COMMUNITY SETTING AND COMMUNITY HEALTH NURSING ROLES

CHAPTER 30- SCHOOL HEALTH (PAGES 613-627)

According to the Centers for Disease Control and Prevention (CDC) (2016), the healthy development of children and adolescents is influenced by many societal institutions, and after the family, the school is the primary institution responsible for the development of young people in the United States. The school environment is also a key setting in which students’ behaviors and ideas are shaped. Just as schools are critical to preparing students academically and socially, they are also vital partners in helping young people take responsibility for their health and adopting health-enhancing attitudes and behaviors that can last a lifetime (CDC, 2017).

BOX 30.1 Youth at Risk

· • Every day nearly 3200 young people start smoking (CDC, 2015).

· • Daily participation in high school physical education classes dropped from 42% in 1991 to 27.1% in 2013 (CDC, 2017).

· • Seventy-five percent of young people do not eat the recommended number of servings of fruits and vegetables.

· • Marijuana use among young people increased from 15% in 1991 to 46% in 2015.

From National Institute on Drug Abuse: National survey of drug use and health, 2015. https://www.drugabuse.gov/national-survey-drug-use-health

Academic success and healthy children and youth are closely intertwined. It is impossible to achieve success in school without maximizing the health of the students. School-age children and adolescents face increasingly difficult challenges related to health. Many of today’s health challenges are different from those of the past and include behaviors and risks linked to the leading causes of death such as heart disease, injuries, and cancer. Examples of behaviors that often begin during youth and increase the risk for serious health problems are the use of tobacco, alcohol, and drugs; poor nutritional habits; inadequate physical activity; irresponsible sexual behavior; violence; suicide; and reckless driving (Box 30.1).

In the United States, approximately 55.6 million children attend school every day (National Center for Educational Statistics, 2016). Their presence creates a unique opportunity for school nurses to have a positive impact on the nation’s youth. The primary providers of health services in schools are school nurses, and there are approximately 73,000 registered nurses working in schools in the United States (U.S. Department of Health and Human Services [USDHHS], Health Services and Resources Administration, 2010).

School nursing is a specialized practice of professional nursing that advances the well-being, academic success, and lifelong achievement and health of students. To that end, school nurses facilitate positive student responses to normal development; promote health and safety, including a healthy environment; intervene with actual and potential health problems; provide case management services; and actively collaborate with others to build student and family capacity for adaptation, self-management, self-advocacy, and learning (NASN, 2017). The National Association of School Nurses (NASN) recommends one school nurse for every 750 students in the general population, one for every 225 students in mainstreamed special education populations, and one for every 125 severely chronically ill or developmentally disabled students; however, caseloads vary widely, depending on mandated functions, socioeconomic status of the community, and service delivery model (NASN, 2015).

More than 21% of the nation’s children live in poverty (National Center for Children in Poverty, 2017). Poverty is defined as an annual income below $24,339 for a family of four (U.S. Census Bureau, 2017). Decreased or inferior health care has been linked to serious health problems, resulting in an increase in absenteeism that may be correlated with failure in school. The school nurse can effectively manage many complaints and illnesses, allowing these children to return to or remain in class.

TABLE 30.1

Racial and Ethnic Breakdown of Uninsured Children in the United States in the Year 2012

Race	Number	Percentage
White	2.9 million	38.8
Hispanic	2.7million	38.1
Black	1.0 million	14.2
Asian and Pacific Islander	306,000	4.3

Data from Children’s Defense Fund: The state of America’s children, 2014. http://www.childrensdefense.org/library/state-of-americas-children/2014-soac.pdf.

Indeed, on a daily basis, school nurses see students with a variety of complaints. Increasing numbers of children are being seen in the school setting because they lack a source of regular medical care. According to the Children’s Defense Fund (2014), nearly 9.2 million U.S. children, or 1 in 11, do not have health insurance. This is a decrease from the nearly 12 million in previous years. Table 30.1 illustrates the racial and ethnic breakdown of uninsured children in the United States in the year 2012. Poor academic performance is strongly correlated with the uninsured status of youth, and conversely, acquisition of health insurance leads to an improvement in school performance. Through education, counseling, advocacy, and direct care across all levels of prevention, the nurse can improve the immediate and long-term health of this population.

There is a need for mental and physical health services for students of all ages to improve both their academic performance and their sense of well-being. This chapter provides an overview of school health and the role of the nurse in the provision of health services and health education. It also offers an in-depth look at the components of a successful school health program and the major health problems of today’s youth.

History of School Health

Before 1840, education of children in the United States was uncoordinated and sparse. In 1840, Rhode Island passed legislation that made education mandatory, and other states soon followed. In 1850, a teacher and school committee member, Lemuel Shattuck, spearheaded the legendary report that has become a public health classic. This report, known as the Shattuck Report, has had a profound impact on school health because it proposed that health education was a vital component in the prevention of disease.

Public health officials and others soon realized that schools played an important part in the prevention of communicable disease. When smallpox broke out in New York City in the 1860s, health officials were faced with trying to implement a widespread prevention program. They chose to target the schools and began vaccinating children. This experience led to the 1870 requirement that all children be vaccinated against smallpox before entering school (Allensworth et al., 1997).

At that time, schools were frequently poorly ventilated and lacked fresh air, effectively spreading diseases among the children. Late in the nineteenth century, a practice of inspecting

schools began to identify children who were ill and exclude them until it was deemed they were no longer infectious. Soon thereafter, compulsory vision examinations became a requirement to identify children who might have difficulty in school. In 1902, New York City hired the first nurses to help inspect children, educate families, and ensure follow-up treatment. Within a few years the renowned nurse Lillian Wald was able to show that the presence of school nurses could reduce absenteeism by 50%. By 1911, more than 100 cities were using school nurses, and by 1913, New York City employed 176 school nurses (Allensworth et al., 1997).

As they became more comfortable in their positions, early school nurses began to take on more active roles in the assessment of children, treatment of minor conditions, and referral for more serious problems. In addition to identification, treatment, and exclusion for communicable diseases and screening for problems that might affect learning, other issues quickly became part of school nurses’ practice. In the early part of the twentieth century the temperance movement led schools to teach children about the effects of alcohol and tobacco. Also early in the twentieth century, “gymnastics” was introduced in schools in an effort to promote physical activity. World War I was a pivotal point for school health services, and the call for a national effort to improve the health of schoolchildren emerged. In 1918 the National Education Association joined forces with the American Medical Association (AMA) to form the Joint Committee on Health Problems and publish the report Minimum Health Requirements for Rural Schools. This group also called for the coordination of health education programs, medical supervision, and physical education. By 1921 nearly every state had laws that required physical and health education in schools. Additionally, fire drills became part of safety education programs introduced during and after World War I (Allensworth et al., 1997).

Even though emphasis was placed on health services in schools, barriers still existed. Many schools and cities were unwilling to take on the task of providing primary health care for all children. The idea that schools should simply identify and refer problems to physicians was a common practice backed by the AMA. By the 1920s, medical services and preventive health services were clearly separated in the public health arena and in the schools, thereby largely supported by each state, which focused more attention on “health education.” The federal government did not get involved with school health until the passage of the National School Lunch Program in 1946. The School Breakfast Program was implemented 30 years later (Allensworth et al., 1997).

There was no impetus to change the direction of school health programs until the 1960s and 1970s. During these decades there was increasing publicity about children living in poverty and the move to mainstream children with disabilities. These two issues, along with an increase in the number of children of immigrants, contributed to changes in school health programs.

During the 1960s the first nurse practitioner training programs opened and made the inclusion of primary care services in schools possible. In 1976 the first National School Conference, supported by the Robert Wood Johnson Foundation, was held in Galveston, Texas. After this conference a variety of school health service models began to emerge with new partnerships and ideas created to provide the most comprehensive health care services for school-age children. In addition, the Education for the Handicapped Act in 1975 mandated that all children, regardless of disabilities, have access to educational services.

The 1980s and 1990s saw several measures aimed at improving the health of schoolchildren. The Drug-Free Schools and Community Act was implemented in 1986 to fight substance abuse through education and was expanded in 1994 to include violence prevention measures. During this period, the Centers for Disease Control and Prevention (CDC), Division of Adolescent and School Health, began funding state education agencies to develop and implement programs aimed at alcohol and tobacco use, physical education, and the reduction of sexually transmitted diseases (STDs) and HIV infection among the nation’s youth. Also, the federal government encouraged states to use part of their maternal and child block grant monies to fund school-based health centers.

The No Child Left Behind Act (NCLB) was signed into law by President Bush in 2002. As part of the NCLB, the Safe and Drug Free Schools and Communities Act (SDFSC) became effective that same year. SDFSC supports programs that focus on prevention of school violence and illegal use of alcohol, tobacco, and drugs. This legislation promotes the involvement of parents and communities in efforts and resources to create a safe and drug-free environment in order to enhance student academic achievement.

