Pinkeye: how do we know when we need to react to real pinkeye and when we can leave it alone because it isn’t actually pinkeye? What even is “pinkeye”?
Warning: there is a gross picture of an eye coming up for the ommetaphobics out there.
To start, “pinkeye” is a blanket term used to describe all forms of conjunctivitis: an inflammation or infection of the conjunctiva – the clear membrane that covers the eye and and also the inside of the upper and lower eyelids. It can be a viral infection, bacterial infection or allergic. Viral and bacterial conjunctivitis are very easily spread by physical contact with the drainage from the person’s eye while allergic conjunctivitis is not. Conjunctivitis can also be caused by an irritant such as chemicals, foreign bodies in eye or in infants by a blocked tear duct.
Some main symptoms of pinkeye are:
Redness of the whites of the eye (the sclera)
Itching of the eye
Thick sticky mucusy drainage that tends to “glue the eye shut” in the mornings – more than just the normal eye boogies we all get
A “gritty” feeling in the eye like there is dust in it,
There can be swelling of the eyelids or even the sclera
Increased redness and swelling of the inner lower eyelid if the eyelids are pulled down gently as pictured below.
So you have a student standing in front of you with a complaint of “red eye”. What can you do with this? We can not diagnose the type of conjunctivitis of course but we should know when to send them to the doctor and when we can send them back to class.
How does the eye feel? is it itchy? painful? gritty? normal?
Did they have lots of goop this morning? Do they have lots of goop now?
Did they get anything in their eye just now like eraser dust, regular dust, dirt/sand, chemicals (soap, sanitizer etc), pool chlorine, cigarette smoke or other environmental pollutants?
Do they have other cold symptoms like a runny/stuffy nose, coughing, or increased allergies?
Do they wear contact lenses and do they take proper care of them?
Have they just had an injury to the eye such as getting poked or hit in it?
With a gloved hand you can gently pull down the lower eyelids and compare if the red one is also swollen and red inside the lower eyelid compared to the normal eye or if both eyes are affected they could both be excessively red and/or swollen.
If you’ve determined that it is probable infectious pinkeye based on the questions and exam then the student should be sent home to be seen by a doctor for official diagnosis and treatment (if applicable). For my district and many others the student must be treated for 24 hours before they can return to school if they are diagnosed with bacterial conjunctivitis. For viral and allergic they may return to school immediately if desired.
Treatments for bacterial conjunctivitis may include:
Antibiotic drops or ointment such as Erythromycin, Ciprofloxacin, or Tobramycin
Discontinue use of contact lenses until treatment course is finished, use new lenses after treatment is finished.
Steroid eye drops such as Tobradex (combo Tobramycin and Dexamethasone) or Prednisolone drops.
Warm compresses to remove the excessive drainage.
Ibuprofen can help with pain and inflammation
If available a parent may choose to use fresh breastmilk on a cotton ball as a compress to treat bacterial conjunctivitis, especially in infants less than 6 months old. Obviously this is not a treatment to be used at school but at home if the parent chooses to. https://pubmed.ncbi.nlm.nih.gov/33098117/
Bacterial pinkeye often is accompanied by a strep throat or otitis media infection. If a child has one they may also develop the others as well.
Prevent it from spreading to others by avoiding touching your eyes, washing hands frequently, not sharing eye drops or makeup with others.
Change pillow cases and face towels often and throw out any mascara or eyeliner that may be contaminated in order to prevent reinfection.
Treatment for viral conjunctivitis may include:
There is no specific medication to treat a viral infection.
Steroid drops if the symptoms are severe
Warm compress for comfort
Artificial tears for comfort
Antiviral medication if the doctor determines that the infection is related to Herpes Simplex virus.
Discontinue contact lenses and use a new pair once infection is cleared up.
Ibuprofen can help with pain and inflammation
Allow the symptoms to run its course.
Viral pinkeye usually accompanies a cold.
Prevent it from spreading to others by avoiding touching your eyes and washing hands frequently.
Treatment for allergic conjunctivitis:
Allergy medications such as Zyrtec, Allegra, Claritin etc.
Seek emergency care as per poison control recommendation or if symptoms are severe. Certain chemical exposure to the eyes can cause scarring, damage to the eye, and possible loss of sight or eye if not properly addressed.
For all types of conjunctivitis it is wise to avoid using any oils, herbs, folk remedies etc (except for the breastmilk – that one is scientifically proven!) as most of these are not sterile or researched or doctor approved and could potentially cause permanent damage to the eye.
At the end of the day, we nurses cannot diagnose or treat conjunctivitis on our own and need a physician’s input. We should be aware of when a student needs to be referred for treatment and what types of treatments we should expect the student to have after they’ve seen the doctor.
Check my TPT for letters to send home informing parents of pinkeye exposure and other great resources!
School nurses are facing burnout like never before. In the aftermath of the Covid pandemic where healthcare workers went from mildly respected to “heroes” and now villains enforcing the rules, the school nurses have been overwhelmed and beaten down with heaps of expectations and very little help.
In addition to our regular jobs of managing students’ diverse health needs and chronic conditions, immunization compliance, day to day injuries and illness, helping students with their mental health, helping teachers with their mental health, clerical work that is expected to be done, and organizing screenings we have been also tasked with Covid testing (schools with 400 – 2000 students), contact tracing, quarantine enforcement, mask enforcement, organizing classroom quarantines and masking, keeping up with the ever changing rules and protocols for managing Covid in schools and being the knowledge ambassador of all things Covid.
Many of us spent almost a year working from home trying to navigate how to be a school nurse from home while some of us spent that year continuing to work in our school buildings directly facing the deadliest time of Covid with little to no support or even recognition. We then went into a full school year loaded with new and changing Covid protocols, nonstop positive cases that required coordinating the logistics of contact tracing and quarantining hundreds of students and teachers sometimes.
No one noticed.
The immense pressure put on us to not only be the person with all the knowledge because we are the Registered Nurses but to singlehandedly coordinate the mitigation efforts in our schools has caused many of us to have greatly increased anxiety (22%), depression (24%), PTSD (30%), and felt bullied and harrassed related to our jobs (48%!!!). Many school nurses have quit or decided to retire. It is a dire situation when school nurses would rather retire early or go to work in the hospital where they feel they will be more respected and treated better (those that have experience working in the hospitals know how bad it has to be to make that choice.)
We need help. We can not do this alone! We need to ensure that there is a nurse in every building, and for some more than one nurse. We need extra nurses and subs to help cover absences (because nurses get sick too and have families that get sick). We need competitive pay to ensure the newer school nurses will stay and to make it worthwhile for us to stay. We need to be evaluated and supervised by school nurse leaders who understand our position. We need a professional ladder of career growth specific to school nurses. We need assistance paying for the education we are required to have specific to school health. We are human, we need understanding and patience and respect.
For those admins and parents who have supported us, we thank you from the bottom of our hearts. This hasn’t been easy for anyone but we are all doing the best we can with what we’ve got. We need the continuing support and understanding of the school and district admins and the parents. For those that feel like it is ok to threaten, harass, refuse to comply please understand that we are doing our best to follow the protocols that we are given by the Health Department and the CDC. We aren’t making the rules but it is our job to ensure that they are followed to the best of our abilities.
The results of this survey filled out by school nurses are scary to say the least.
A question I’ve seen asked by a few CSN’s recently is “How do I know when a student should be sent home versus sent back to class?” Is there a specific formula to make that decision? The short answer is no. Every situation is individual and every kid has different needs so what might send one kid home might not send another kid home.
