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Assessment Basics for the School Nurse: Ears

Something I think many school nurses struggle with – myself included – is looking in ears. What are we looking at in there and why does it matter when RNs can’t diagnose or prescribe anyway?

Well we can certainly look and assess and determine if the student needs to have further evaluation at the doctor or not but no, we can’t diagnose the ear infection or prescribe antibiotics; nor can we clean out the wax in a school health room setting.

Good otoscopy requires lots of practice to know what you’re looking at. My first piece of advice is to look in every student’s ears that it is convenient to so you can get a good handle on what it might look like in different ages and sizes and different states of health.

Some reasons we might need to check a students ears might include: ear pain, difficulty hearing, failure of audiogram hearing screen, sensation of foreign body, noted drainage or bleeding from ear, or injury to ear.

Equipment needed for examination

  1. Otoscope: The Welch-Allyn is your best bet for a solid otoscope. You can find many styles of Welch-Allyn to meet your needs. I also have a digital otoscope with a screen that I’m still learning to use so the jury is still out on whether it is a good investment or not. Make sure that whatever scope you get that you have extra batteries and bulbs for it.
  2. Otoscope speculae: You should have a supply of disposable speculae for your scope in multiple sizes depending on the size of the patient. They are mostly universal but make sure they fit your scope before buying.
  3. Ear-ease or rice pack for heat therapy: This is a cool little tool that helps put moist heat on an earache. People swear by it. If you don’t have an ear-ease you can just make a rice pack with a baby sock and some rice – sprinkle a little water on it and microwave it to make it warm (not hot!).
  4. Audiometer: If the student’s issue is hearing loss then you may want to check their hearing as part of the ear exam. Audiometers can be purchased through school nurse supply companies such as schoolhealth.com or schoolnursesupplyinc.com.

Steps to performing an ear exam

  1. Examine the outside of the ear first. Do you note any drainage, bleeding, redness, lesions, or swelling? Is there a piercing that needs attention? Bug bites, scratches, etc?
  2. Observe the face around the ear noting if there is any swelling, lesions, redness or drainage to the corresponding eye, jaw, cheek, neck and mastoid area. This can be an indicator of mastoiditis, a progression of inner ear infection.
  3. For a child you will want to pull the pinna (outside part of the ear) straight back. For an adult or teen you will want to pull the pinna up and back to straighten the ear canal. In children the ear canal curves inward but as a person grows the ear canal begins to curve more upward.
  4. Insert your otoscope speculum with the light turned on.
  5. You may have to move around a bit to get a good look at the inside of the ear. Reposition the pinna if needed by moving it up, back and down until you can see in the ear canal.
  6. Observe the ear canal for excessive wax (some wax will be normal). Do not attempt to remove wax if it is occluding.
  7. Observe the ear canal for redness, bleeding or discharge, or foreign objects.
  8. Observe the tympanic membrane (TM) for redness, inflammation, leaking of fluid, bulging, myringotomy tubes, or perforations. Typically the TM should be mostly flat, gray, kind of shiny, and somewhat translucent.
  9. Document what is observed and call parent with any concerning findings.

