soap to remove foreign material. If feasible, allow a running stream of lukewarm water to pour over the wound.

o During wash, if necessary, try to remove debris or other foreign materials by gently rubbing with 4x4 gauze pads.

o Do not scrub a wound imbedded with dirt or other foreign material/debris. Instead, refer to healthcare provider.

• Assess and document tetanus immunization status.

• Do NOT use povidone-iodine, Dakin's solution and hydrogen peroxide for cleansing wounds. These solutions can damage normal tissue and hinder neodermal development necessary for healing. Only use antibiotic creams/ointments.

• Small abrasions may be left open to the air.

• Cover larger abrasions with a sterile, non-adherent bandage.

• After partial thickness abrasions are cleaned, a moist wound dressing can be applied within two hours of injury. ² This dressing can be a hydrogel or hydrocolloid dressing and can be any of a variety of brand-name products. This dressing must stay in place at least forty-eight hours and up to seven days to enhance optimal wound healing. Moist wound dressings allow rapid resurfacing or re-epithelialization of wound surfaces and allow for migration of proteins necessary for wound healing.

• Notify parent/guardian if the abrasion is more extensive or deeper than a superficial abrasion. Complete the assessment/treatment section of the injury report if the abrasion was the result of an injury or fall at school. Note : Work with the school staff who observed the incident and document the incident