Before I get into specific guidelines to consider, I want to point out two things: 1. Listen to your teachers. They are with these students most of the day and they know when they are not themselves. Often the students trust the teachers and confide in them if something needs addressing. Don’t just assume that the teachers are “trying to do your job” because most of the time they are just trying to do theirs. It’s a team effort. And 2. You’re the boss of your health room. Don’t feel pressured into sending students home or keeping them at school. You do your assessment, you make the medical decisions.
Sending a student home should be considered when the health issue is impacting their ability to learn in class.
So here are some basic guidelines that can be used to decide if they should stay or if they should go. This is not an exhaustive list as it is dependent on the student at the time.
Fever: If the student has a fever over 100.4 they should go home (in some places the rule is still 100.0 because of Covid). In most schools they should not return until they are fever free for 24 hours with no fever reducing medications. They should not be given fever reducing medications and sent to school, or be given medication and sent back to class. Also consider Covid testing.
Excessive coughing: cough unrelated to known asthma or allergies that is disruptive and causes inability to focus on class. If they are coughing up a lung and miserable then send them home. Check a temp and consider Covid testing.
Vomiting or diarrhea: If a student is vomiting due to sickness they should go home. Often you will find little ones that saw something gross that made them throw up, or they gagged on their food and have a low threshold for vomiting – in cases like that they can get themselves together and return to class. Consider how they look (pale, clammy, feverish, in pain, etc), how they report that they feel (tummy hurts? Gonna throw up again?). Check a temp and consider Covid testing. If the student is having diarrhea they should be sent home.
Needs emergency care: Injuries that require sutures should be picked up as soon as possible and have that addressed immediately. Broken bones or suspected broken bones should be picked up as soon as possible for emergency evaluation. Anything that requires the activation of EMS for the problem obviously should not be in school ie: anaphylaxis, use of Epinephrine, asthma attack that is difficult to control,
communicable disease (diagnosed or suspected): Obviously we can’t diagnose but there are a few things that we can send home for suspected concern such as suspected pinkeye, suspected scabies, suspected strep throat, lice – per your district policy as many districts are not excluding immediately for lice, and obviously Covid if they are tested at school and test positive.
Pinkeye: while we can’t diagnose pinkeye we can assess for the obvious signs for it such as eye redness, swelling, copious discharge, intense itching, and pull down the lower eyelid to look for increased redness or swelling inside the lower eyelid. Pinkeye can be viral or bacterial but we won’t know until they see a doctor. Due to it’s highly contagious nature, the student should be sent home to be evaluated.
Seizure: While not all seizures require the student to be sent home, some can. In general, absence seizures are fairly benign and the student can continue their day. Some grand mal seizures can cause the student to urinate or defecate on themselves, or require emergency medications or EMS calls in which cases they should obviously be sent home. Some students who have a seizure may be postictal but be allowed to remain at school. That is an individual issue that should be addressed with the parent and student as part of their action plan.
Asthma: most of the time a student with an asthma flare can be treated and return to class. On occasion the measures at school are not enough to treat the flare and the student may need to be picked up to be closely monitored by their guardian and possibly seek medical care or use their nebulizer at home.
Diabetic Emergencies: high and low blood sugars can generally be treated at school and the student can return to class when stable but if they are having a difficult day with managing or they are very out of control and symptomatic then the parent can be called to pick them up to closely monitor at home and/or seek medical care (or EMS if appropriate)
Certain head injuries: obviously minor head bumps do not need to be sent home but a more severe head injury with other symptoms such as change in consciousness, needs sutures, severe pain, or dizziness would need to either be sent home with parent for medical evaluation or sent to hospital.
Sickle Cell crisis: Often sickle cell issues can be managed at school with a little bit of rest, hydration and Tylenol but if the symptoms are more severe or not settling with the usual measures then the student should be sent home. If a Sickle Cell student develops a fever the parent should be notified immediately as per their action plan.
Covid: Districts all have varying rules regarding Covid protocols but in general if a student tests negative at school but is symptomatic then they should be sent home to see the doctor and have a PCR test or an alternative diagnosis.
CSN’s clinical judgement: The CSN is here to make these decisions. If the nurse examines the student and feels that they are sick and need to be sent home then there you have it. Sometimes the nurse (and teacher) knows that the student is not a complainer or that they don’t look right or seem like themselves.
Again, this is not an exhaustive list of when to send a student home. Most of the time it’s a judgement call but your safest bet is to call the parent and let them decide what they want to do if you are unsure if they should stay or go. Districts all have varying guidelines as to certain protocols like lice and covid so look into the specific protocol for your district or state to be sure.
Would you add anything to this list? Message me and let me know what you think!
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One of our most favorite things: the bloodbath that ensues when a student gets a random nosebleed at school and runs through the halls to the nurse for help, all the while leaving a trail of blood in their wake. What’s a busy school nurse to do?
First thing’s first: we need to get that under control then we can ask questions about what happened and what they were doing when it started. Did they get punched in the face? Is it super hot inside or outside? Do they have allergies? Were they picking? Is it winter and the forced air heat is on drying everyone’s mucus membranes out? Did they stick something up there? Do they maybe just get nosebleeds sometimes when they are stressed or upset? Very importantly, do they have a bleeding disorder (hemophilia, Von Willebrand’s)?
Back to getting the bleeding under control: Here are some conventional and unconventional tips.
Grab some tissues or paper towels (preferably NOT those waterproof brown ones we all know so well) and get to pinching the lower part of the nose so the nostrils are closed. Instruct the student to tip their head FORWARD not backward. Leaning forward will reduce pressure on those veins allowing them to form clots and lighten the bleeding some. Additionally, leaning forward will help avoid getting the blood in their throat potentially causing choking, aspiration, and upset stomach.
Continue to pinch the nose for a good 5-10 minutes. You can try using a clothespin or a nose clamp to help pinch the nose correctly, or just pinch with a gloved hand.
If there is a large clot in the nostril you may have the student gently blow and remove that and then continue pinching the nose until bleeding stops.
Try putting ice on the bridge of the nose. Putting ice in this spot will help constrict the blood vessels and slow or stop the bleeding.
Try putting ice on the back of the neck. While the scientific research does not support this, it is said that ice on the back of the neck can constrict the blood vessels in the nasal mucosa. It might not work but many feel that it does and it can’t hurt right? People also swear by using cold keys or a cold butter knife on the back of the neck in a pinch. https://www.baltimoresun.com/news/bs-xpm-2008-05-01-0805010077-story.html
Try putting ice in the mouth – ice cubes or popsicles. Have the student try to hold the ice on the roof of their mouth with their tongue. According to physician responders to an article in the British Medical Journal, ice packs to the neck or nasal bridge are less effective than placing ice in the mouth. https://www.bmj.com/content/344/bmj.e1097/rapid-responses
Try the “thumping the foot” method. You determine which nostril is bleeding, then remove the shoe from the OPPOSITE foot and give two whacks with the heel of your hand to the heel of the bare foot (not so hard that you hurt them though!). Alternatively, have the child stomp their foot on the ground hard with the opposite foot from the bleeding nostril. Again, this is a non-scientific method but allegedly it works!
Try placing a cotton roll or rolled up gauze under the top lip inside the mouth and give a little pressure to the upper lip frenulum.
Try comercial nosebleed products that should stop the bleeding (if you are allowed to use them in your health room) like nasal gels, quickseal nose plugs, or the Bleedcease brown seaweed things. Use at your own risk though, these types of products may not be approved for use in the school health room but might be helpful at sports or at home.
Try the old wives tale of placing a copper penny on the forehead while also pinching the nose and tilting forward. No one knows why this allegedly works but people swear by it. Maybe it is related to the cold near the blood vessels helping them to constrict or maybe it’s just buying time for the bleeding to stop on it’s own. There is no scientific merit to this but perhaps we will experiment and see…
Do not use nasal sprays at school for nosebleeds. This may be the standard of care in an ER or at home but it is not appropriate to use medications at school. That being said, at home an adult can try using Afrin nasal spray or a nasal spray with Phenylephrine to constrict the blood vessels and stop the bleeding. Again, this method is not for use at school by the school nurse for kids.
