Calling all the stressed out school nurses trying to navigate through the real emergencies, paperwork, screenings 504’s and IEP’s and minor injuries/illnesses! Are you inundated with kids who sneezed once or bumped themselves on a desk or door? Kids with loose teeth or dirty clothes? Now with the fabulous addition of Covid-19 to our workload what does that mean for us?
We school nurses have a ton to deal with all day. It can definitely get difficult to get through it all. An important helpful factor in managing your health room is communication with teachers and staff. Everyone needs to be on the same page.
Teachers and other staff have the right and the ability to triage students they are sending out of their classrooms and make a determination as to whether it is an emergency or can wait. They are allowed to tell the student with a stomachache to wait, or tell the student with a loose tooth to wait it out and stay in class. The goal is to keep the kids in class anyway right? When it comes to most issues like the cuts and scrapes, the loose teeth and the wet pants, the rules still apply but now we need to work even harder to keep the kids in class or with their pods so we don’t have too much “contamination” around the school, and especially in the health room.
You need staff to understand and respect your health room hours and allow you to wade through all the work you have for each day. One way for them to help you is to understand what things are actually an emergency and what isn’t. It’s understandable that someone who isn’t medical may not know how to handle possible medical issues but at the same time, they are teachers and they know the kids and can make that determination in most cases.
The first thing you need to do is to establish set health room hours and let everyone know. It can be tough to get everyone to follow the hours if you haven’t already established something like this. I have made multiple signs which I email out to the staff periodically and also have posted in multiple areas in my school – including my door. Your health room hours can be whatever works for you. If you need to give yourself two hours in the morning to get your screenings and computer work done and an hour or so in the afternoon to get documentation done then do what works. Some people are more comfortable having an open door policy or a locked door policy.
In our current climate, my plan and many others plans are to keep a locked door/appointment only policy. Some nurses have even installed a wireless doorbell (found here: https://amzn.to/3m5e1vL) on their office door for visitors. I plan to do the same. I have also created an epass in Google Forms (instructions here: https://youtu.be/LxlfPLPI0wM) so the teachers can send a pass to you and you can call to set up the appointment. Teachers can also just call you or radio when they need you. I also plan to modify my normal routine by meeting the students where they are as opposed to having them come to me so as to avoid having students leaving their pods.
I have created an information packet for the teachers that lists common emergencies/health issues and how to handle them in class if possible. It contains things like managing a loose tooth, managing cuts and scrapes, or general non-Covid related issues. It also includes a section for what to do with Covid-suspected students though, just in case. See below a sample of that. I made it in Google Slides and used my own Bitmoji.
Next, you have to establish what is considered an emergency and what is not. Understandably, many people who are not medically trained have no idea what is or isn’t an emergency and may think that everything or nothing is an emergency. You can communicate this information to all staff to help be sure everyone is on the same page.
Some examples of emergent reasons to be seen by the school nurse are:
1. Bleeding: excessive bleeding, difficult to control bleeding, needs more than just a band-aid. Paper cuts, small scrapes, etc can either wait until the nurse is available or a staff member can dispense a band-aid if one is available.
2. Breathing Bad: Short of breath at rest, asthma, wheezing. “Out of breath” from playing at recess or gym or sports is not an emergency. If a student is newly short of breath unrelated to normal physical activity then the nurse should be consulted.
3. Broken: Obvious broken bone, excessive swelling, inability to walk or use body part. Banged knees, bumped elbows, other minor bumps and hurts can wait.
4. Barfing: Vomited more than once, witnessed by staff, visibly ill. A kid who reports that they vomited in a trash can in the bathroom when no one was around and is obviously well is certainly not an emergent issue. Often they vomit from coughing, or little kids choke and have a bad gag reflex, or they get stressed out. Vomiting is not always an emergency or even always an indicator of sickness. Vomiting can be a sign of Covid however, so the nurse should be consulted for a case of witnessed vomiting, especially when associated with any other new symptoms.
5. Bee Sting: This is self explanatory. Bee stings hurt like crazy and should be handled right away, especially for a person who may be allergic to bees (documented allergy), or a person who is exhibiting symptoms of an allergic reaction (you might not always know they are allergic till it happens.)
6. Burning Up: Obvious fever, feels hot to touch. Fever over 100.4 should be sent home and stay home until 24 hours fever free (as a general guideline but some districts may have different rules). See link to Covid-19 guidelines from the PA DOH.
7. Big Bump: Witnessed head injures resulting in bruises, bumps, change in mental status or bleeding. “I bumped my head on a wall while in the bathroom/walking down the hall/etc etc” and they don’t have any concerning symptoms then it is safe to wait for the nurse to be available. Chances are, when they wait a few minutes they will forget about it.