The Patient Protection and Affordable Care Act was signed into law March 23, 2010, by President Obama. Under this act, an initial 95 million dollars was awarded to 278 school-based health centers (SBHCs) as part of a capital program to create new sites and expand existing services in 2011. In 2012, an additional 14.5 million dollars was awarded to 45 SBHCs for expansion of services in medically underserved areas (USDHHS, 2013). See the later discussion of SBHCs.

School health services vary widely among states and school districts. There continues to be a lack of coordination among providers, with no single agency responsible for tracking services. Recognizing that there are differences among schools in the United States and that important health information must be delivered to children and adolescents, the USDHHS addressed many related issues in the Healthy People 2020 program. Objectives targeting children and adolescents are written for diverse areas, including physical activity, sex education and HIV prevention, nutrition, smoking prevention, injury prevention, and school absences related to asthma. The Healthy People 2020 box lists a few of these objectives related to school health.

School Health Services

The School Health Policies and Programs Study describes school health services as a “coordinated system that ensures a continuum of care from school to home to community health care provider and back” (Allensworth et al., 1997, p. 153). School health services goals and objectives vary from state to

state, community to community, and school to school. These differences reflect wide variations in student needs, community resources, funding sources, and school leadership preferences. Many organizations, such as the American School Health Association and NASN, are involved in the care and welfare of school-age children and have compiled and adopted definitions, standards, and statistics related to school health.

FIG. 30.1 The eight components of school health programs.

According to the School-Based Health Alliance (2014), there are 2315 SBHCs located in 49 out of 50 states, including the District of Columbia. Most SBHCs are staffed with a nurse, a nurse practitioner, or physician assistant. The following services provided in these centers typically include first aid, medication administration, and preventive screenings (vision, hearing, scoliosis, and acanthosis nigricans). Nearly all schools maintain health records on students and, at a minimum, monitor immunization status per federal and state laws. Most authorities agree that comprehensive school health programs should have the following eight components (Fig. 30.1): health education; physical education; health services; nutrition services; counseling, psychological, and social services; healthy school environment; health promotion for staff; and family and community involvement.

Healthy People 2020

Selected Objectives for School Health

· AH-5.6: Decrease school absenteeism among adolescents due to illness or injury.

· AH-8: Increase the proportion of adolescents whose parents consider them to be safe at school.

· DH-14: Increase the proportion of children and youth with disabilities who spend at least 80% of their time in regular education programs.

· EMC-1: (Developmental) Increase the proportion of children who are ready for school in all five domains of healthy development: physical development, social and emotional development, and approaches to learning, language, and cognitive development.

· EMC-4: Increase the proportion of elementary, middle, and senior high schools that require school health education.

· ECBP-5: Increase the proportion of the nation’s elementary, middle, and senior high schools that have a full-time registered school nurse–to-student ratio of at least 1:750.

· EH-16: Increase the proportion of the nation’s elementary, middle, and high schools that have official school policies and engage in practices that promote a healthy and safe physical school environment.

· FP-12: Increase the proportion of adolescents who received formal instruction on reproductive health topics before they were 18 years old.

· IID-10: Maintain vaccination coverage levels for children in kindergarten.

· IVP-27: Increase the proportion of public and private schools that require students to wear appropriate protective gear when engaged in school-sponsored physical activities.

· MHMD-6: Increase the proportion of children with mental health problems who receive treatment.

· NWS-10: Reduce the proportion of children and adolescents who are considered obese.

· NWS-2: Increase the proportion of schools that offer nutritious foods and beverages outside of school meals.

· OH-1: Reduce the proportion of children and adolescents who have dental caries in their primary or permanent teeth.

· PA-4: Increase the proportion of the nation’s public and private schools that require daily physical education for all students.

· RD-5.1: Reduce the proportion of children aged 5 to 17 years with asthma who miss school days.

· SA-18: Reduce steroid use among adolescents.

· TU-3: Reduce the initiation of tobacco use among children, adolescents, and young adults.

· V-2: Reduce blindness and visual impairment in children and adolescents age 17 and under.

From HealthyPeople.gov: Healthy People 2020: Topics & objectives. www.healthypeople.gov/2020/TopicsObjectives2020/default.aspx Accessed: February 21, 2018.

Health Education

An objective of Healthy People 2020 sets a goal that middle, junior, and senior high schools provide health education courses in priority areas. The CDC (2016) identified the following six high-risk behaviors, utilizing the Youth Risk Behavior Surveillance System (YRBSS), as needing to be targeted in health education courses:

· 1. Alcohol and drug use

· 2. Injury and violence (including suicide)

· 3. Tobacco use

· 4. Poor nutrition

· 5. Lack of physical activity

· 6. Sexual behavior that results in STDs or unwanted pregnancies

These problems and behaviors are preventable and often coexist. They also lead to both social and educational problems that contribute to our nation’s high dropout and unemployment rates and crime statistics.

The National Health Education Standards were established to promote positive health behaviors for students in all grades (CDC, 2016). These standards give educators, administrators, and policy makers a framework for developing and designing

health education programs in schools. The standards are written to promote personal, family, and community health in students, targeting grades 2, 5, 8, and 12. The standards provide a guide for curricula development in health education and specify that the students will (1) comprehend concepts related to health promotion and disease prevention to enhance health; (2) analyze the influence of family, peers, culture, media, technology, and other factors on health behaviors; (3) demonstrate the ability to access valid information, products, and services to enhance health; (4) demonstrate the ability to use interpersonal communication skills to enhance health and avoid or reduce health risks; (5) demonstrate the ability to use decision-making skills to enhance health; (6) demonstrate the ability to use goal-setting skills to enhance health; (7) demonstrate the ability to practice health-enhancing behaviors and avoid or reduce health risks; and (8) demonstrate the ability to advocate for personal, family, and community health.

BOX 30.2 Purposes of the Youth Risk Behavior Survey System

· • Determine the prevalence of health risk behaviors.

· • Assess whether health risk behaviors increase, decrease, or remain the same over time.

· • Examine the co-occurrence of health risk behaviors.

· • Provide comparable data among subpopulations of youth.

· • Provide comparable national, state, territorial, tribal, and local data.

· • Monitor progress toward achieving the Healthy People 2020 objectives and other program indicators.

From Kann L, McManus T, Harris WA, et al.: Youth risk behavior surveillance—United States, 2015, MMWR Surveill Summ 65(No. SS-6):1–174, 2016.

In 1990, to learn more about high-risk behaviors among youth, the CDC (2016) instituted the Youth Risk Behavior Surveillance System. The YRBSS survey is conducted every 2 years among selected high school students throughout the United States in both private and public schools. Box 30.2 lists the purposes of the YRBSS. Reports from the survey provide valuable information that can help improve health education programs in schools.

Injury Prevention

Injury prevention should be taught early in schools, and the information should be age appropriate. For example, bicycle safety, including the importance of wearing a helmet and the proper use of backpacks, must be stressed beginning in elementary schools. Safety on the schoolyard and playground is also important for this age group, because approximately 200,000 children per year are injured on playgrounds in the United States (U.S. Consumer Product Safety Commission, 2009). Motor vehicle safety should be included in programs for adolescents who are beginning to drive. These motor vehicle safety programs should include the hazards of distracted driving (e.g. cell phones, texting), which are issues affecting all drivers.

Sports safety is particularly important among adolescents as participation in sports continues to grow, especially among girls. More than 3.5 million children younger than 14 years receive medical treatment in emergency rooms each year for sports-related injuries (Safe Kids USA, 2011). Injuries occur most commonly on playgrounds, on athletic fields, and in gymnasiums. Orthopedic injuries (e.g., strains, sprains, fractures, and dislocations), dental injuries, neurological problems (e.g., traumatic brain injury [TBI] and concussion), ophthalmic injuries, cuts, abrasions, and bruises are frequently seen. TBI accounts for more 20,000 of these injuries and continues to be a significant concern for health care providers and school nurses (Cheng et al., 2016).

Use of proper equipment should be mandatory for children and adolescents participating in sports activities. Fitted mouth guards, shin guards, pads, helmets, and other protective gear should be required to prevent injury. Regular hydration and frequent rest periods should be required to prevent heat-related illnesses, especially during hot weather. Effective warm-up and cool-down exercises should be encouraged to prevent muscle strain. Schools that participate in aquatic sports should include pool safety. The school nurse has a unique opportunity to work with the athletic staff to promote these kinds of policies.

The sports physical is a good time for the school nurse to counsel the student about the risk of health problems related to physical activity. This is also an appropriate setting for the nurse to question girls about menstrual irregularities and to ask all students about their eating behaviors, feelings about their weight, and history of musculoskeletal injuries. The nurse can use this setting to teach the importance of stretching exercises to help prevent injuries.