You should try to avoid using packing, tampons, or things that are inserted into the nose to stop a nosebleed. This will have to be removed later and can cause more bleeding when removed. Leave the nasal packing to the ER docs. https://www.med.umich.edu/pdf/Nosebleed-Dos-and-Donts.pdf
Now that the bleeding has stopped, What should we do going forward?
Once the bleeding is under control, the nurse can carefully put some plain vaseline into the nostril to moisturize the mucus membrane using a long cotton tipped applicator. This will not always stop the bleeding but can prevent further damage from dry nasal passages causing increased bleeding. Neosporin also works but for many it is considered a medication and thus prohibited for use in the health room without an order.
If it is permitted in your district you can give some nasal saline in the nose to help moisturize.
Instruct the student to refrain from picking their nose, sticking tissues or anything up there, and not to blow their nose for a while after to prevent re-bleeding.
Inform the parent about the nosebleed and instruct them to use vaseline, saline nasal spray, and if possible a cool mist humidifier at home if it is a dry air season.
When is a nosebleed an emergency?
When the bleeding does not stop by 30 minutes.
When the bleeding is so heavy that it is pouring down the throat and out of the nose causing a potential choking hazard.
When the patient is lightheaded, pale, or has a decreased level of consciousness.
When the nosebleed is accompanied by severely elevated blood pressure, rapid heart rate, chest pain or lightheadedness.
When the patient is on blood thinners.
When the patient has a bleeding or clotting disorder such as hemophilia or Von Willebrand’s.
When the nosebleed is caused by a severe head or facial trauma.
I want to preface this post with the caveat that as registered nurses we are not able to diagnose any condition but we can perform our examination and give recommendations as to what we believe the issue might be. The students would always have to follow up with a doctor or nurse practitioner for diagnosis and treatment.
A Wood’s Lamp is an ultraviolet light or “blacklight” that comes in many sizes and shapes and can be used to check for certain skin conditions, head lice, or corneal abrasion (which we would not be doing at school as that is a procedure to be performed by a doctor). The Wood’s lamp was invented in 1903 by physicist Robert Wood. It was used starting in 1925 to diagnose fungal infections in the hair and has found practical use ever since. It is frequently used by estheticians and dermatologists to examine skin and skin conditions.
What would we use the Wood’s lamp for in the health room?
Head lice/nits: live nits (lice eggs) will glow white under the woods lamp. empty nit cases will glow grayish. This can help determine if the student is suffering from dry skin or hair product flakes (will not glow under the lamp), or if the white spots in the hair are nits. Live lice can be seen without the light but will also glow.
Ringworm and Tinea Capitis (ringworm on the scalp), Pityriasis Versicolor or Tinea Versicolor (fungal skin infection) and other fungal skin infections: While it seems fairly obvious what ringworm looks like through the naked eye (red circle, clear in the center, maybe flaky), the Wood’s lamp can help confirm that the student needs to cover the area and see a doctor as soon as possible. This fungal infection on the skin would glow bright blue-white or yellow-green under the lamp. While it might be beneficial to know ringworm vs other fungal infections, again, we can’t diagnose so a generic “likely fungal, need doctor to evaluate and treat” is sufficient. No need for specific diagnoses.
Scabies: Will fluoresce under woods lamp. No diagnosis can be made but strong suspicion can be suggested and recommend seeing doctor for evaluation and treatment.
Bruises: Bruises don’t glow but you can see the demarcation of the bruise and often get a better idea of the shape and size under the lamp if needed. Honestly, I would be unlikely to be examining a bruise that closely in a school health room setting. If anything, I would be using this knowledge to determine something like if it is a bruise or if it is a stain on the skin.
Urine: Glows yellow/green under the blacklight. Again, I would be unlikely to be determining urine stains vs other fluid stains in a school health room setting but the need for this knowledge could come up for some reason.
Germs: a blacklight or a Wood’s lamp can show poorly or unwashed hands! A great educational tool for students to show the importance of washing hands and how germs are spread.
A Wood’s Lamp can also show a corneal abrasion with the use of Fluorescence strips, however, a school nurse can not perform that examination and would require a doctor, PA, or NP to perform, diagnose, and treat.
Have the client position themselves comfortably.
Explain to the client that the Wood’s light has the same characteristics as a typical black light; the room will be darkened, and the black light will be turned on to examine for fluorescence of the lesion in question.
Have all lights turned off.
Ideally with a real Wood’s Lamp (as opposed to a blacklight) the lamp should warm up for approximately 1 minute before using to have the best visualization.
Hold the Wood’s light approximately 6 to 8 inches from the lesion in question, and observe the characteristics of the fluorescence of the lesion.
Where can you get your own Wood’s Lamp?
I got a little rechargeable one from Amazon found here (click the picture to link to the product):
Amazon also has many options or battery powered, corded, or rechargeable lithium ion battery. (Click the pictures for links to the products):
If you buy your supplies for SchoolHealth.com you can try some of these options also:
Woods Lamp can look for conditions such as ringworm, other fungal skin infections, lice, scabies, bruises, urine, and clean hands, among other concerns.
School nurses can not diagnose any conditions but this is a helpful tool for us to point a parent in the right direction if needed.
School nurses have long been using the BMI (Body Mass Index) scale to determine risk for childhood obesity. Each year we check heights and weights of our students and then send home a letter to parents reporting that their child is over or under weight based on the BMI scale. But is this really the right thing to be doing based on current evidence based research? Personally, I think not.
What is BMI? Body mass Index, or BMI is a supposed measure of a person’s percentage of total fat mass or percentage of body fat. It is an equation based on a person’s height and weight that determines a person’s level of body weight related health.
Some history of the BMI scale: It was a (flawed, somewhat nonsensical) mathematical equation invented in the early 1800’s by a mathematician named Lambert Adolphe Jacques Quetelet as a way of determining the “fatness or fitness” of a collective population of males (not an individual or female). The formula, BMI=k/m2, made little sense from the beginning. Why did we have to square the height in meters but not the weight? No one knows. It also didn’t take into account lean muscle vs body fat, waist size, or bone density. It became a frequently used tool in the 1970’s and forward by doctors as a measure of an individual’s weight related health status as it was easier to use than the other methods such as skin fold caliper testing and underwater weight displacement testing despite the fact that it was not meant for individual statistic analysis nor did it have any basis in actual health. So basically some guy with no health background, albeit very intelligent, made up an equation to evaluate statistics of a health issue and we have just run with it for literal centuries out of convenience.
So why should we change this practice? As mentioned, the BMI does not take into account lean muscle, waist size or bone density vs body fat. As most of us know, muscle and bone are more dense than fat therefore a person with more muscle mass or bone mass is bound to have a higher overall weight. A person could have low body fat, lots of lean muscle and bone tissue and still fall into an “obese” category according to BMI. It’s not measuring the fat percentage of the person, only the weight to height ratio which isn’t helpful in this setting. We’ve all had plenty of students who come up as “obese” when we can see that they are solid muscle. A 17 year old football player who is 6’4″ and 250 lbs. and works out every single day might be a brick wall of solid muscle but according to BMI he is obese and must make changes to their health habits. This is obviously not an accurate assessment.
Should we continue to be concerned about students being over and underweight? Absolutely yes. Depending on the reason for the weight (fat) gain of the person, they aren’t always “unhealthy” however, chronic obesity can lead to diabetes, heart disease, lung disease, cardiovascular issues, infertility, pregnancy and childbirth complications, arthritis, sleep apnea (which can be deadly!), body pain, fatigue, surgical complications, and anxiety and depression, and bullying. As school nurses we are also aware of the fact that a student who is gaining weight rapidly may have some social issues at home going on like abuse or neglect, food insecurity, eating disorder, or mental health issues that would also need to be addressed.