Things you may see on exam and what to do about them

  1. Earwax occlusion: earwax blocking the ear canal. Do not attempt to remove the earwax, removal should be performed by the physician or under a physician’s supervision. If the student has ear pain but you can’t see enough to determine if there is anything wrong you are safest to just call the parent and let them know and they can have the doctor manage it.
  2. Fluid in ear: this can be difficult to see at times but you might see a few bubbles behind the TM. Sometimes if there is a lot of fluid it can cause the TM to bulge out and you can see the line of fluid behind the TM. Fluid in the ear can be caused by allergies, a cold virus or an ear infection.
  3. Possible infection aka acute otitis media or AOM: possible/probable ear infection can cause the TM to appear red, inflamed, and possibly have fluid or pus behind it. Since we can not diagnose or treat this we must refer the student to the doctor to be examined and treated.
  4. Swimmers ear aka otitis externa: Inflammation/infection in the ear canal outside of the TM. Usually it will hurt when you attempt to move the pinna to look in the ear. It will appear red or inflamed to the walls of the ear canal. Ask the student if they have been swimming or submerging their ears in water any time recently or if they have suffered any foreign bodies recently. Again, if noted, this needs to be further evaluated by a physician and treated as they wish.
  5. Ruptured or perforated eardrum: a hole in the TM usually from a buildup of fluid and pressure. You may see the tear or hole or you may see leakage of fluids. This often is accompanied by intense pain and then sudden relief when the pressure has subsided. This requires a phone call home and a trip to the doctor for further evaluation.
  6. Abrasions: If the student is sticking anything in their ear and scratching the ear canal they may have abrasions or scratches and some minor bleeding present. Just leave it alone and advise the student to refrain from placing anything in ears going forward. Note any signs of infection related to the wound and call home if needed.
  7. Myringotomy tubes: Often the tubes will remain in place for a few years but on occasion will migrate out and fall out. You may see intact tubes in the TM or you may see a tube embedded in wax or just sitting there in the ear canal. Just leave it alone and document. Let the parent know that you noted the tube has fallen out so they can have it addressed if needed.
  8. Foreign body: Kids do the darndest things. You might find anything in the ear from wads of tissue, cotton from q-tips, or bugs to pills, beads, berries and tiny legos. If a foreign body is noted call the parent to have them evaluated at the doctor. Do not attempt to remove the foreign body unless it is close to the outside and easy to grasp and remove.
  9. Infected piercing: If there is a piercing on the ear that shows signs of infection such as acute pain, redness, swelling, or drainage the student needs to be evaluated by the doctor. Do not remove the piercing but clean gently around it if possible. If there is irritation from an earring get a parent’s permission first to remove the earring and clean the piercing. Do not put the earring back in, place it in a small zip lock bag and send it home.
Examples of tympanic membrane disorders
Fluid behind the eardrum

In the health room

  1. As I mentioned, as RN’s in an autonomous setting such as a school health clinic, we don’t have the ability to diagnose or treat findings on an ear exam. It is important that we call the parent or guardian with any findings and impress on them that the student should see the doctor for further evaluation. You can report to the parent what your observations are but avoid stating things such as “they have an ear infection” because that would be assigning a diagnosis. Instead try letting them know that the student has ear pain and it appears red and inflamed inside so they need to be evaluated further by the doctor to determine treatment.
  2. Practice makes perfect. Look in as many ears as you can so you can get an idea of how they should look and what is abnormal.
  3. Never perform any procedures such as earwax removal, ear lavage, or foreign body removal in the health room. Any procedures to the ears aside from general exam should be performed by the doctor or under a doctor’s supervision, NOT at school.
  4. Google is your friend! There is nothing wrong with pulling up pictures of eardrums on Google so you can compare what you see with some images of various ailments.
  5. Educate your students when appropriate. Make sure they know that they should never put anything in their ears including q-tips. Make sure they know not to try and dig out wax themselves. Parents should also avoid using q-tips and removing wax and refer to the doctor if there is a concern.

Tips and tricks

  1. Ear-ease or moist heat: The ear-ease is a cool little tool that uses warm water over the ear to help relieve some ear pain with moist heat. You can get it from Amazon or some of the school nurse supply companies. Alternatively you can make a heat pack using rice and a baby sock: put the rice in the sock and tie it closed. When you need to use it sprinkle some water on it and warm it up in the microwave for a few seconds. Avoid burns by making sure to knead it well and ensure it is not too hot before using it on a student.
  2. Not all ear infections require antibiotics. Some are viral or allergic in etiology and can be remedied by using decongestants and supportive care.
  3. Tylenol or Motrin: Tylenol or Motrin can of course help in a pinch to relieve pain but will not get to the root of the problem.
  4. Decongestants/cold medicine: Decongestants can help relieve fluid and pressure in the ear caused by colds and allergies. This should be reserved for the parents to give at home unless they have appropriate doctor’s orders to be given at school.
  5. Chewing gum: chewing motion can help relieve pressure in the ears by helping them “pop”.
  6. People have been known to use warm (not hot) olive oil in the ear to relieve ear pain. This should be reserved for home and not performed by the school nurse.
  7. Another home remedy for ear pain is to use a few drops of onion juice in the sore ear. Apparently the quercetins in onions have antiinflammatory properties and can help with minor earaches. Alternatively one could use ginger juice, garlic oil, tea tree oil, or oil of oregano for relief of inflammation. Placing anything in the ear should be done at home by the parent or under the doctor’s supervision, not the school nurse. This should be avoided if the person has a perforation or myringotomy tubes. Note: these remedies are not medically proven and may carry risk.

When is ear pain an emergency?