Many school districts have school safety committees that make recommendations for sports-related safety. These committees collect data on injuries, develop safety inspection policies, and plan staff training and student education related to school environmental factors. Nurses are vital members of school health teams and committees from instituting injury prevention programs to injury response on the athletic field.

Tobacco Use

For the past several decades, major concerns have been raised about long-term health problems associated with adolescents’ use of tobacco, alcohol, and illegal substances. There is an increased likelihood that these youthful abusers will ultimately engage in other high-risk behaviors. Adolescent smoking has been closely correlated with alcohol use and other drugs. Smoking by young people can cause serious health problems, such as heart disease; chronic lung disease; and cancers of the lung, pharynx, esophagus, and bladder. Factors that have been associated with youth tobacco use include low economic status, peer pressure, smoking by parents, a perception that tobacco use is the norm, low levels of academic achievement, exposure of advertising, and history of aggressive behavior such as membership in gangs (CDC, 2016).

Although there has been improvement over the last decades, smoking remains a major problem in this country and is the single leading preventable cause of death in the United States. Cigarette smoking has declined significantly, but the usage of other forms of tobacco has emerged; this includes electronic cigarettes, hookah, pipes, bidis, flavored tobacco, and smokeless tobacco (CDC, 2016). Prevention should be a priority in youth

because 9 out of 10 cigarette smokers first tried smoking by 18 years of age (USDHHS, 2014). Of continued concern, it is estimated that more than 25% of high school students in 2015 used some form of tobacco (CDC, 2016). Further, an estimated 3200 youth under the age of 18 try their first cigarette each day, with an additional 2100 youth becoming daily smokers (USDHHS, 2014). White high school students have the highest rate of consumption of tobacco in various forms, at 24.0%, followed by Hispanics at 23.9%, and blacks at 21.0%. Finally, percentage rates for any tobacco product usage are 20.3% in females and 30.0% in males (CDC, 2016).

Substance Abuse

The use of alcohol and other drugs is associated with problems in school, injuries, violence, and motor vehicle deaths. All 50 states and the District of Columbia have outlawed the sale of alcohol to anyone under the age of 21, yet it is still the most commonly used and abused drug among children and adolescents. In 2014, statistics show that 33% of 15-year-olds and 60% of 18-year-olds had tried alcohol; thus use increased in frequency as youths progressed in school (Substance Abuse and Mental Health Services Administration, 2016). Furthermore, approximately 17.7% of high school students reported they had five or more drinks of alcohol in a row within a couple of hours at least 1 day within the last 30 days (CDC, 2016). Additionally, almost 32.8% reported having had at least one drink of alcohol during the last 30 days (CDC, 2015). Alcohol use is more prevalent among Hispanics (34.4%) and whites (35.2%) than blacks (23.8%) (CDC, 2015).

The most commonly used illicit drug in the United States is marijuana. In 2015, 38.6% of young people reported using marijuana one or more times in their lives (CDC, 2015). A new disturbing trend is the use of synthetic marijuana as known as K2, Spice, fake weed, King Kong, or Moon Rocks, with 9.2% of high school students reporting its use in 2015 (CDC, 2015).

The use of other illegal drugs in high school students includes cocaine (5.2%), hallucinogenics (6.4%), Ecstasy (5.0%), inhalants (7.0%), heroin (2.1%), methamphetamine (3.0%), steroids (3.5%), and prescription drugs (opioids, depressants, or stimulants) (16.8%) (CDC, 2015). Of significant concern is the growing abuse of prescription drugs. Opioids (e.g., Vicodin or OxyContin), depressants or antianxiety medications (e.g., Valium or Xanax), and stimulants (e.g., Ritalin or Adderall) are the most commonly abused. Many times students obtain these drugs from other family members who have been prescribed the medication or from the illegal sale on the streets or through the Internet.

The use of anabolic steroids has decreased somewhat among high school students, declining from 3.6% in 2011 to 3.0% in 2015, but the issue should remain a concern to school health nurses because of the number of athletes who abuse the drugs (CDC, 2015). Many athletes believe that anabolic steroids will produce an increase in strength and muscle mass and enhance their performance. There are more than 100 different types of anabolic steroids, and all require a prescription. Abuse or improper use of anabolic steroids can result in severe problems, including renal impairment or failure; liver cancer; cardiovascular problems such as high blood pressure and elevated cholesterol levels; and sexual changes such as testicular shrinkage, clitoral enlargement, and accelerated puberty (National Institute on Drug Abuse, 2016.

BOX 30.3 Teen Pregnancy

· • The U.S. teen birth rate is one of the highest among developed countries.

· • 249,078 babies were born to teenagers aged 15 to 19 in 2014.

· • Black and Hispanic youth have a disproportionately high rate of teen pregnancy.

· • Teen mothers are less likely to complete high school.

· • Teen mothers are more likely to be single parents and to live in poverty.

· • Birth rates among teenagers vary substantially from state to state.

Data from Centers for Disease Control and Prevention: About teen pregnancy, 2016. https://www.cdc.gov/teenpregnancy/about/

Sex Education

A number of objectives of Healthy People 2020 address issues of human sexuality and prevention of pregnancy, STDs, and HIV. These issues are important for the nurse working with older children and adolescents.

Many teens become sexually active at an early age, and despite recent declines, pregnancy rates continue to be high (Box 30.3). Data obtained from the YRBSS reveals a decrease from 47.4% in 2011 to 41.2% in 2015 of adolescents in grades 9 through 12 who have had sexual intercourse (CDC, YRBSS, 2016).

Sex education in the school setting is a controversial topic. Opponents of sex education believe that parents have the responsibility for teaching this content to their children. Laws in certain states prohibit or dramatically limit sex education in public schools. However, 24 states and the District of Columbia mandate that public schools teach sex education (National Conference of State Legislatures, 2016). Proponents argue that for many children sex education will not be addressed in the home. If this information is not taught in schools, children may receive inadequate or incorrect information from peers, media, or other sources. Contrary to some concerns, there is no research that concludes that sex education in the schools increases sexual activity. According to the Future of Sex Education Initiative (2012), the following seven topics are considered fundamental to a comprehensive sex education curriculum: anatomy and physiology, puberty and adolescent development, identity (sexual orientation), pregnancy and reproduction, STDs and HIV, healthy relationships, and personal safety. School nurses have been caught in the center of this controversy but historically have advocated for education on normal human sexuality that encourages discussion in an objective, nonjudgmental manner and in which students are free to ask questions and receive correct answers.

Tattoos and Body Piercings

Tattoos and body piercings are a form of self-expression and attention-seeking behavior. Their popularity has risen dramatically in the last decade. The procedures are often done at home, on the streets, or in parlors where sterile technique and safety precautions are not practiced. Both hepatitis C and methicillin-resistant Staphylococcus aureus have been linked to tattoos and

body piercings. This fact presents an opportunity for the school nurse to teach students the importance of making healthy decisions on whether to have such procedures done and, if so, under what conditions they will be performed.

Dental Health

One of the most common complaints of school-age children is dental caries. There are numerous contributing factors, including poor oral hygiene, lack of fluoridated water, and lack of funds or insurance for dental care. More than half of children have dental caries by the time they are 8 years of age. This disease is more common in lower-income children, and approximately 66% of those between the ages of 12 and 19 have had tooth decay. Untreated cavities can greatly affect a child’s quality of life and cause pain, absence from school, and decreased self-worth (CDC, 2015). Proper brushing of teeth should be taught along with good nutritional habits and the importance of regular dental checkups. Children should also be taught the relationship between high-sugar foods and dental caries.

Physical Education

One of the major objectives of Healthy People 2020 is improvement of health and fitness through regular physical activity. Children today are less active than children in the past. Daily enrollment in physical education classes among high school students dropped from 42% in 1991 to 29% in 2013 (CDC, 2013). Children are becoming more sedentary as a result of increased use of computers and television and decreasing requirements for physical education. It was reported in 2011 that 31% of high school children used a computer 3 or more hours a day and 32% watch television 3 or more hours a day (CDC, 2012).

A sedentary lifestyle is associated with obesity, hypertension, heart disease, and diabetes. Studies show that people who are active have a better quality of life and outlive those who are inactive. Habits in childhood are likely to continue into adulthood, making it imperative that children are taught the importance of being physically active at a young age. Studies also show that children and adolescents who are physically active have increased self-confidence and self-esteem and decreased anxiety, stress, and depression. Regular physical activity helps build and maintain healthy bones and muscles.

Physical education should focus on activities that children can continue into their adult years, such as walking, swimming, biking, and jogging. The educational content should change as the child ages. For example, what may appeal to a young child, such as playing on the playground with friends, is different from what motivates an adolescent, such as competitive sports and aerobic exercise. The CDC has made 10 recommendations for the promotion of lifelong physical activity (Box 30.4).