The effects of being chronically underweight are also numerous including anemias, malnutrition, vitamin deficiencies, infertility, pregnancy and childbirth complications, surgical complications, growth and development issues – especially in developing children, fatigue, hair loss, poor immune system thus frequent illness, or poor learning. Weight loss or a child who is severely underweight can also be a sign of other health issues that need to be evaluated such as many cancers, HIV, eating disorders or other psychiatric issues, abuse or neglect, poverty and food insecurity, or even drug use.
We absolutely need to continue monitoring the height and weight of students and comparing to previous measurements so we are able to notice if there is an issue happening that should be addressed.
What are some reasons that it would be difficult to change this practice? BMI is still used by the CDC and WHO as the best assessment tool (despite the known fact that it is not actually best practice). It is also tied to Medicaid billing which is tied to school districts receiving funding for health services. I believe that this can be changed though if the powers that be are all on board with managing this in a different more evidence based way.
What should we do instead of using BMI? The BVI (body volume index) is a slightly different method of determining body fat percentage but unfortunately not possible for school nurses to do as it deals with water displacement measurements. You can see more about how this works here.
The University of Alabama reports that studies using the Tri-ponderal Mass Index (TMI) give a more accurate estimation of body fat percentage in children ages 8 years to 17 years. It is a similar formula to BMI but it cubes the height instead of squaring the height. More studies are needed to determine accuracy in varying ethnicities and age groups. University of Alabama StudyJournal of Pediatrics article.
RFM (relative fat mass index). This is a method of using tape measure measurements to measure the distance around the waist in comparison to height of the patient. This does not rely on weight at all. This can absolutely be done in a school setting. I would want to do it with one student at a time privately. As with all of the methods, this would also require educating the students about why we are doing it and what it means as we are being slightly invasive (ie: touching their body). Relative Fat Mass is a better measurement of body fat percentage than Body mass Index. To perform this assessment you will measure around the waist then measure your height and divide waist measurement by height measurement. A normal result should be approximately 0.5 or lower.
These results can be incorrect however when it comes to younger children or the elderly therefore not necessarily a good option for elementary school. This is possibly not the best method to use in a school setting due to the aforementioned inconsistencies for younger children and also it may be embarrassing or too invasive for the student.
Skin fold Calipers is another way to measure body fat. This is a tool that you use to gently pinch the skin folds in certain areas of the body and it has a measurement that tells the percentage of fat. You need to take a measurement from a number of different specified areas and then do the equation to figure out body fat percentage. Many of the calipers come with a chart to help you figure out the numbers. Personally I find this to be both invasive to the student and embarrassing for them to have someone “pinching their fat” then talking about it so I wouldn’t want to do this. I know I would be mortified if they wanted to do this to me at school.
BIA (Bioelectrical Impedance Analysis): this is a great method that is performed using a machine that can measure body composition including body fat, lean muscle, and water content of the body. The handheld machine sends an undetectable electrical current through the body which slows based on what kid of tissue it is going through therefore it can easily measure adipose, water, and lean muscle. It can be done using a simple handheld machine, or even many scales come equipped to measure this information. These machines can be purchased for anywhere from $40 – $300+ on Amazon and are very simple to use. According to research, BIA can be accurately used in children 8 years old to 20 years old. This would be an excellent alternative to using BMI in school if the district has the budget to purchase these machines.
Growth chart tracking without the BMI component. Just as they do at the pediatrician, Students heights and weights can be plotted on a growth chart for a visual picture of increased or decreased weight. We always said at the pediatrician that we don’t care what percentile the child is in (because that is BMI) but we are interested in seeing if they are following a curve appropriately. Are they dropping drastically or going up drastically? It gives us a picture of which students need to be addressed for unexpected weight gain or loss. This wont give a picture of fat percentage or overall health but then neither does calculating a BMI. This would be a simple, noninvasive, reasonable method in a school setting for evaluating a student’s weight.
Financial responsibilities for making these changes:
BIA machine: $40
Converting BMI setting in computerized charting system to reflect changes.
Training nurses to use BIA machine and documentation of new procedure: 1-2 hours salary
Measuring tapes: $10
BMI is an outdated tool that does not benefit us as much as previously thought.
Alternatives to using BMI may include Relative Fat Mass Index (RFI), skin fold calipers, Bioelectrical Impedance Analysis (BIA), growth chart tracking (without BMI component).
Tracking weight/growth in students is important to continue to do in order to prevent or manage weight related health issues and/or monitor for concerns such as abuse, neglect, or mental health issues.
This is a difficult issue to reform as CDC and WHO continue to use BMI and it is also linked to Medicaid reimbursement for school funding.
What do you think as a school nurse? Should we fight to change this practice and go with evidence based research or leave it be?
I’ve seen some chatter recently about school staff and the dissemination of student health information – specifically what staff are allowed to say to students in relation to health issues and what the nurse is allowed to say to staff about students’ health issues.
Situation #1: The school nurse has a student in the health room. A staff member walks by and sees them and comes in to say “Hey, Student, what’s wrong??” and comes in and maybe feels a forehead, asks follow up questions like “did you tell your mom this morning?” or “did the nurse call your parents to come pick you up?” or “did you try x-y-z to fix the problem?” What’s a school nurse to do? Do you allow or encourage the chit-chat? Do you get offended because I’M the nurse? Do you give a dismissive response to end the interaction?
Situation #2: The nurse receives health forms for a student that indicate serious health concerns that affect the student’s day to day time at school such as epilepsy. The student requires the use of a safety helmet, receives medications, and has frequent grand-mal seizures at school. This requires health information to be shared with multiple members of the school team. How is this information disseminated and to whom? What information is divulged?
A reoccurring theme I’ve seen is “That’s against HIPAA to tell anyone anything!” Well it’s not.
What is HIPAA? HIPAA stands for Health Insurance Portability and Accountability Act. Per the US Department of health & Human Services, HIPAA is defined as “The HIPAA Privacy Rule establishes national standards to protect individuals’ medical records and other individually identifiable health information (collectively defined as “protected health information”) and applies to health plans, health care clearinghouses, and those health care providers that conduct certain health care transactions electronically. The Rule requires appropriate safeguards to protect the privacy of protected health information and sets limits and conditions on the uses and disclosures that may be made of such information without an individual’s authorization. The Rule also gives individuals rights over their protected health information, including rights to examine and obtain a copy of their health records, to direct a covered entity to transmit to a third party an electronic copy of their protected health information in an electronic health record, and to request corrections.” In short, healthcare entities (and the employees within) can not share protected health information including patient identifying information in relation to the health information with anyone that is not in a position of need-to-know.
Those who work in hospitals and doctor’s offices are well aware of the issue of staff discussing patient information in public places (chatting about your crazy patient while having lunch in the caf), staff looking up patient information in the computer systems that they don’t have permission to access (like looking up your neighbor’s lab results), or posting anything to social media that would reveal a patients identity in relation to their healthcare. We also of course know that we don’t discuss patient issues with people outside their care team.
All that being said, does this also apply to school nurses maintaining the medical privacy of students in the health room? Sort of but no. Yes a student’s privacy should be maintained as much as possible and yes their medical information should be disseminated on a need-to-know basis but sometimes a large portion of the staff is considered “need-to-know”, especially as it relates to serious medical issues that can affect many teachers, classes, and staff members. The information doesn’t need to be broadcast to the entire school – parents and all but it does need to be told to any staff that is interacting with that student.