  1. When it is accompanied by a penetrating injury ie: stuck a pencil in the ear and poked the eardrum. Call the parent to have evaluated ASAP.
  2. When is is accompanied by a real head injury. Assess the head injury and call the parent to have evaluated. Call 911 if the injury is severe.
  3. When they do not have tubes but they have fluid or blood leaking out. This can be an indicator of an acute perforation or a head injury and should be evaluated ASAP.
  4. When there is a foreign body in the ear.
  5. When it is accompanied by a fever. Call parent to have evaluated.
  6. When it is accompanied by acute hearing loss, dizziness/vertigo, or extreme sharp or throbbing pain.

If you have anything to add to ear assessments please feel free to follow and comment! I would love some experts to weigh in.

References

https://ppemedical.com/blog/how-to-perform-a-thorough-ear-examination/

https://www.ebmconsult.com/articles/otoscope-examination

https://www.ncbi.nlm.nih.gov/books/NBK553163/

https://www.gohealthuc.com/library/earache-remedies

https://kidshealth.org/en/parents/otitis-media.html?ref=search

Assessment Basics for School Nurses: Orthopedic Injury

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Something I think many school nurses might struggle with is orthopedic assessment. Someone comes in crying with an injury but how do we know what we might be working with and what we should do about it?

The most common types of orthopedic injuries that we would see with kids at school are of course broken bones, sprains and strains, shin splints, ACL injuries, and traumatic brain injuries (TBI, concussions). Concussion is a conversation for another post but we will go over some basic possible fracture assessment for this post.

Despite what many people think, nurses do not gain x-ray vision in nursing school.

Common types of fractures

  • Non-displaced: the bone is cracked but stays aligned.
  • Stress: Small cracks in the bone usually from repeated stress such as running or gymnastics.
  • Buckle: Not a true fracture but happens when the bone is compressed such as a fall on an outstretched hand and the bone bends and causes injury but does not break.
  • Displaced angulated: Full break, bones are out of alignment and on an angle.
  • Displaced translated: Full break, bones are out of alignment with each other but not angled.
  • Displaced Rotated (spiral): Full break, bones moved in a twisting motion when breaking.
  • Displaced greenstick: Partial break, one side breaks and the other side bends much like bending a fresh stick from a tree.
  • Comminuted: Full break, bone is in multiple pieces.
  • Compression: Like a buckle fracture, bone is compressed hard enough to collapse in on itself. This can happen from falling on outstretched hands, falling from a high height and landing on feet, or a car accident when the passenger’s feet are up on the dashboard.
  • Open: Fracture that involves the bones breaking through the skin.
  • Closed: Fracture that does not break the skin.
  • Growth Plate Fracture: A break in the bone over the growth plate in children.

Common pediatric fractures:

(Links on each area to the Boston Children’s Hospital patient education forms) found here: https://www.childrenshospital.org/conditions/fractures

Shoulder, upper arm

Elbow

  • occult elbow injury: A possible fracture to the elbow but is too difficult to see on x-ray.
  • olecranon fracture: Fracture of the pointy part of the elbow, part of the ulna (one of the two forearm bones).
  • medial epicondyle fracture: Fracture of the bottom of the humerus, in the elbow joint, on the inside part of the arm.
  • lateral condyle fracture: Fracture of the bottom of the humerus, in the elbow joint, on the outside part of the arm.

Forearm

Hand, wrist

Lower leg

Ankle, foot

  • ankle fracture: Fracture of the lower part of the tibia or fibula closer to the foot.
  • metatarsal fracture: fracture of the bones inside the foot that attach to the toes.

Symptoms of a possible fracture:

  • Pain: pain can sometimes be referred to an area other than where the actual fracture is ie: hip fracture can present as pain to upper leg. Supracondylar humeral fracture can present as pain to elbow and forearm.
  • Swelling: Edema to area surrounding injury.
  • Obvious deformity: Sometimes fractures don’t always “look broken” but other times they look really broken. Obvious deformity requires x-ray.
  • Difficulty moving limb or area in question: Range of motion may be decreased, inability to move limb or area in question without pain. In severe cases we won’t ask the patient to move the limb to assess but sometimes decreased ROM is obvious.