Health Services

Health care provided in schools includes preventive services such as immunizations and health screenings. This component of a comprehensive school health program may also involve emergency care, management of acute and chronic health conditions, appropriate referrals, health counseling, education about healthy lifestyles, and medication administration.

BOX 30.4 Guidelines for School Programs: Promoting Healthy Eating and Physical Activity

· • Use a coordinated approach to develop, implement, and evaluate healthy eating and physical activity policies and practices.

· • Establish school environments that support healthy eating and physical activity.

· • Provide a quality school meal program and ensure that students are offered only appealing, healthy food and beverage choices outside the school meal program.

· • Implement a comprehensive physical activity program with quality physical education as the cornerstone.

· • Implement health education that provides students with the knowledge, attitudes, skills, and experiences needed for healthy eating and physical activity.

· • Provide students with health, mental health, and social services to address healthy eating, physical activity, and related chronic disease prevention.

· • Partner with families and community members in the development and implementation of healthy eating and physical activity policies, practices, and programs.

· • Provide a school employee wellness program that includes healthy eating and physical activity services for all school staff members.

· • Employ qualified persons and provide professional development opportunities for physical education; health education; nutrition services; and health, mental health, and social services staff members, as well staff members who supervise recess, cafeteria time, and out-of-school-time programs.

From Centers for Disease Control and Prevention: School health guidelines to promote healthy eating and physical activity, MMWR Recomm Rep 60(RR-5):1–76, 2011. www.cdc.gov/mmwr/pdf/rr/rr6005.pdf.

Immunizations

Immunizations are a vital component of routine health care, providing long-lasting protection against many diseases. Vaccine-preventable deaths are at record-low levels. Many communicable diseases have been reduced by more than 99% as a result of immunizations. Undervaccination of children, especially those in large urban areas, is a concern because of the potential for disease outbreaks.

All states now require proof of immunization status or evidence of immunity before a child can enter school. Certain exceptions based on religious and philosophical beliefs or medical contraindications may apply. The school nurse plays an important role in verifying compliance with immunization requirements and in educating children and parents about the benefits of immunization. See the CDC website (https://www.cdc.gov/vaccines/schedules/hcp/index.html) for current immunization schedules.

Health Screenings

Many children in the United States are not appropriately screened for certain treatable conditions. Impaired vision and hearing can result in poor academic performance, slowed emotional development, and stress-related disorders. Early identification and treatment of these problems is highly effective and less costly. Vision and hearing screenings are provided at most schools according to a schedule set by the state or school district. These screenings usually occur upon a child’s initial entry to school and at least once during elementary, middle, and high school. Children and adolescents may need to be screened

more often on the basis of family history, developmental delays, recurrent ear infections, or exposure to loud noise.

Vision screening is required in most states, with referrals as needed. The standard Snellen vision chart is the usual screening tool. Screening for strabismus is a nursing responsibility, and this condition must be identified and treated early to prevent amblyopia. If left untreated, amblyopia may result in loss of vision. Referral to an eye specialist is a critical component of all abnormal eye examination results.

Scoliosis or postural screening should be done to identify spinal deviations in an effort to prevent secondary problems. Spinal problems may lead to cosmetic, functional, or emotional problems. Scoliosis screening in the school consists primarily of a visual inspection of the back. The American Academy of Pediatrics and the American Academy of Orthopedic Surgeons recommend screening of all girls at 10 and 12 years and boys once at either 13 or 14 years (Hresko et al., 2015).

The assessment of high blood pressure during childhood is important in identifying children who have hypertension and who will benefit from early intervention and follow-up. Vascular and end-organ damage from hypertension can begin in early childhood. Periodic blood pressure measurements are inexpensive and should be performed routinely for all children. Other periodic screenings may be mandated by various state or district regulations. These include body mass index (BMI) (height and weight) and dental screenings.

The Children’s Health Insurance Program is a national program designed for children of families who earn too much money to qualify for Medicaid but cannot afford the high cost of health insurance. Medicaid-eligible children are guaranteed access to comprehensive health care services and routine dental examinations. Medicaid created the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) service because of the large number of uninsured children. EPSDT, a comprehensive child health program for the uninsured under the age of 21, includes health education and periodic screening. Services provided under the EPSDT program are often performed through the public health offices in each state, but may occur in community health clinics and schools. Screening services must include a comprehensive health and developmental history, an unclothed physical examination, immunizations and laboratory testing that are age appropriate, and lead toxicity screenings (Centers for Medicare and Medicaid Services, 2017).

Emergency Care

Schools are a common site of injuries ranging from minor scrapes, bruises, and fractures, to more severe life-threatening events such seizures, head injuries, severe asthma attacks, and mass casualty incidents. Injuries may occur in school buildings or classrooms or during physical education classes or athletic events. Emergencies can include natural events, such as hurricanes, tornadoes, and earthquakes, or manmade disasters, such as hazardous material spills, fires, and acts of terror. Basic first aid equipment should be available in all schools. The school nurse must be knowledgeable about standard first aid and certified in cardiopulmonary resuscitation and use of an automated external defibrillator. The school nurse must also be responsible for the development of a school emergency plan that provides school staff with a guide to facilitate quick response in case of a student or school emergency.

Care of the Ill Child

The school nurse is responsible for monitoring the health of all students. For students with acute or chronic illnesses, administration of medications or treatments may be necessary. The nurse is often required to assess an ill child to determine the type of illness or health problem and develop a management plan. Two commonly encountered chronic illnesses are asthma and diabetes.

In 2014, 8.6% of U.S. children younger than 18 years had asthma, which was most prevalent among poor children (16.4%) and non-Hispanic black children (18.4%) (CDC, 2014). Asthma is one of the most common chronic childhood conditions, causing more than 4.6 million people to miss more than 1 day of school or work (CDC, 2011). Because asthma is so prevalent, it is recommended that school-based support exists for children who have it. Actions undertaken by some schools across the country include immediate access to asthma medications, development and implementation of asthma action plans, and student and staff education on asthma. An assessment tool has been developed to determine how well schools assist children with asthma (Box 30.5). Answers to all the questions in the assessment tool should be “yes.” “No” answers indicate that students may not be in an environment conducive to asthma control.

According to the American Association of Diabetes Educators (AADE, 2016), diabetes is prevalent in school-age children, affecting around 190,000 people younger than 20 years. Most cases of diabetes in this cohort is type 1, but type 2 diabetes is being diagnosed with increasing frequency in children. Type 2 diabetes in youth is projected to increase by 49% in the next 40 years, and the number of children diagnosed with type 1 diabetes is expected to increase 23%. The figures are disproportionately larger in minority populations. Childhood obesity and the decline in physical activity are considered major factors in this development (American Diabetes Association [ADA], 2012). In general, teachers are inadequately prepared to care for children with diabetes and must rely on the school nurse. Children should be able to participate in their care to the extent that they are able (ADA, 2012). With the growing number of children who have diabetes, it is imperative that the nurse recognize the signs and symptoms of hypoglycemia and hyperglycemia in order to assist children in the monitoring of glucose levels and the administration of insulin or glucagon. The ADA has specific recommendations based on age, as shown in Box 30.6.

Medication Administration

Administration of medications is a service provided almost universally by school districts across the country. The use of medications by school-age children has increased over the last several years, allowing many children to attend school despite serious health problems.

Medication administration in the schools is a serious undertaking. Issues facing the school nurse include safety, monitoring of both therapeutic and side effects, proper documentation, confidentiality, and ongoing communication with the student and family. Only those medications considered necessary are administered at school.

BOX 30.5 How Asthma-Friendly Is Your School? Checklist

Children with asthma need proper support at school to keep their asthma under control and be fully active. Use the following questions to find out how well your school assists children with asthma.

□ Yes□ No	Is your school free of tobacco smoke at all times, including during school-sponsored events and on school buses?
□ Yes□ No	Does the school maintain good indoor air quality? Does it reduce or eliminate allergens and irritants that can make asthma worse? Check if any of the following are present: □ Cockroaches □ Dust mites (commonly found in humid climates in pillows, carpets, upholstery, and stuffed toys) □ Mold □ Pets with fur or feathers □ Strong odors or fumes from art and craft supplies, pesticides, paint, perfumes, air fresheners, and cleaning chemicals
□ Yes□ No	Is there a school nurse in your school all day, every day? If not, is a nurse regularly available to help the school write plans and give the school guidance on medicines, physical education, and field trips for students with asthma?
□ Yes□ No	Can children take medicines at school as recommended by their doctor and parents? May children carry their own asthma medicines?
□ Yes□ No	Does your school have a written, individualized emergency plan for teachers and staff in case of a severe asthma episode (attack)? Does the plan make clear what action to take under different emergency situations such as fire, weather, or lock-down? Whom to call? When to call?
□ Yes□ No	Does someone teach school staff about asthma, asthma action plans, and asthma medicines? Does someone teach all students about asthma and how to help a classmate who has it?
□ Yes□ No	Can students actively participate in physical education class and recess? (For example, do students have access to their medicine before exercise? Can they choose modified or alternative activities when medically necessary?)