The answer is also no because HIPAA privacy rules exclude information considered educational records which includes school health room information. Educational records are covered under FERPA (Family Educational Rights and Privacy Act). It works the same though – basically personally identifying educational records of a student including health room records and information should have privacy maintained under FERPA. You can read more here: https://studentprivacycompass.org/covid-19faqs/
However, the answer is YES when it applies to private schools that do not receive federal funding. When it comes to an institution that does not receive federal funding the privacy laws become a gray area between HIPAA, FERPA, and no privacy laws. The HIPAA law might come into play when it relates to the school nurse specifically if they are providing healthcare to the student however, the school nurse is not providing health insurance managed medical care or billing for services. In this case I would think that the nurse would have to use their good judgement and refer to the HIPAA and FERPA laws to decide what they think is best.
In a case such as scenario #1, a staff member comes to the health room and starts asking the student questions. Is it appropriate? Probably not. But is it illegal? No. The patient is allowed to say anything they want to anyone they want about their own health. Most staff members who are coming in and asking a kid what’s wrong likely know the student already and are doing so because they care. Many times they are in “mommy mode” and just being a person. They are generally not trying to “do your job” or intrude (unless they are but that’s a different issue). You don’t have to tell their business to everyone but you can allow the student to tell what’s wrong if they want to. You can even say that to the student – “you don’t have to talk if you don’t want to”. What would be considered illegal is if the nurse then began explaining the issue to the staff member who is only asking out of curiosity. Use your judgement in what you want to say.
I frequently have staff members telling me that they aren’t totally sure what they are allowed to say health-wise and what they aren’t. According to Frontline Educational Services, “FERPA does not require written consent when “school officials” with “legitimate educational interest” review student records. Such access does not require prior notice to parents or guardians, other than the usual, annual FERPA notice provided by schools.” This means that the teachers, paras, and other school staff that have a genuine educational need to know health or educational information about the student are allowed to know/ask about it. If the staff’s only interest in the student’s health is curiosity then it is technically illegal for them to ask or be told about the student’s health status. That being said, the teacher and related staff members are absolutely allowed to ask parents or be told about a student’s history of asthma, allergies, seizures, etc. as it relates to their education in their class. It’s important to note that while they have the right to know the information, they do not have the right to suggest treatments or management of anything.
The area that this comes into question relating to teachers is when it comes to ADHD and ADHD medications. While there are no laws stating that a teacher can’t suggest a student be evaluated or medicated for ADHD, it is in very poor taste and can be construed as discrimination if that subject is broached inappropriately. This should be addressed through the Special Education team. You can read more about this issue here: https://www.understood.org/articles/en/can-a-school-make-medication-a-requirement-for-my-child-to-attend
This information applies in the case of scenario #2. The teachers and related staff need to be aware of the student’s seizures and information surrounding that issue in order to appropriately care for the student should a seizure happen at school. This information should be shared with anyone who is directly working with that student including PE, paras, admins, subs, and specials teachers.
Scenario #3: The school nurse needs some specific medication orders from a doctor’s office. Should they ask the parent and have the parent ask the doctor’s office OR should they cut out the middle man and call the doctor’s office themselves and request the information. The school nurse is allowed to call the doctor’s office themselves. The doctor is permitted to share the information with the school nurse for health maintenance purposes. Some offices might ask for a parent to sign a release and that’s fine if that is their policy. Personally I always ask the parent’s permission first – that way I can verify what doctor I should be calling.
At the end of the day, just be nice. There is no need for being defensive or snippy if someone asks about a student. You can just let them know politely “they are sick” or “we are all good now” if someone asks. If you wanted to you could just ask the student if they want to explain or not and then leave it at that.
FERPA applies to educational records including health room information
HIPAA applies to specific medical institutions that are billing for services such as hospitals and doctor’s offices, not school health rooms.
If someone needs to know medical information about a student because they have an educational interest in that student (their teachers, paras, etc.) you can tell them all the stuff.
If someone is just curious then you don’t tell them anything but the student can tell them anything they want.
Teachers can ask/ be told about student’s health issues but they can not suggest any treatments.
Teachers should not discuss ADHD and ADHD medications with parents as it can be construed as discrimination. Refer to the SEL for that issue.
Check out links at the bottom for 504 plan info and more helpful forms for seizure disorders!
When I was a kid I remember a guy at school who had seizures. It was a whole big thing – we were out at recess and he had a grand mal seizure while playing soccer. I was too young to remember what happened after that initial seizure: did they call 911? Did they roll him over? All I remember is that he was the only kid I ever knew growing up who had seizures and he continued well into adulthood (still has them last I heard). My daughter knew one girl in school who took medications for seizures and learned all about them from her. When she moved on to college she had a friend on her dorm floor who would have frequent seizures and because she is the child of a nurse and also well versed in seizure management she was able to take charge when no one else knew what to do in their first few months of college away from home.
What does it mean to have a seizure disorder and how can we help manage that at school? A seizure is basically a disruption of the electrical signals in the brain. They come in many forms that you may have heard of such as absence (aka petite mal), tonic-clonic (aka grand mal). The two main ones that we see most frequently are:
Absence seizure: Also known as petite-mal seizure, a type of generalized seizure that affects both sides of the brain. The patient is unaware of what is happening. They tend to “zone out” for a period of time (like 20-30 seconds) and may stare, smack lips, or have fluttering eyelids. Afterwards they generally do not have a postictal state but don’t remember what was happening during the seizure. These happen in children ages 4-14 but have been seen in younger children also. They are often outgrown but until they outgrow it they are treated with medication to prevent worsening symptoms.
When a person has an absence seizure there isn’t really anything to do during it as often you may not notice that it started or stopped and they don’t generally have any symptoms afterward. If you see that they are having a seizure just keep an eye on them that they don’t progress into anything further like a tonic-clonic.
Generalized tonic-clonic: Also known as a grand mal seizure, this is what most people think of when they think of a seizure. The person will be unconscious, with shaking or jerking limbs and very stiff muscles. The patient can become injured from the jerking activity or from falling with the seizure or can often bite their tongue or lips during it. This person may lose control of bladder and/or bowels or vomit during their seizure. They are likely to have a postictal state that can last a few minutes or a few hours where they will be super tired or maybe have a headache. Often those who have been dealing with seizures for a long time can have an “aura” prior to the seizure that alerts them to it occurring. The aura can consist of things like smelling a specific smell, flashing lights that aren’t there, feeling of impending doom (sudden fear of something bad is happening), or general nausea.
When it is noted that a person is having a tonic-clonic seizure the first thing to do is start timing it. Note the exact time it started if you can. Generally, if the seizure lasts longer than 5 minutes you should be administering emergency meds and calling 911. Then you want to be sure to protect their head to prevent any further injuries. This just means placing a pillow or clothing or something underneath their head so they don’t hit the floor or any objects. Try and move anything out of the way that could injure them if you can but do NOT try to hold them down. Roll them on their side in case they vomit so they don’t aspirate on the vomit. Never put anything in their mouth to prevent tongue biting – that’s an old wives tale that you should place a spoon or a bite block in their mouth to prevent them from “swallowing their tongue” (that’s not a thing – it’s physically impossible.)
Other types of seizures include:
Focal Aware Seizure: Exactly what the name implies: a partial focal seizure that the patient is awake and aware but perhaps frozen and can’t move. Lasts around 2 minutes.
Focal Impaired Awareness Seizure: A psychomotor seizure or a temporal seizure, similar to the focal aware but the patient has decreased awareness of the episode.
Atypical Absence Seizure: Patient is not fully aware, may stop talking and stare, blink, moving lips. Lasts 5-30 seconds, often goes unnoticed.
Atonic Seizure: “Drop seizure”, patient becomes limp, can fall to the ground. Generally lasts less than 15 seconds. These patients often require safety helmets to prevent head injuries from unexpected falls.