How to assess possible fractures

  • Mechanism of injury including height of fall: What caused the injury? Did they fall from standing? Fall off a structure?
  • Strength and Range of motion: Depending where the injury is located and how severe, assess if the person is able to move the area or not. Do they have pain when moving the area?
  • Bruising
  • Swelling
  • Erythema
  • Deformity: Is there an obvious area of deformity from the injury? Is the bone or limb bent at an abnormal angle?
  • Capillary refill: We are concerned about blood flow to the area if it is an arm or leg that is injured. Check capillary refill to assess for any compromise in blood flow.
  • Distal pulses: Check pulses below the injury to assess compromise to blood flow.
  • Distal sensation: Assess the level of sensation to the area below the injury. Can they feel your touch like normal? Not at all?
  • Distal temperature: Assess the temperature of the limb below the injury. If it is cold or cool they may have a compromise in blood flow. Heat at the injury site can also be an indicator of a fracture.
  • Pulseox: Check the pulseox if the injured limb is an arm. This is also to assess compromise of blood flow.
  • Assess for other injuries: Check for other injuries such as head trauma, abrasions, bleeding, other possible fractures, or bruising, and address them as appropriate.

What to do with a possible fracture

  • If fracture is suspected call the parents immediately. Call 911 depending on the severity of injury.
  • Splinting: We aren’t splinting like they do in the ER but we do need to immobilize for comfort to get the student to to the ER for evaluation. This can be in the form of a pre-formed plastic splint and an elastic wrap, or even a cardboard splint and elastic wrap. The goal is stabilization and immobilization to prevent further injury. Alternatively, if injury is severe and splinting will cause more damage, do not move the person to splint, keep them comfortable and still until EMS arrives to take over.
  • Ice: Ice will help reduce swelling and inflammation, can potentially decrease some discomfort as well.

In the Health Room

We have all been in a position where we have missed a fracture because it didn’t seem so serious when the student was in our office. Sometimes they don’t cry, they don’t have a ton of pain, they don’t have any obvious signs that would indicate a broken bone. I have learned the hard way to always report the injuries to parents even if it doesn’t seem serious. Give them a heads up that the student got hurt and while it seems ok right now the potential exists that it could change and require a medical evaluation. Write a note home, call them, send a text or a classdojo message, whatever it takes.

As I stated previously, we don’t receive our x-ray eyes in nursing school, we don’t know if something is broken or not without an x-ray.

Make sure you lay eyes on the injury even if it seems trivial. Take off the shoe, pull up the pant leg, take off the jacket and confirm the appearance of the injury.

Document the situation and assessment.

When is a possible fracture an emergency?

All possible fractures should be addressed emergently but some may require EMS attendance as opposed to waiting for a parent to transport to the ER.

  • If the injury is caused by a major trauma like a fall from a structure
  • If there is bone sticking through the skin.
  • If the person is unable to move or you can’t move the injury without causing pain.
  • If the injury involves the spine, neck, head or back.
  • If the person is unresponsive
  • If there is bleeding that can’t be controlled.
  • If there are weak or absent pulses or neurovascular exam indicates compromise.

Check out these system assessment documentation forms on Teachers Pay teachers: https://www.teacherspayteachers.com/Product/School-nurse-health-assessment-forms-bundle-8525470

References:

Can We Change This Narrative That Teachers Can’t Be Our Allies?

I’ve been watching a lot of posts on social media about school nurses being annoyed when the teachers suggest things that may be wrong with a student or suggest what they think the student needs.

The complaints of teachers feeling foreheads and sending a student to have their temperature checked, teachers noting that a student “looks sick”, teachers suggesting that so-and-so “needs ice” for an injury seem to throw some school nurses into a tailspin of upset that the teachers are “out of their lane”.

I am the school nurse and my literal job is to be here checking temperatures and assessing illness and injury and responding accordingly. My education is in nursing (and a little bit of teaching too) so I feel confident that I can assess students’ health concerns on a daily basis. I’m the one who is supposed to be using my nursing judgment to make health decisions in the school.

Treat teachers like allies, not enemies.

But are we truly so arrogant as healthcare providers that we can’t recognize that we are a team? I’m not spending most of my days with these kids, the teachers are. They see them all day every day and know them well enough to know if they aren’t well. Many of them are already parents and are capable of determining a warm forehead or a fake sickness complaint versus a real sickness, or drama versus real pain from an injury. Many of them have also been teaching for many years and know kids well enough to determine if they need some nursing attention or not.