If the answer to any question is “no,” students in your school may be facing obstacles to asthma control. Uncontrolled asthma can hinder a student’s attendance, participation, and progress in school. School staff, health professionals, and parents can work together to remove obstacles and promote students’ health and education.

From National Heart, Lung, and Blood Institute, National Asthma Education and Prevention Program, NAEPP School Asthma Education Subcommittee: How asthma friendly is your school? 2008. www.nhlbi.nih.gov/health/public/lung/asthma/friendly.pdf

BOX 30.6 Expectations of the Child With Diabetes

Toddler and Preschool Age

· • The child should be able to determine which finger to prick.

· • The child can usually choose an injection site.

· • The child is generally cooperative.

Elementary School Age

· • The child should be able to assist in all diabetes tasks at school.

· • The child is usually able to perform his or her own fingerstick glucose monitoring.

· • The child can administer his or her own insulin with supervision.

· • The child is usually able to let an adult know when he or she is experiencing a hypoglycemic episode.

Middle School and High School Age

· • The child should be able to perform self-monitoring of blood glucose.

· • Most children should be able to administer their own insulin with supervision; adolescents should be able to administer insulin without supervision.

· • All children may need assistance with blood glucose testing when the glucose level is low.

Data from American Diabetes Association: Diabetes care in the school and day care setting, Diabetes Care 35:S76–S80, 2012.

The following guidelines from NASN (2017) should be included in school medication policies:

· • Delegation (including training and supervision of unlicensed assistive personnel)

· • Medication orders

· • Prescription and over-the-counter medications

· • Proper labeling, storage, disposal, and transportation of medication

· • Documentation of medication administration

· • Rescue and emergency medications

· • Off-label medications and investigational drugs

· • Complementary and alternative medications

· • Psychotropic medications and controlled substances

· • Medication doses that exceed manufacturer’s guidelines

· • Student confidentiality

Medications commonly given in schools include analgesics and antipyretics (e.g., acetaminophen [Tylenol] or ibuprofen [Advil]), antacids, antitussives, anticonvulsants, antiemetics and antidiarrheals, antifungals, antihistamines, and antibiotics. Medications used to treat attention-deficit hyperactivity disorder (ADHD) are among the most commonly administered. In a report released in 2015, 9.5% of children in the United States between 4 and 17 years were diagnosed with ADHD, and this number appears to be increasing (Pastor, 2015).

Alternative and complementary medicine includes practices and products outside the realm of conventional medicine. Medication administration policies should exist that reflect local and state laws that address these products. The request for the administration of any of these medications provides the nurse with an excellent health teaching opportunity.

School nurses must be aware of medications that are being self-administered on school grounds and must provide education as needed to both children and parents. Rescue medications such as albuterol for asthma or an EpiPen for a child with a severe allergic reaction must be administered quickly to affect asthma symptoms, and the nurse must be familiar with its expected effects to properly assist the child who needs it. It is now legal in all 50 states for students to carry and self-administer asthma medications (NASN, 2017).

TABLE 30.2

Overview of Increase in Number of Students With Disabilities∗

Type of Disability	1976–1977	1990–1991	2000–2001	2009–2010	2013–2014
All disabilities	8.3	11.4	13.3	13.1	12.9
Specific learning disabilities	1.8	5.2	6.1	4.9	4.5
Speech or language impairments	2.9	2.4	3.0	2.9	2.7
Developmental delays	—	—	0.4	0.7	0.8
Emotional disturbance	0.6	0.9	1.0	0.8	0.7
Hearing impairment	0.2	0.1	0.2	0.2	0.2
Orthopedic impairments	0.2	0.1	0.2	0.1	0.1
Other health impairments	0.3	0.1	0.6	1.4	1.6
Visual impairments	0.1	0.1	0.1	0.1	0.1
Multiple disabilities	—	0.2	0.3	0.3	0.3
Autism and related disorders	—	—	0.2	0.8	1.1

∗ Children age 3 to 21 years served in federally supported programs for the disabled by type of disability: selected years 1976– 1977 through 2013–2014.

From National Center for Education Statistics: NCES fast facts: students with disabilities, 2016. https://nces.ed.gov/fastfacts/display.asp?id=64

Children With Special Health Needs

In 1976, Public Law 99-142 was enacted, giving all students, including those who are severely handicapped, the right to public education in the least restrictive environment possible, regardless of mental or physical disabilities. The Education for All Handicapped Children Act of 1973 and the subsequent Individuals with Disabilities Education Act (IDEA) of 1990 enhanced the opportunities for children previously served in acute care and long-term care settings to have access to public education. Children affected by these laws include those who are hearing impaired, mentally challenged, multihandicapped, orthopedically impaired, “other” health impaired (e.g., chronic or acute health problems such as a heart condition or epilepsy), seriously emotionally disturbed, speech impaired, visually handicapped, or who have a specific learning disability.

The development of health care services and technology has enabled students whose conditions may have prevented them in the past from leaving an institution or controlled environment to attend public school. Many of these children need nursing services of varied types (e.g., tube feedings, suctioning, catheterization) to continue their progression in school. Public Law 94-142 requires school nurses to screen or identify children in need of special education and related services and to participate in the development of an interdisciplinary individualized education program (IEP) that includes educational goals and specific services to be provided. The nurse is also responsible for the development of an individualized health care plan (IHP) for all students requiring continuous nursing management while at school. Table 30.2 gives an overview of the increase in the number of students with disabilities.

Student Records

Health records are maintained for all students according to individual school district policy. At a minimum, student health records should include immunization status, pertinent history, results of screenings and examinations, and IHPs. The Family Educational Rights and Privacy Act, a strong privacy protection act, protects student education and health records. Student health records should be afforded the same level of confidentiality as that given to clients and patients in other settings (i.e., sharing confidential information with others without approval is considered unethical and improper except in emergency situations).

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) was instituted in 2003. A major component of HIPAA is ensuring confidentiality of personal health information. Public schools that provide health care services fall under HIPAA regulations. Private schools that do not receive federal funding but engage in HIPAA-related activities are also governed by this act.

Delegation of Tasks

Not every school has a full-time nurse available on site. A nurse may be assigned to three or four schools, resulting in delegation of certain tasks to unlicensed personnel. Each state’s Nurse Practice Act stipulates which procedures may be delegated. The responsibility for assessment, diagnosis, goal setting, and evaluation may never be delegated. When tasks are delegated, the nurse must provide appropriate education, written procedures, and ongoing supervision and evaluation of the caregivers.

Nutrition

School-age children are undergoing periods of rapid growth and development and have complex nutritional needs. They must eat a variety of foods to meet their daily requirements. Diets should include a proper balance of carbohydrates, protein, and fat, with sufficient intake of vitamins and minerals. Children and adolescents share a well-known preference for junk food (Box 30.7), and their diet is often high in fat and sugar and frequently consists of fast-food items, such as hamburgers and French fries, instead of fruits and vegetables. Skipping meals, especially breakfast, and eating unhealthy snacks contribute to poor childhood nutrition. Identifying nutritional problems, counseling, and making appropriate referrals are important in the school setting. The school nurse should consider cultural influences on diet when teaching students and assessing their nutritional status.

Poor nutritional status is closely associated with poverty. Federally funded programs such as the School Breakfast Program and National School Lunch Program were initiated to ensure that all children have access to these meals during the school day.

Eating Disorders

It is imperative that the school nurse recognize the association between feelings of inadequacy and unhealthy eating practices in adolescents and young people. These self-perceptions begin early in life; therefore education and counseling must begin in

elementary school. Prevention should concentrate on eliminating misconceptions surrounding nutrition, dieting, and body composition and should stress optimal health and personal performance. Outside influences such as social media, celebrity admiration, commercials, and advertisements make this a serious problem.

BOX 30.7 Vending Machine Food Choices

In 2004, the National Association of School Nurses addressed the issue of unhealthy foods found in school vending machines and sold in school fundraising projects. The organization specifically resolved that schools should provide healthy food choices in school vending machines and for sale in fundraising projects.

Data from National Association of School Nurses: Resolution: vending machines and healthy food choices in schools, 2004. www.nasn.org.

School nurses must also be aware of eating disorders and related risk factors. Anorexia, bulimia, and binge eating are the three most common eating disorders, and anorexia is ranked number three in terms of chronic disorders in adolescents (NIMH, 2016). Binge eating is defined as recurrent, out-of-control eating of large amounts of food whether a person is hungry or not. Anorexia is a severely restricted intake of food based on an extreme fear of weight gain. Literature has shown that anorexia is multifactorial, seen primarily in females, and often correlated with family dysfunction or a history of sexual abuse. Bulimia is a form of anorexia characterized by a chaotic eating pattern with recurrent episodes of binge eating followed by purging. Health consequences of eating disorders may include reduction of bone density, severe dehydration, tooth decay, and potentially fatal electrolyte imbalances.