Clonic Seizure: Patient is unaware, may have jerking motions of limbs. They are rare and mostly happen in babies.
Tonic Seizure: The patient suddenly stiffens ie: muscle TONE increases. Lasts about 20 seconds, patient may be aware or somewhat aware during this.
Myoclonic Seizure: Brief shock like jerks or twitching of a muscle group. They last generally a few seconds, very hard to notice often.
Gelastic and Dacrystic Seizure: Gelastic can cause uncontrolled laughing or giggling, often called “laughing seizures”. Dacrystic is a “crying seizure” The patient is aware but can not control the emotional episode.
Febrile Seizure: a seizure that occurs in children ages 3 months to around 6 years old when they have a high fever. These can often be full body convulsions lasting less than 15 minutes. They occur in 2% – 5% of children and can also run in families. They can not be treated with lukewarm baths or Tylenol and do not require daily medication. The patient may be prescribed a rescue medication like Diazepam for a seizure that lasts longer than 5 minutes.
Refractory seizure: Seizures of any kind that are not controlled or easily controlled with medication therapy. Even with medications the seizures are frequent and sever enough that they interfere with every day life.
Status Epilepticus: When a seizure does not stop by 5 minutes or more than 1 seizure within the 5 minute period without returning to normal level of consciousness between events. This is a medical emergency and needs immediate medical attention as it can lead to brain damage.
Common Medications: Most patients with seizure disorders are treated with a daily maintenance medication. It is important for the school nurse to know the dosages and time of day each medication is taken in case the patient is transported to the hospital. These are generally dosed by weight and a change in weight, even a minor change, can make a huge difference in side effects and efficacy. A lot of these medications can cause drowsiness, headaches, behavior or mood changes, or weakness. Often once the person has become regulated to the dosage they have less side effects but the nurse should be aware that these side effects are a possibility when changing doses or meds. These are some of the more common ones you might see used but there are many.
Emergency rescue medications: Medications used to stop a seizure. If a student has a known seizure disorder it is wise to have an emergency medication on hand for them in case of emergency. Check your state laws regarding who is able to administer emergency meds aside from the nurse.
It is very important to know how and when to use the rescue med for a seizure. *Generally* if a seizure is lasting longer then 5 minutes you will use the rescue med and call 911. Check the doctor’s orders for the medication and create an action plan with all the information for the individual student.
Other treatments for seizure disorders
Vagus Nerve Stimulator (VNS): an implantable device similar to a pacemaker that stimulates the vagus nerve. This device can reduce amount of seizures, shorten length of seizures and also stop an acute seizure. If a patient is having an acute seizure the device has a magnet that can be swiped over it to cause it to send a stronger signal to the brain to try and stop the seizure.
Ketogenic diet: You may have heard of this revolutionary weight loss diet “Keto”. It was actually invented specifically to treat people with epilepsy and diabetes. It is a high fat low carb diet that causes the body to burn fats instead of sugars creating ketones in the body. They aren’t sure why it works but something about the ketones affects the brain’s functioning and lowers seizure frequency. There are risks to using this diet and it should be supervised by the doctor to be sure the patient is receiving the appropriate nutrients.
For my students with seizure disorders I keep a binder with each student’s information separated with dividers. I include a log to track their seizures at school, their action plan, their 504 information, and report sheets in case of calling 911. This way we have everything in one place to document and keep track.
Seizure Disorder 504 Information. In the interest of not reinventing the wheel, these accommodations are borrowed directly from the Epilepsy Foundation
EXERCISE, PHYSICAL ACTIVITY, AND REST PERIODS:
Physical education instructors and sports coaches must be able to recognize the student’s seizures and assist with first aid.
Responsible school staff members will make sure that any needed emergency AEDs such as Diastat are available for student at the site of his/her physical education class and team sports practices/games.
School staff shall ensure that if student has a seizure and needs to sleep or rest afterwards or otherwise needs to rest during the school day, he or she will have the opportunity to do so in a safe, supervised, comfortable setting. The setting does not have to be the school nurse’s office, and supervision does not have to be provided by the school nurse, unless physician orders so require.
Student will be permitted/suggested to wear safety helmet if prescribed by physician.
Student shall have access to needed food and liquids as required during the school day in order to maintain the protocol of the ketogenic diet.
Student parent/guardian shall provide pre-measured supplies of food and liquid to the school on a daily basis.
School staff who work with student shall be trained regarding the ketogenic diet so that violations of the diet do not occur at school.
As appropriate, classmates of student shall be given information about the ketogenic diet so that they do not share food with him/her.
As appropriate, during class parties or celebrations with food, alternatives shall be arranged for student that enable him/her to partake in the celebration if s/he will be unable to eat or drink during the party time. Such alternatives may include, but are not limited to, playing a special role in the celebration, choosing music for the party, or being the “emcee.”
VAGUS NERVE STIMULATOR
School staff who work with student shall be trained regarding the vagus nerve stimulator (VNS) and how it works.
A staff person shall be identified who shall be trained to swipe the magnet over
the VNS in the event that student has a seizure, as stated in the attached Seizure Action Plan.
A log shall be kept of each instance in which the VNS is swiped and the parents shall be notified at the end of each school day in which a swipe occurred.
ROUTINE ANTIEPILEPTIC DRUGS AND DIASTAT ACUDIAL
As stated in the attached Seizure Action Plan, student shall be given his/her prescribed doses of AEDs in accordance with physician orders.
School staff shall identify a person and a back-up person to be trained to administer Diastat or other appropriate emergency AEDs to student in accordance with physician orders, as stated in the attached Seizure Action Plan. A trained staff member shall be available to perform this task all times during which student is at school or attending a school-related activity or event.
FIELD TRIPS AND EXTRACURRICULAR ACTIVITIES
Student will participate in all field trips, extracurricular activities, and school-related activities and events (such as sports, clubs, enrichment programs, and overnight trips) without restriction and with all of the accommodations and modifications, including necessary assistance and supervision by identified school or contract personnel, set out in this Plan.
Student’s parent/guardian will not be required to accompany him/her on field trips or any of these other listed events or activities.
A trained person shall be designated to be available on site at all field trips, extracurricular activities, and other school-related activities and events to provide administration of any necessary medication in the event of a seizure, or any other seizure first aid as needed.
The student’s AEDs will travel with the student to any field trip or extracurricular activity on or away from the school premises
CLASSROOM WORK AND TESTS
If student has a seizure during a test, he or she will be allowed to take the test at another time without any penalty.
If student has side effects from AEDs that affect his/her ability to concentrate on schoolwork or tests, s/he may have extra time to complete assignments and tests without any penalty.
If student arrives to school late because of an adjusted start time due to the need to wake up later to avoid morning seizures, s/he will not be penalized for work missed and will be given an opportunity to make up the work.
Student shall be given instruction without penalty to help him/her make up any classroom instruction missed due to epilepsy care.
Student shall not be penalized for absences required for medical appointments and/or for illness related to his/her epilepsy.
DAILY INSTRUCTIONS AND COMMUNICATION
Every substitute teacher and substitute school nurse shall be provided with written instructions regarding student seizure care and a list of all school nurses and staff involved in his/her care at the school.
Student’s parents shall be informed each day of any seizures that occurred at school or at any school-related activity or event. The information given to the parents shall be in writing and shall include information about the type(s) of seizures that occurred, any first aid or other treatment provided, and any other relevant information.
As stated in the attached Seizure Action Plan, in the event of an emergency such as a seizure that results in an unusual response, school staff shall contact 911 and notify student’s parents.
EMERGENCY EVACUATION AND SHELTER-IN-PLACE
In the event of an emergency evacuation or shelter-in-place situation, student’s Section 504 Plan shall remain in full force and effect.