If a teacher sends a kid with a hall pass that states their temp is 99 (either because they are guessing or because they have a thermometer and checked) is it really the end of the world? You can still give your nursing recommendation and move on. They are still being sent to you to assess and it doesn’t change your recommendation if they guess at a temperature. If the teacher has a thermometer, thank them for taking the time to triage the student and trying to keep them in class. After all, that is our common goal isn’t it?

Personally, I welcome the teachers’ input about the students. Often they are the ones that the students choose to speak to. They are the ones that might be seeing parents at pickup and talking to them. Most teachers get to know their kids and families well and are a great resource for the nurse.

I welcome teachers taking the initiative to help the students. Sure, I’d like to be the one to make the call if someone should go home sick since it is my job and all so there are of course some boundaries to be observed but that is something that can be discussed and easily remedied if that is an issue for you. I have teachers that are happy to text a parent or call because they have a relationship with them already, I don’t mind but would appreciate a heads up in the case that they do. In fact, this happened today when I stopped in a classroom and the teacher offered to call the parent for me. I appreciated it because that took a task off my plate leaving me with time to do other things.

Communicate, educate, collaborate. Everyone works together.

We need to have an open line of communication between the nurses and the teachers. There is no reason that the procedures can not be amicably discussed and an agreement reached. We need to understand their position in wanting to help the students and they of course need to understand our position of trying to do our job.

It’s never too late to establish ground rules that everyone can work with. Inform the school staff that they are welcome to call parents if they want to but please inform you if they are going to do that. As a nurse we know that we need to document all situations that we are involved with. If something comes back to bite anyone it should be documented for you to refer to.

Ask that they send sick kids to you instead of just sending them home – after all, this is what I’m here for. Keep the lines of communication open: if the teacher feels that the student needs to go home or be seen for whatever reason then have a conversation about their concerns and come to an agreement. Part of our job is educating, teachers and staff included. If after you’ve discussed and they have been educated they decide to continue the same actions then kiss it up to god and let it go. I’m rarely one to say things are “not my problem” but there comes a time where you have done what you can and now you step out of it.

At the end of the day communicate, educate, collaborate. Everyone works together for the good of the kids.

Headaches

Headaches: another enigma, maybe second to tummyaches. What causes them, and how do we manage them at school?

Headaches are literally a pain in your head or face. More specifically, a headache is an activation of nociceptors (a sensory receptor for painful stimuli) in and around the layers of tissue of the brain. These nociceptors can be activated by many different stimuli including tension, increased blood flow, grinding teeth, poor sleep, nasal and sinus congestion and much more!

Fun fact: your actual brain does not feel pain, the sensory receptors are only present in the meninges, not the actual brain tissue which is why they can do brain surgery without causing pain.

Causes of headaches

Some most common causes of headaches are (this is not an exhaustive list):

  • Tension/stress: most common in children and young adults, caused by the muscles in the head and neck tensing up and activating the pain receptors. Tension/stress headaches usually feel like a squeezing or pressure, pounding, generally constant and all over the head or radiating down the neck. While uncomfortable these headaches are not dangerous. They can generally be relieved by over the counter medications like Ibuprofen, Acetaminophen or Naproxen.
  • Poor sleep: lack of sleep can cause both tension headaches or be a migraine trigger. Poor sleep can activate the nociceptors causing headaches. Fatigue can cause poor posture and muscle pain leading to tension type headaches.
  • Poor diet: low sodium and potassium can cause a headache so if you’re dieting or maybe just were too busy and skipped a meal you might find yourself with a headache. From personal experience I’ve also found that eating too low carb causes headaches (yeah I tried that keto diet for about a year and had raging headaches the whole time!) Also lack of caffeine, if you’re a true coffee addict, can definitely cause a headache: caffeine narrows the blood vessels surrounding the brain which helps reduce headaches cause from increased blood flow. Decreased caffeine means increased blood flow which equals headache. This is also how/why Excedrin works!
  • Dehydration: as mentioned above, low sodium can lead to headaches, but also when you’re low on fluids in general your brain tissues can shrink which puts pressure on the nerves around your brain causing pain. Keep your brain nice and plump!
  • Poor posture: poor posture causes tension in the back and neck which can lead to pain in the back of the head and neck.
  • Nasal and sinus congestion/colds: If you have inflamed or congested sinuses they are causing pressure on the brain, eyes and facial area which will cause a frontal headache.
  • Hormones: drops in estrogen levels can cause a headache and are linked to migraines. For those that menstruate, you might find that right before your period when there is a drop in estrogen you have headaches. For those who are perimenopausal or menopausal you may struggle with headaches due to lack of estrogen production.
  • Eye strain/screen time: Making your eyes work too hard whether from too much screen time or not wearing your glasses makes the eye muscles contract too much activating the pain receptors in that area. It’s important to take breaks from screens periodically and always wear your glasses. It’s also important to have regular eye exams to ensure that your glasses prescription is up to date if applicable.
  • Elevated blood pressure: this gives an all over pounding pulsing headache.