Female Athlete Triad

The “female athlete triad” is a syndrome consisting of eating disorders, amenorrhea, and osteoporosis. Pressure to attain a particular body shape or weight considered desirable in a selected sport may put the female athlete at risk for development of this disorder. The triad is a complex problem with psychological and physiological factors. It can result in menstrual irregularities, premature osteoporosis, and decreased bone mineral density; if taken to the extreme, it can become life threatening.

Obesity

Obesity is the fastest-rising public health concern in the nation and will likely overtake tobacco use as the single leading preventable cause of death. The obesity rate has more than doubled in children and tripled in adolescents over the past three decades. Today one in five school-aged children (ages 6 to 19) are considered obese (CDC, 2016). Statistics show that obese children and adolescents are more likely to become obese adults. Obesity and its prevention or treatment must be of concern to the school nurse (CDC, 2013).

Although many of the underlying causes of obesity are not well understood, several contributing factors have been identified; they include reduced access to and affordability of nutritious foods, decreased physical activity, and cultural and genetic influences. Obesity is associated with development of diabetes, dyslipidemia, hypertension, and other disorders, such as osteoarthritis, sleep apnea, different cancers, and cholelithiasis. In addition, obesity may result in social and quality-of-life impairment, and obese children often have low self-esteem and may be labeled by their peers and ridiculed (CDC, 2013). The school nurse should determine the BMI for all adolescents. A BMI greater than the eighty-fifth percentile for age and gender indicates the need for further assessment and referral. To be successful, the treatment of obesity must begin early and must be multifaceted. Some of the solutions include improved health education related to nutrition and dietary behavior, increased physical activity and physical education programs, healthier school environments, and better nutrition services.

Nutritional Education Programs

Nutritional education is essential and must include parents, teachers, and the child. Children need to know the basics of good nutrition, how to make healthy snack choices, and the importance of balancing physical activity with food intake. Obesity, dental caries, anemia, and heart disease can be reduced or prevented with proper education and lifestyle changes. In addition, all adolescents and school-age children should receive counseling regarding intake of saturated fat.

The United States Department of Agriculture (USDA) Food and Nutrition Service (FNS) provide nutritional education for food service educators, professionals, parents, and child care providers, The USDA and FNS have a number of resources, including MyPlate, Team Nutrition, Let’s Move, and SNAP-Ed Connection. These programs focus on healthy nutritional choices and health promotion and disease prevention topics in school and child care settings. Comprehensive school-based nutrition programs and services should be provided to all students. The ultimate goal of these efforts is that children will make healthy nutritional choices both inside and outside the school setting.

Counseling, Psychological, and Social Services

The mental health of a child or adolescent is affected by physical, economic, social, psychological, and environmental factors. Children, like adults, often hide problems from others. They may see problems as a sign of weakness or as a lack of control. Children may also be trying to protect themselves or someone they love and so do not seek help, with tragic results. Promotion of mental health and reduction or removal of threats to mental health is important to children and adolescents. This can be an enormous challenge for school nurses as mental health is difficult, yet essential, to assess.

Children and teens often struggle with depression, substance abuse, conduct disorders, self-esteem issues, suicidal ideation, eating disorders, and underachievement or overachievement. They may also have to cope with physical or mental abuse, chronic health conditions, or pregnancy. Common warning signs of stress in children are presented in Box 30.8. Drugs and alcohol can enter a child’s life as early as elementary school. Many children live in single-parent households with little social or economic support. They may not have enough to eat or a safe, warm place to sleep, yet are expected to come to school each day ready to learn. Services aimed at helping children cope with these problems are often lacking or too costly for many families.

Ethical Insights

An Ethical Dilemma: What Would You Do?

You are working as the school nurse in a rural high school when Grace, a 15-year-old female student, enters the clinic. Grace appears very worried, and, after several hesitant starts, she begins to cry and tells you that she is sexually active with a 17-year-old senior. She goes on to tell you that she has missed her last period and that her home pregnancy test result was positive. She states that she is afraid to tell her parents because she feels that they will be very disappointed in her and because she is afraid of what her father will do. She asks you where she can go to get an abortion. You speak with Grace for quite a while and encourage her to speak with her parents. She leaves the clinic a little more composed and promises you that she will think about what you have said. The next day Jenny, Grace’s mother, comes into the clinic and asks to speak with you. She confides that she is worried about Grace and asks whether you know what is going on with her child. What would you do in this situation?

Although maintaining confidentiality and a professional relationship respectful of the student’s wishes is vital, state laws and school district policies determine what a school nurse may do, and in some cases is required to do, when providing care to minor children. In order to deal with personal and sensitive information such as described here, the school nurse should be well versed in relevant laws and policies and should follow them. When in doubt, contact a supervisor.

BOX 30.8 Warning Signs of Stress

· • Problems eating or sleeping

· • Use of alcohol or other substances (e.g., sedatives, sleep enhancers)

· • Problems making decisions

· • Persistent anger or hostile feelings

· • Inability to concentrate

· • Increased boredom

· • Frequent headaches and ailments

· • Inconsistent school attendance

The nurse or teacher may be the only stable adult in a child’s life who will listen without being judgmental. Therefore one of the most important roles of the school nurse is to act as counselor. Children may come to the school nurse with various vague complaints, such as recurrent stomachaches, headaches, and history of sexually promiscuous behavior, and the nurse must look beyond the initial complaint to identify underlying problems.

Major depressive disorders often have their onset in adolescence and are associated with an increased risk of suicide. In 2014 suicide was the second leading cause in both the 10- to 14-year and 15- to 19-year age groups (CDC, 2014). Suicide attempts are more common than completed suicides. A 2015 survey of students in grades 9 through 12 showed that 8.0% attempted suicide in the preceding year and 17% seriously considered suicide (CDC, 2015). The nurse and other school personnel must be on the alert for suicide clusters that are often known to follow a successful suicide. Adolescents may approach school nurses and other school professionals for help before a suicide attempt. The call for help may be subtle and not recognized as such. Therefore it is important for the school nurse to be cognizant of the warning signs associated with suicide and to recognize and refer at-risk adolescents to appropriate mental health professionals (Box 30.9).

Unfortunately, a large number of children are victims of abuse. Physical and psychological abuse and neglect are usually a result of many interacting factors, such as poverty, social isolation, and drug and alcohol abuse. School nurses and other school personnel are mandated to report suspected cases of child maltreatment and neglect. The nurse must be alert to subtle changes in behavior or physical appearance that may point to abuse. Box 30.10 outlines some of the signs and symptoms of child maltreatment.

BOX 30.9 Truths About Adolescent Suicides

· • Most adolescents who attempt suicide are ambivalent and torn between wanting to die and wanting to live.

· • Any threat of suicide should be taken seriously.

· • Warning signs usually precede a suicide attempt; they may include depression, substance abuse, decreased activity, isolation, and appetite and sleep changes.

· • Suicide is more common in adolescents who are dealing with bisexuality or homosexuality without support or in a hostile school environment.

· • Education concerning suicide does not lead to an increased number of attempts.

· • Females are more likely to consider or attempt suicide, and males are more likely to complete a suicide attempt.

· • One suicide attempt is more likely to result in a subsequent attempt.

· • Sixty percent of completed suicides in children and adolescents are committed with guns.

· • Most adolescents who have attempted or completed suicide have not been diagnosed as having a mental disorder.

· • Suicide affects all socioeconomic groups.

BOX 30.10 Possible Signs of Abuse and Neglect

Physical Abuse

· • Has unexplained burns, bites, bruises, black eyes, or broken bones

· • Is wary of adult contact

· • Appears frightened of parents or other relatives and cries when it is time to go home

Neglect

· • Is frequently absent from school

· • Steals food or money

· • Lacks adequate medical or dental care

· • Appears dirty or disheveled or is underweight

· • Does not have proper seasonal clothing

Sexual Abuse

· • Has difficulty walking or sitting

· • Reports new onset of nightmares or bedwetting

· • Refuses to change into gym attire or participate in physical activities

· • Runs away from home

· • Becomes pregnant or has a sexually transmitted disease

Emotional Abuse

· • Exhibits changes in behavior, such as acting out or extreme passivity

· • Exhibits delay in either physical or emotional development

· • Has attempted suicide

· • Exhibits inappropriate adult or infantile behavior

Data from Child Information Gateway: What is child abuse and neglect? Recognizing the signs and symptoms, 2013. https://www.childwelfare.gov/pubs/factsheets/whatiscan.cfm.