The school nurse or other person identified by school staff and named in this Plan, shall provide seizure care as outlined in this Plan and will be responsible for transporting student’s medication. He or she shall remain in contact with student’s parents/guardians, and shall receive information, guidance, and necessary orders from the parents regarding seizure care.
A while back someone had mentioned in a Facebook post about a student playing with her “glitter bottle” in her health room and it got me thinking about how much I love glitter, and what a cool idea it would be to get/make my own glitter bottles.
What is a “glitter bottle” or a “sensory jar” you ask? Sometimes also referred to as a “calm down jar”, it’s a toy that helps kids (and adults) settle their brain down a bit and refocus. You just get comfy and flip the jar around watching the glitter swirl and settle and float around while breathing in and out and focusing on the movement and sparkles. Sounds relaxing.
You can also use them as a sort of “time out timer” for little ones. They sit in their time out or rest area for the amount of time it takes for the glitter to fall and then hopefully feeling refreshed they can join the activity again. You can decide if it will be a fast or slow timer depending how much corn syrup you add.
Here are the details:
To begin you will need a clean bottle or jar. I bought these craft bottles from Amazon but the Voss water bottles are perfect for this. You can also use a Mason Jar as long as you have a water tight lid for it and you aren’t afraid of glass breaking. I tried using various glass bottles from Hobby Lobby but they didn’t work out so well for this project – too leaky.
Next you will need clear corn syrup. Some people also choose to use clear Elmer’s glue but I like the corn syrup the best – like this one Karo Syrup. I found my Karo Syrup in the cereal aisle at Walmart with the pancake syrup but you can also find it on Amazon.
Now the best part – you need glitter! You can pick color combinations and glitter sizes – I like a combo of small shaped glitter like stars and hearts, very fine glitter and some larger sequins of varying shapes so there is something interesting to look for in the bottle. I tried something that was larger glitter flakes but they didn’t react with the corn syrup very well so avoid those (they got too clumpy and ruined the whole jar). You can find some glitter options here.
Start by filling your bottle about halfway with corn syrup. It doesn’t have to be exact, there are no hard rules here.
Next add your glitter. You can decide how much you want but I used about a table spoon or less of a few different ones. If you finish and you feel like you want more glitter then you can open it up and add more later. You would be surprised at how a small amount spreads out! I also add the sequin shapes at this time – just a sprinkle or two so there’s something interesting floating around to look for.
Now you will add warm or hot water carefully on top of the glitter and corn syrup and fill almost to the top. Leave a space for air so the solution is able to move around and also some space in case you want to add more corn syrup or glitter. You should use distilled water for this to prevent mold from growing but it is not required. You can choose to use cool water instead of warm but the warm water mixes with the corn syrup faster.
Close the lid tightly but not so tight you cant get it off. Start inverting the bottle to mix all the ingredients together. Now you can decide if you’re happy with how the glitter is floating – if it is too watery then add more corn syrup and if it is too thick add more water. You can also top off the glitter now if you want to. Make sure there is a small space of air at the top (because physics).
Once satisfied with the ratios of glitter, corn syrup and water, carefully remove the lid, dry off the top of the bottle and the lid, and add some glue to the threads where the lid goes on, put the lid back on and seal it up.
And that’s it! I’m obsessed with playing with these things and am constantly shaking them up on my desk. While the kids are waiting for whatever reason in my office they enjoy flipping them around and looking for the shapes and watching the glitter swirl.
What you’ll do: Promote the physical well-being of students so they can succeed academically. School nurses conduct student assessments; administer first-aid, medication, and treatments; and educate students about their health.
Where you’ll work: K-12 public, private, vocational, and alternative schools; health departments, military bases, and community, state, and federal organizations
Degree you’ll need: Depending on state and school requirements, an Associate Degree in Nursing (ADN) or a Bachelor of Science in Nursing (BSN)
Median annual salary: $75,330
School nurses provide a bridge between students, parents, and teachers to address the physical, mental, emotional, and social health needs of students so they can thrive in the classroom.
Use these steps as a guide to pursue a career as a school nurse.
1: Find the Right School
There are many factors to consider when choosing a nursing school. While you’ll want to find a program with a location, cost, student-to-faculty ratio, and programming to meet your needs, you’ll also want to look for:
Accreditation:A degree from an accredited nursing school meets requirements for state nursing licenses and professional certifications. It also ensures that your credits are transferable to other accredited institutions toward advanced degrees and that your eligible for federal financial aid.
Job placement and career counseling: These services can help you set career goals, network, and find your first role.
“The additional education is always beneficial so if one does not have a BSN, it is important to get one as most employers are requiring it for work anyway,” says Emily Hunter, BSN, RN, CSN, a certified school nurse and founder and author of Your Favorite School Nurse blog.
3: Apply to School
Admission requirements for BSN programs vary by school. If you already have an ADN, you may be able to reduce the time you’ll need to finish a BSN with an RN-to-BSN bridge program.
Depending on the BSN program you choose, you may have to meet some or all of the following admission requirements:
High school diploma or GED
Advanced math, biology, and chemistry prerequisites
Professional and/or academic recommendations
Personal statement of purpose
In-person or virtual interview
Standardized test scores from the SAT or ACT
Passing score on HESI Admission Assessment (A2) Exam
4: Complete Your Coursework and Clinicals
A BSN includes advanced science coursework and helps nurses develop a broad skillset in patient-centered care, clinical judgment, physical assessments, leadership, and community—all critical to working as a school nurse.
As part of your nursing program, you’ll get hands-on training in nursing care through clinical hours in a healthcare setting. Clinical requirements can total 700 to 800 hours, though hours can vary widely by program.
The NCSBN offers a practice NCLEX-RN exam. You may also benefit from other types of test preparation, including review courses, flashcards, and/or study groups.
Here’s a general breakdown of what the exam covers.
Safe and Effective Care Environment
Health Promotion and Maintenance
The NCLEX-RN is a computerized test that you’ll have five hours to complete. Most of the questions are multiple-choice, with some fill-in-the-blank, multiple-response, and drag-and-drop-style questions.
The NCLEX is also “computer adaptive.” This means that the questions you receive are determined by your response to the previous question. If you answer a question incorrectly, the next question is slightly easier. If you answer correctly, your questions increase in difficulty. You continue to answer questions, from a minimum of 75 to a maximum of 265, until the computer determines your level of competence, or your time runs out.
In addition to passing the NCLEX-RN, you’ll need to meet any other state-specific criteria before you receive a license. These requirements may include:
Comprehensive background check
Proof of good moral character
Resolution of back payments for child support or other unfavorable marks on your records
6: Gain Experience as a Nurse
While most schools don’t require nurses to have specific experience, working in a clinical environment could give you invaluable experience to bring to the role of school nurse.
“Many of us do come from hospitals and have experience in emergency, ICU, labor and delivery, home care, or peds,” says Hunter. “I think it is important to get a good handle on your skills in a more hands-on nursing position before doing this job.”
While you can strengthen your skills in many types of clinical settings, working in pediatrics can give you the best foundation for school nursing, Hunter says. “I worked as a medical assistant for 11 years in a pediatric primary care office and learned so much that I apply today to my job such as looking in ears, understanding rashes’ behavior, ADHD, disabilities, various childhood ailments, and understanding immunizations intimately.”
You’ll have many options for gaining clinical experience. Here are the top three employers of registered nurses, as reported by the U.S. Bureau of Labor Statistics (BLS):
Ambulatory services, such as physicians’ offices and outpatient care centers: 18%
Nursing and residential care facilities: 6%
7: Become Eligible for Certification
The Nationally Certified School Nurse (NCSN) certification is an optional credential, but some states require it. Earning the certification is considered proof that you’ve demonstrated your competency to work as a school nurse based on established professional standards.