Types of headaches

  • Migraine: A migraine is a headache that can cause severe throbbing pain or a pulsing sensation, usually on one side of the head. It’s often accompanied by nausea, vomiting, and extreme sensitivity to light and sound. Migraine attacks can last for hours to days, and the pain can be so severe that it interferes with your daily activities.
  • Tension: most common in children and young adults (and school nurses!), caused by the muscles in the head and neck tensing up and activating the pain receptors. Tension/stress headaches usually feel like a squeezing or pressure, pounding, generally constant and all over the head or radiating down the neck. While uncomfortable these headaches are not dangerous. They can generally be relieved by over the counter medications like Ibuprofen, Acetaminophen or Naproxen.
  • Cluster: Cluster headaches, which occur in cyclical patterns or cluster periods, are one of the most painful types of headache. A cluster headache commonly awakens you in the middle of the night with intense pain in or around one eye on one side of your head. Bouts of frequent attacks, known as cluster periods, can last from weeks to months, usually followed by remission periods when the headaches stop. During remission, no headaches occur for months and sometimes even years.

Assessment

When a student complains of a headache at school you will need a little bit of information about what’s going on so you can decide how to adequately treat their symptoms.

  • Where does it hurt exactly? This can help you pinpoint better what type of headache they are having and if it might be related to poor vision, not wearing glasses, new onset of a cold, or maybe ear pain mistaken for headache pain.
  • What were you doing when it started? Were they in a loud room? Straining to see the board in class? Getting ready to take a test or do a task they don’t want to participate in? Doing strenuous physical activity? Is it superficial pain from a new injury?
  • Are there any cold symptoms or fever present? We know that nasal and sinus congestion can cause a headache, and a fever will very likely cause a headache also. Definitely check a temperature to be sure.
  • Does the student have a history of headaches or migraines? If they have a history of headaches or migraines you may already have an action plan for them to treat their headaches.
  • Does the student have a recent history of head injury or concussion? If they are post-concussive they are likely to suffer from headaches for a few days or weeks. You should have an action plan of some sort for this already.
  • Has the student eaten or drank fluids today? if so what fluids? As we know now, not eating and dehydration are our biggest culprits for headaches. If the only fluids they had today was soda or coffee then they could still be dehydrated because caffeine dehydrates you (even though it can also help a headache, it could also cause the headache).
  • Are they on any medications or had any medication changes that might cause headaches? Some medications can cause headaches such as SSRIs like Zoloft when first started. Others like Adderall or ADHD stimulants can raise blood pressure causing a headache as well. Additionally, you want to make sure they haven’t already taken something that would interact with medicine you might give them.
  • Check a blood pressure: elevated blood pressures can cause a pounding headache, especially if they don’t normally have high blood pressures.
  • If applicable, is the person using alcohol or illicit drugs and are they possibly hungover?

What can you do about headaches at school?

  • W.O.W: Water, Oxygen, Wait. have the student drink some water – like 8 ounces or more. have them sit down and take about 10 slow deep breaths. have them wait about 30 minutes and see if things have improved or not.
  • Hydration: The student needs to be sure to drink lots of water. Alternatively, Gatorade/Powerade, sports drinks and juice with sugar in it can help with hydration. It also helps to have a little bit of salty food along with the water (assuming it’s not blood pressure related) because water follows sodium so you will retain the fluids if you add a little salt (that’s why Pedialyte tastes like salty juice)
  • Eat a balanced meal: They need to eat! A balanced meal that includes vegetables/fruits, carbs, and something with sodium and potassium would of course be ideal but anything will do even if it’s just crackers.
  • Have them lie down in a quiet dark room for a bit and relax. You can even show some deep breathing or meditation techniques for relaxation.
  • OTC meds: Try Ibuprofen or Acetaminophen as directed by standing orders and/or parents permission. You want to know if they have already had any other medications like Dayquil, Ibuprofen or Acetaminophen already so they don’t accidentally have too much. make sure they don’t have an allergy to those medications. make sure you have appropriate consent to give those medications. If the student has an empty stomach be sure to have them eat something along with these meds to avoid upset stomach.