In cases of child abuse or neglect, the school nurse may help the child learn problem solving, coping mechanisms, and steps to build self-esteem. The role of the nurse may extend outside the school campus. The nurse may need to work closely with families and social services to develop an appropriate health plan for a particular child.

Healthy School Environment

A healthy school environment is one in which distractions are minimized and that is free of physical hazards and psychological health risks. The NASN believes that all students and staff have an inherent right to learn and work in a healthy school environment and that the school nurse can “assess the learning environment for risk factors, educate the community on the impact of environmental exposure, and advocate for the need to address environmental pollution issues” (NASN, 2014).

Violence

Violence is a major public health problem because it threatens the health and well-being, both physical and psychological, of many children and adolescents. According to the U.S. Department of Justice, Bureau of Justice Statistics (2016), during the 2014 school year, students were victims of 850,100 nonfatal victimizations at school, including 363,700 thefts and 486,400 violent crimes. Further, during the 2012–2013 school year, 31 homicides occurred at school in K–12 schools (CDC, 2016). In high school–aged youths, 7.8% of students reported they had been in a physical fight in the last year, and 5.6% stated that they did not attend school for one or more days because they felt unsafe (CDC, 2016).

In recent years, there have been a number of shootings and other acts of serious violence in schools. The CDC (2016) reported that 4.1% of children admitted to having carried a weapon at least 1 day out of the last 30 and that 6.0% had been threatened or injured with a weapon on school property within the last year. The school shooting at Columbine High School in Littleton, Colorado, in 1999 was probably the first time that people in this country realized how unsafe schools could be. More recently, the mass shooting, in Newtown, Connecticut, killed 20 children and six adults, making it the nation’s worst K–12 school shooting.

School nurses and other school personnel should be aware of risk factors and signs that could indicate a tendency to violence. Factors common in those who commit violent acts in school include being male and having a history of being ostracized or bullied in school. Media influences such as movies and video games that desensitize the impact of violence are being studied more closely as a possible cause of increased violence among children and adolescents. Children involved in school shootings often have a need for instant gratification, have easy access to guns, and may have a history of discipline problems.

Although the number of students who commit violent acts is small, these random acts are frightening, and school officials struggle with ways to prevent their occurrence and to recognize the signs of troubled youth. Violence prevention programs should begin in elementary schools. Children who exhibit aggressive behavior in elementary school are more likely to exhibit antisocial and violent behavior as adolescents and adults. Programs should target stress management, conflict and anger resolution, and personal and self-esteem development. Nurses should use data collected through the YRBSS and other local data as a means of assessment when developing violence policies and prevention programs in the school and community. Additionally, nurses should initiate and participate in research that examines the complex developmental, social, and psychological factors surrounding violence.

Terrorism

Schools may not be the primary target in an act of terrorism, but they will be affected. Events following the September 11, 2001, terrorist attack illustrate potential problems facing schools, which may include fear and panic among students, teachers, and parents and anxiety among those directly affected.

Every school is expected to have an emergency management plan. In fact, many states mandate that schools develop plans to address the potential threat of a terrorist attack or natural or manmade disaster. School nurses must be prepared to act after any form of terrorism has occurred. The school nurse has an important role as a potential first responder in any emergency situation and should be an active participant in planning and policy development.

Health Promotion for School Staff

Although specific numbers vary, it is estimated that schools in the United States employ more than 5.5 million teachers and other employees. Health promotion programs at the work site have beneficial results, including positive effects on blood pressure control, daily physical activity, smoking cessation, stress management, and weight control. Staff who participate in health promotion programs increase their knowledge and positively change their attitudes and behaviors relative to smoking practices, nutrition, physical activity, stress, and emotional health. Health promotion programs improve morale, reduce job stress and absenteeism, and heighten interest in teaching health-related topics to students. School nurses play an important role in all levels of prevention through assessment, planning, intervention, and evaluation. The school nurse can assist the faculty and staff by giving workshops on exercise and nutrition, screening for increased blood pressure, and establishing weight management programs.

Family and Community Involvement

School nurses are often asked to provide health education to family, parents, and the community on a variety of topics, such as sexuality, STDs, health promotion, communicable diseases, and substance abuse. Health education in the community consists of programs that are designed to positively influence parents, staff, and others in matters related to health. School nurses are a resource in the community and can take a leadership role in developing programs that positively affect the community. School nurses may also serve as consultants and advocates for other community health programs.

Programs that engage the parents in school activities should be based on community needs and resources. Studies show that students who have parental support are more successful, experience less emotional distress, eat healthier, and are more actively engaged in learning. School nurses can promote parental

involvement through the establishment of clear communication, involving parents as volunteers and including them in the planning of health-related events at schools. The nurse must also recognize that an increasing number of children are being raised in nontraditional families—single parents, grandparents, gay or lesbian couples, and interracial couples. When addressing issues with families, the nurse cannot let personal feelings alter the plan of care and must be aware that what worked with one family situation will not necessarily work for another.

School nurses need to understand the needs of families and how these needs may affect children in the school setting. The Annie E. Casey Foundation (AECF) looks at some of these key needs using the KIDS COUNT Index. The index looks at four domains that kids need in order to thrive: 1) economic well-being, 2) education, 3) health, and 4) family and community. Using these, the AECF measures the status of child well-being at both state and national levels. In 2016, Minnesota ranked first among all states in overall child well-being, with Mississippi coming in last (AECF, 2016). During the past 6 years, there has been progress in some of the domains of child well-being (health and education) but setbacks in others (economic well-being, family, and community).

Nurses should become adept at working in the public sphere by increasing their visibility and becoming skilled in working with the media and legislators. The media can be useful in assisting school nurses with health education advocacy.

Active Learning

· 1. Explain how the Healthy People 2020 objectives can be used to shape school-based health care.

· 2. Log on to one of the websites for school nurses such as http://www.schoolnurse.com/ or https://www.nasn.org/ and review the many resources available.

· 3. Interview a member of the local school board about controversial subjects in health education (e.g., sex education).

· 4. Review the most common diseases and reported injuries in school-age children in your area. Develop a plan for how the school and the community can work together to decrease their incidence.

· 5. Interview the parents of several school-age children. Ask what health services they would like to see provided in the school setting.

· 6. Arrange with the principal of a local school to have a discussion session with children in a particular grade level. Ascertain what their eating habits are and then develop a class that can enhance healthy eating.

School Nursing Practice

School nursing is a specialty practice. School nurses need education in specific areas, such as growth and development, public health, mental health nursing, case management, program management, family theory, leadership, and cultural sensitivity, to effectively perform their roles. They must be prepared to work with children of all ages and cultures and under variable circumstances. The nurse must also keep abreast of issues affecting children and must participate in research that explores and expands the role. The school nurse’s practice is relatively independent and autonomous, even though the school nurse functions as a member of an interdisciplinary team. For entry into school nursing, it is recommended that nurses hold a minimum of a bachelor’s degree. The school nurse must be able to identify and access professional development opportunities in order to maintain competency in the care of children and adolescents.

School nurses function in many roles. Among these are care provider, student advocate, educator, community liaison, and case manager. Additional skills needed by school nurses include the ability to supervise others, to practice relatively independently, and to delegate care. The American Nurses Association developed competencies relevant to school nurses and updated them in 2011. School Nursing: Scope & Standards of Practice (3rd ed) can be purchased at https://portal.nasn.org/members_online/members/viewitem.asp?item=S001&catalog=MAN&pn=1&af=NASN.

The school setting is a perfect place to conduct research on how children adapt to life transitions such as divorce, illness or death of a loved one, illness of either themselves or a peer, and domestic violence. The health-related behaviors of the young are a rich source of research opportunities. The school nurse must be aware of and interested in participating in different research studies.

Research Highlights

Research Priorities for School Nursing

The National Association of School Nursing (NASN) has identified critical areas for needed research in which there is no evidence supporting or identifying best practices and the cost-effectiveness of nursing practice in school (NASN, 2016). These critical areas are:

· • Diabetes and Asthma: Determine the impact of school nurse interventions on students managing their chronic conditions in the school environment.

· • Identified School Nurse–Sensitive Indicators: Determine the impact of school nurse interventions on issues such as attendance, medication administration accuracy, immunization rates, seat time, or health office visits.

· • Cost–Benefits Analysis: Conduct analysis of the various interventions used by the school nurse with regard to prevention services, emergency room visits, student safety, and care coordination.

· • Current Models of School Nurse Practice: Evaluate registered nurse (RN) practice on campus versus an RN managing multiple campuses and the impact(s) on student health, safety, and academics.