The National Board for Certification of School Nurses (NBCSN) administers the certification exam. To qualify, you must:
Have an academic transcript with proof of one of the following:
A bachelor’s degree or higher in nursing from an accredited program
A Master of Education (M.Ed.) with a concentration in school nursing or school health services from an accredited institution approved by the NBCSN
Have at least 1,000 hours of work experience in the last three years
Submit an application online within 30 days of the start of one of three annual test dates
Pay the $360 exam fee.
8: Prepare for Certification
There are free and fee-based resources to help you prepare for the exam.
The NBCSN Handbook for Candidates is a great place to start. It will give you access to these free exam prep materials:
Test Prep Infographic, a guide that includes a roadmap for studying during the weeks before the exam
National Exam Candidates Discussion Group/Online Study Group
Challenge the School Nurse archived questions, which are similar to questions on the exam
Test Taking Techniques e-course from Nurse Builders
You may also find it worthwhile to purchase an online practice exam from NBCSN. Professional exam prep instructors and organizations also offer study books, online courses, and video or in-person review courses.
9: Pass the Certification Exam
The four-hour exam is administered during two- to three-week periods at computer-based testing facilities across the U.S. and Canada.
NBCSN also offers remote proctoring, which allows you to take the exam at home. You’ll need a camera, microphone, and a quiet and well-lit room for this option.
The certification exam includes a maximum of 200 multiple-choice questions on these topics:
Health Problems and Nursing Management—27%
Health Promotion/Disease Prevention—20%
Special Health Issues—14%
10: Meet State Requirements
Some states require certification to work as a school nurse, and states in general may have other requirements, such as:
Job opportunities in your local public schools could depend on local funding. School districts that have tight budgets and limited resources may have a higher student-to-school nurse ratio. As a result, nurses in these districts may be responsible for more students and perhaps more than one school.
Competition for jobs can vary by district. And if a school doesn’t have a nurse, it may be due to a lack of funding rather than a lack of qualified candidates.
If full-time opportunities aren’t immediately available, you may be able to gain experience in a part-time position, which some districts use to save money. Working at a boarding school, summer camp, or alternative school could be options as well.
12: Keep Certification Current
You’ll need to renew your NCSN credential every five years. To qualify for recertification, you’ll need to provide documentation of:
Current RN license
Employment as a school nurse or related position, including at least 2,000 hours of clinical practice in school nursing during the past five years, with at least 750 of those hours in the last three years
75 approved hours of continuing education or professional activities
Payment of the $245 recertification fee
13: Advance Your Training
Earning certification doesn’t have to be the end of your education. There are many ways to expand your skills if you want to move up or into related roles.
If you take post-graduate coursework in school nursing after earning a BSN, you may be able to apply those credits toward a master’s in nursing, education, or public health. A graduate degree may be required for supervisory roles across school districts or larger geographical areas.
“We take classes to become a certified school nurse and then, for me, those credits counted toward my master’s degree in education: school health services,” says Hunter.
If you have a BSN, you’re also positioned to pursue specialty certifications that may boost your pay. For example, school nurses are typically required to have BLS certification, says Hunter. Becoming certified as a CPR instructor could open opportunities to train and certify school staff in CPR, which could mean higher pay, she says.
Decide if School Nursing Is Right for You
Like any new career journey, you’ll need to decide if school nursing is right for you. Talking to current school nurses and potentially shadowing them while they work is one way to get a firsthand perspective of the role before you invest time and money in training.
“I have found that this role is much like being an ER nurse in that you have often very little information and supplies and have to make do with what creativity you can come up with,” says Hunter. “You never know what’s going to come in your office—is it a bellyache because we hate math or is it a kid who punched glass and needs stitches? A pregnant teen or a kid that fell and maybe has a broken bone?”
In addition to being able to respond in any situation, it also helps to have certain personality traits. “I think the personal characteristics needed for this role would include organization skills, time management skills, and the ability to be flexible and adapt,” says Hunter. “You have to be able to see through some stories and get to the real issues at hand.”
What You’ll Do
While your role may vary depending on the size and type of school, here are some common responsibilities and duties of a school nurse:
Administer medication and treatment for chronic conditions such as asthma, diabetes, seizures, and sickle cell disease
Conduct annual vision, hearing, health, and mental health screenings
Oversee school infection control standards
Respond to health emergencies involving children and staff
Maintain student health records, including immunizations
Develop educational plans for students who need accommodations due to their ability to learn
Identify child abuse, bullying, and drug abuse
Connect students and families with social services related to healthcare, food, shelter, and other support
“School nursing can be extremely rewarding. There is so much more than giving out band-aids and ice packs—that’s the easy part!” says Hunter. “We have to be ER nurses, special ed teachers, mommies, counselors, and even teachers.”
Pros and Cons to a Career as a School Nurse
There are many reasons to pursue a career as a school nurse, including:
Regular work hours, generally 8 a.m. to 3 p.m. Monday through Friday
Opportunity to be home on snow days, holidays, and during summer break
Autonomy to do things your way since most school nurses work alone
Rewards of helping children in need
Potentially less stressful environment versus working in a hospital
Opportunity to make an impact and develop relationships with students
And as with any job, there also are challenges to being a school nurse:
Potentially lower salary than other nursing specialties
Sometimes heavy workload if you’re the only school nurse on staff
Lack of recognition as an important part of the school community
Little administrative help with forms and paperwork
Less opportunity to interact with other healthcare professionals
Responsibility to make potentially life-saving decisions without oversight
Potential to be assigned across multiple schools
Likelihood of dealing with the messiness of vomiting, colds, lice, and other common childhood health issues
School nurses serve as an important link among students, teachers, coaches, and parents. This requires effective communication and collaboration.
In addition to handling everyday injuries and illnesses, you’ll work to prevent a student’s medical issue from interfering with their ability to learn.
“If the student also has educational issues in addition to the medical issues, then the nurse will be on the IEP (individualized education program) team to help manage the medical accommodations,” Hunter says.
In addition to handling everyday injuries and illnesses, you’ll work to prevent a student’s medical issue from interfering with their ability to learn.
On a broader level, a school nurse contributes to the school environment by educating staff and students on a range of health care issues, including infection control, recognizing signs of distress, and first-aid.
Elementary School vs Middle School vs High School
While many of your duties will be the same no matter the school, elementary, middle, and high school students can present different challenges. “Those are three totally different jobs!” says Hunter.
Here’s a look at responsibilities that can differ by age.
Address issues affecting proper growth
Coordinate medication and treatment for chronic conditions
Handle a higher number of bumps, bruises, and common conditions like stomachaches and fever than likely at older grades
Address issues related to physical and emotional bullying
Deal with more complex behavioral issues
Identify and educate students and staff about the dangers of fads like TikTok challenges
Less hands-on care for chronic conditions like diabetes since teenagers can often manage on their own
Address issues related to sexual activity, including STDs, date rape, and teen pregnancy
Provide alcohol and drug education and identify substance abuse
According to the BLS, the annual median salary for RNs is $75,330, with those in the lowest 10% of the profession earning $53,410 and those in the top 10% making $116,230.
Annual Median Salary for RNs:
While the BLS doesn’t report salaries by specialty for RNs, earning a BSN and certification may increase your salary potential and help you stand out among job candidates, especially in a field that values advanced education. Where you work, your experience, and other factors also can influence your salary.
Pursuing a nursing career may be a wise investment of your time and money. The BLS predicts 9% growth in jobs for nurses from 2020 to 2030, slightly above the average rate for all occupations.
Your employment opportunities as a school nurse will vary depending on the school districts in your area. While some districts hire nurses part time and pay lower salaries, others employ nurses as part of their teachers’ union and pay them on a scale that aligns with teacher salaries, Hunter says.