8. Seizures: A student or an adult who is having a seizure should be addressed immediately. Call the nurse right away and note the exact time the seizure started so the nurse can time it. In general a seizure lasting greater than 5 minutes will require a call to 911 and possibly emergency medications if available.
9. Allergic Reactions: Someone who is short of breath, has hives, wheezing, facial swelling, tongue swelling, difficulty speaking, change in mental status, loss of consciousness, or has a known allergy and has been exposed should emergently see the nurse (or call the nurse to come to the scene). Hopefully the student has an Epi-pen if there is a known allergy but 911 and parents should likely be called depending on the situation.
10. Diabetic Emergencies/Management: A student who is a known diabetic and is experiencing loss of consciousness, changes in mental status (drowsy, confused, speech slurred) should be seen immediately. A student who is a known diabetic and feels that he needs a blood sugar check or feels unwell should be permitted to see the nurse immediately. A student who has scheduled times to manage blood sugars and insulin should see the nurse at the correct times.
11. Any student with a known medical condition that may require nursing intervention should be sent to the nurse as soon as possible.
12. NEW cough that is not related to known allergies or asthma exacerbation. If the teacher doesn’t know they should call you. As we all know, cough, shortness of breath and fever are our #1 symptoms we are watching for.
13. Fever over 100.0. The teachers are allowed to check a temperature if they want but those students should be referred to the nurse if there is a suspicion of C19. According to the PA DOH if a student has a fever they should stay home or be sent home and may return when they have either a negative C19 test, and/or quarantined for 10 days, and/or an alternate diagnosis.
Here are the Pennsylvania Department of health guidelines (and a LOT of other helpful info) for those readers in PA: https://www.education.pa.gov/Schools/safeschools/emergencyplanning/COVID-19/Pages/default.aspx. This site gives tons of resources and information on how to handle C19 in the school setting and sums up what to look for far better than I can!
I’m also giving you the National Association of School Nurses (NASN) page with all of their resources to help: https://www.nasn.org/nasn-resources/practice-topics/covid19.
What is NOT considered an emergency?
1. Potty Accidents: For my district potty accidents are not a nursing issue. The students should have extra clothes but if they don’t then parents should be called to bring them clean clothes. Check with your nurse to see what procedure is.
2. Seasonal Allergies: There is nothing the school nurse can do to manage seasonal allergies in school unless a student has medications that have been ordered by the doctor and the proper paperwork to dispense it. In general, if a student has allergies then it should be managed at home. A parent can always be called to address the issue if needed but it is not an emergent issue.
3. Mosquito bites/bug bites (aside from bee stings): In general, not an emergency. The nurse (in my district) can administer Hydrocortisone cream to an itchy bug bite but for the most part they have to wait it out.
4. Loose Teeth: Definitely not an emergency. A teacher is more than welcome to explain to a student that loose teeth are a natural, normal part of life and need no intervention aside from wiggling it till it comes out and the occasional mouth rinse if bleeding. Loose teeth may bleed, and they may be sore but such is life. Some nurses may be comfortable with pulling teeth but I choose not to do that as I feel it is a procedure that some parents may not prefer I do. It’s safer to just not do it.
5. Minor cuts and scrapes with or without bleeding: if the nurse is not available then the student can wait. If the teacher has bandaids then they may give one. A student may stay in class until it is an appropriate time to leave.
6. Dirty Clothes/got water on them/spilled food: This is not an emergency. Water dries, food can be wiped off. Chronically unkempt students should be addressed by the nurse and/or the counselor but it is not emergent to leave a class and manage unless the teacher feels it is an appropriate time.
Another idea that one could try is a “sick bench” for recess. In general students should not be leaving recess and lunch to visit the nurse as they have greater ability to wander or be away from their class without permission. Often, if they complain that they are sick at recess, have a tummy ache, or bumped themselves on something they can have a time out on the sick bench and take a break. You will notice that often waiting a few minutes cures them. Pain subsides, tummy aches from running around and playing hard will subside on their own.
A teacher or staff member has the ability to triage students health needs and make the call if they need to leave class right away and see the nurse or if they need to wait until the current lesson is finished before leaving. As always, everyone has the option to call the nurse and ask questions or discuss issues they have concerns about.
This is not an issue of “the nurse doesn’t want to see kids” but an issue of trying to keep the kids in their classes and cut out extraneous wandering about the school, and staying out of class. Our responsibility is keeping butts in seats as much as possible by keeping sick kids out and healthy kids in their classes.
With all of the added C19 guidelines, triaging does become a bit sticky at times. Remember, our job is not to diagnose but our job is to assess. We should be aware of what to look for in a suspected C19 case and refer them to their doctor of choice for continued care. Follow the algorithms put forth by your state’s DOH and/or the CDC and you can’t go wrong. Try to be as flexible and understanding as you can be and remember that the teachers and staff don’t have experience with this any more than most people – we are all muddling our way through this!