Additionally, Gordon and Barry (2006) surveyed 263 school nurses to identify what the nurses believed to be the top research priorities for the specialty. Ten areas were identified as being priority research topics. These priority areas, and examples for each, are presented here:

· • Obesity/Nutrition: Nutrition and weight-loss counseling programs, eating disorders, obesity in children and teens, important of exercise

· • Legal/Ethical Issues: Legal liability when delegating to nonmedical personnel, ethical issues related to children with Do Not Resuscitate orders, confidentiality, HIPAA mandates

· • Emergencies: Emergency preparedness, administering epinephrine autoinjectors (EpiPens) in school, standing orders for emergencies

· • Health Education: Effective curricula for health promotion on hot topics (drugs, sexual activity, nutrition, exercise)

· • Absenteeism/Attendance: The school nurse’s impact on student attendance, impact of absenteeism on educational success, strategies to decrease absenteeism

· • Injuries: Playground safety, sports injuries

· • Health Services: Funding of school health services by using matching reimbursement (Medicaid), access to health services for students and their families, benefits and cost-effectiveness of school health services

Data from Gordon SC, Barry CD: Development of a school nursing research agenda in Florida: a Delphi study. J Sch Nurs 22(2):114–119, 2006.

Active Learning

Attend a meeting of the school nurse association in your area. Identify the major pros and cons of being a school nurse. Look at factors such as working conditions, number of children assigned to each nurse, job functions, and job satisfaction.

School-Based Health Centers

School-based health centers are one of the best ways to offer comprehensive health care services to school-age children and adolescents. It is important to note that the center or clinic works in collaboration with, but does not take the place of, the school nurse. The collaboration between the school nurse and the SBHC staff prevents fragmented care and duplication of services. SBHCs provide an interdisciplinary team approach with personnel such as nurse practitioners, social workers, psychologists, and physicians. Services provided in these centers include nutrition education, injury treatment, general and sports physicals, prescriptions, pregnancy testing, laboratory services, immunizations, gynecological examinations, medication dispensing, social work services, and management of chronic illnesses. Close collaboration must exist within and among the community, the educational board, and the families for such a center to develop and flourish.

Active Learning

· 1. Visit a comprehensive school-based clinic in your area. Discuss how the care given in this type of clinic differs from the care that a school nurse can provide. Review the protocols of both settings and see how they differ.

· 2. What is the cultural makeup of your local area? How should this knowledge influence the school nurses’ practice?

Future Issues Affecting the School Nurse

Our nation’s youth are our greatest asset and our hope for the future. The school nurse’s role must constantly evolve to meet the demands of this future hope. Issues that will face the school nurse of tomorrow include ethical dilemmas, use of telehealth, continued threat of school violence, threat of bioterrorism, new and emerging infectious diseases, and increase in antibiotic-resistant diseases. The school nurse will need to understand and appreciate the multicultural community in which he or she will practice.

Case Study Application of the Nursing Process

Student With Lice

The nursing process is a systematic, organized approach to problem solving that nurses use when working with clients. It is neither fixed nor stagnant. It is a flexible process that allows for ongoing changes. This case study illustrates the use of the nursing process in a school setting.

Sandra Baker is a nurse at an elementary school in a small town. A second-grade teacher brought Carrie Broussard to the clinic and told Sandra that Carrie had been scratching her head all day and she was worried that Carrie might have an infection.

Assessment

Carrie was 7 years old. Her shoulder-length blond hair appeared neat and clean. When questioned by Sandra, Carrie replied that her head had been itching for 2 or 3 days, but she denied any pain or trauma. Sandra noted that Carrie did not have a fever or swollen lymph nodes, but examination of her scalp revealed multiple excoriated areas. Carrie’s hair was examined with a Wood’s light, and Sandra saw adult lice at the base of the hair follicles on the back of her head, near the nape of the neck. She also saw multiple nits. Sandra learned that Carrie had two brothers in the school and one sister who was a toddler at home.

On Carrie’s initial visit to the clinic, Sandra assessed the following:

· • Temperature

· • Lymph nodes

· • Scalp for any abnormal findings

Diagnosis

Individual

· • Head lice

Family and Community (School)

· • Potential for spread of infestation in both family and school

· • Educational opportunity to prevent the spread of lice by teachers and family members

Planning

Sandra was familiar with the school district’s policy that covers head lice in schoolchildren. According to the policy, the nurse must do the following:

Individual

Long-Term Goal

· • Carrie’s return to school after successful treatment

Short-Term Goals

· • Contact Carrie’s parents to tell them about the lice.

· • Inform Carrie’s parents that she must be picked up from school.

· • Recommend treatment based on school protocol.

· • Provide guidelines for returning to school.

Family and Community

Long-Term Goal

· • Ensure that the teachers, staff, and family members have the necessary education relative to prevention and treatment of head lice.

Short-Term Goals

· • Examine the hair of all other children in Carrie’s class for lice, and treat each according to the school protocol.

· • Check the hair of all siblings who attend the school for lice.

· • Check the hair of all students in the siblings’ classes if lice are identified.

Intervention

Family

Carrie’s brothers, David and Paul, were brought to the clinic for examination. Both brothers had lice. Sandra contacted Mrs. Broussard, explained the situation to her, and requested that she come to the school to pick up her children. When Mrs. Broussard arrived at the school, Sandra gave her

written information on treatment and prevention of lice and showed her what nits and lice look like. Mrs. Broussard was also instructed to check other members of the family not attending this school, especially those who share hairbrushes, pillowcases, and towels, because all family members with lice must be treated or the lice would continue to be passed from member to member. Sandra also explained procedures for cleaning combs, brushes, bedding, and potentially contaminated clothing and toys. Finally, Mrs. Broussard was informed that the children could return to school the day after treatment.

It was obvious to Sandra that Mrs. Broussard was embarrassed. To ease her mind, Sandra carefully explained that head lice are highly contagious, are easily passed from child to child, and are not an indication of poor hygiene. Mrs. Broussard repeated the instructions and left with her three children.

Community

Sandra examined all of the students from each of the Broussard children’s classes for head lice. From the three classes, she identified five more children with head lice and notified their parents. Those children had siblings in three additional classrooms and she repeated the procedure for each of them. At the end of the day, she had identified a total of 15 children with head lice and contacted all parents.

Sandra investigated whether the teachers and staff desired an information session on the transmission and spread of head lice because so many students had lice. She discovered that it had been 2 years since this was done, and so she arranged a class for the coming week for the teachers and teachers’ aides to learn how to identify and treat head lice.

Evaluation

Individual and Family

Mrs. Broussard brought Carrie, David, and Paul to school the following day, and on examination Sandra found their hair to be free of lice and nits. Mrs. Broussard expressed her appreciation for the nurse’s help and nonjudgmental approach to the problem.

Community

Over the next 2 days, Sandra reexamined all of the children in the affected classrooms and found that the infected children had been successfully treated and that there were no new cases. New cases were not identified during the remainder of the semester. The teachers and staff gave her positive feedback about the head lice education class and asked for it to be repeated at the beginning of each school year.

Levels of Prevention and School Health

School nursing encompasses all three levels of prevention (i.e., primary, secondary, and tertiary), and all three may be practiced individually or concurrently. Table 30.3 lists examples of school nursing interventions for each of the three levels of prevention.

TABLE 30.3

Examples of Prevention and the Role of the Nurse in the School Setting

Example	Nurse’s Role
Primary Prevention
Nutrition education	Provide education to children and parent(s); consult with dietary staff
Immunizations	Provide for or refer to source(s) for immunizations; offer consultation for immunization in special circumstances
Safety	Provide safety education; inspect playgrounds and buildings for safety hazards
Health education	Teach healthy lifestyle education; develop health education curriculum for appropriate grade levels; provide health education to parents, faculty, and staff; develop suicide prevention and sex education programs
Secondary Prevention
Screenings	Schedule routine screenings for scoliosis, vision and hearing problems, eating disorders, obesity, depression, anger, dental problems, and abuse
Case finding	Identify at-risk students
Treatment	Administer medications; develop individualized health plan; implement procedures and tasks necessary for students with special health needs; administer first aid
Home visits	Assist with family counseling and assess special and at-risk students
Tertiary Prevention
Referral of student for substance abuse or behavior problems	Serve as an advocate; assist with resource referrals; assist parents, faculty, and staff; consult with neighborhood and law enforcement officials; initiate outreach programs
Prevention of complications and adverse effects	Follow-up and referral for students with eating disorders and obesity; participate with faculty and staff to reduce recurrence and risk factors; serve as a case manager
Faculty and staff monitoring	Follow-up for faculty and staff experiencing chronic or serious illness; follow-up of work-related injuries and accidents

Summary

Components of a comprehensive school health program have been clearly identified and discussed. Many of the Healthy People 2020 objectives specifically relate to issues that can be addressed in the school setting. The role of the school nurse has changed dramatically since its inception and continues to evolve to meet the demands of school-age children, their parents, and the communities in which they live. School nurses continue to reduce the number of days and the frequency with which students miss school related to illness. They have become child advocates, counselors, health promoters and collaborators, educators, researchers, and resources in both the school and the community.