When do you need to worry about a headache?

  • Thunderclap headache: a sudden onset of severe head pain not associated with a new injury. It is indicative of aneurysm rupture or bleeding in the brain and you should call 911.
  • Headache accompanied by extremely stiff neck and fever: this is indicative of possible meningitis and needs to be addressed immediately.
  • Headache associated with loss or change of consciousness: This can be indicative of many things such as a stroke, a head injury, or an aneurysm rupture. This is an emergency and you should call 911.
  • Headache associated with head/neck injury: A severe head injury or neck injury should be addressed emergently.

Headache hacks

  • W.O.W as listed above: Water, Oxygen, Wait. have the student drink some water – like 8 ounces or more. have them sit down and take about 10 slow deep breaths. have them wait about 30 minutes and see if things have improved or not.
  • Salt: If attempting to hydrate have the person eat something like potato chips or pickles along with the water. As I mentioned, water follows sodium and their body will retain the fluids better with some sodium on board. Just be sure that headache isn’t related to high blood pressure as this will make blood pressure worse.
  • Tapping: There is tons of literature for EFT tapping for headache relief but in a nutshell sit in a quiet, dark room and with one or two fingers from each hand firmly tap 10 times above the eyebrow, on the temples, below the eyes, near the TMJ, then on top of the head. Repeat this cycle a few times while also trying to breathe and focus on the tapping. Here is the video I like for this: https://www.youtube.com/embed/htDzY6kmau8
  • Acupressure: take your thumb and forefinger and push them together. in the middle of that area there will be a slight bulge of muscle. Take your other and and squeeze that spot for a few minutes. There are devices that also help with this that look like a little clip that you put on there to give the pressure.
  • Ice: some people love a good ice eye mask or headache helmet. Personally I feel like it makes my headaches feel worse so I avoid but worth a try!
  • Peppermint oil or other menthol oils: mixing peppermint essential oil with a carrier oil and applying it to the temples can help with a headache. Also, inhaling any sort of menthol type of oil can help clear sinuses. This isn’t something for nurses to use at school though as there may be allergies or sensitivities to these items.
  • Horseradish. Not kidding! Just smelling it can clear the sinuses and open nasal passages. They even make a nasal spray with horseradish and cayenne pepper (I do NOT recommend unless you’re very brave because it kind of hurts a lot but it works!)
  • If you are a chronic migraine or headache sufferer like myself, you are probably willing to try literally anything to get rid of a headache. Here is an article outlining all sorts of things you could try: https://www.healthline.com/health/migraine-herbal-home-remedies-from-around-the-world#butterbur

https://www.lindora.com/faq/what-can-i-do-to-prevent-headaches-while-dieting-for-weight-loss/#:~:text=Low%20Sodium%20%26%20Potassium%20Can%20Cause,sodium%20levels%20get%20too%20low.

https://www.mayoclinic.org/diseases-conditions/tension-headache/in-depth/headaches/art-20046707#:~:text=It’s%20not%20a%20coincidence%20%E2%80%94%20headaches,in%20children%20and%20young%20adults.

https://www.brainfacts.org/ask-an-expert/if-the-brain-cant-feel-pain-why-do-i-get-headaches#:~:text=In%20some%20situations%2C%20chemicals%20released,migraines%20are%20considered%20vascular%20headaches.

https://my.clevelandclinic.org/health/diseases/9639-headaches

https://www.healthline.com/health/lack-of-sleep-headache#sleep-and-headaches

https://www.lindora.com/faq/what-can-i-do-to-prevent-headaches-while-dieting-for-weight-loss/#:~:text=Low%20Sodium%20%26%20Potassium%20Can%20Cause,sodium%20levels%20get%20too%20low.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5784553/

https://www.mayoclinic.org/diseases-conditions/chronic-daily-headaches/in-depth/headaches/art-20046729

Customer Service as a School Nurse

A school nurse recently posed a question asking how she can learn to better communicate with parents and staff in a school setting and the conversation of “customer service as a nurse” came up. Communicating with parents, students, and coworkers is a huge part of being a school nurse, and even as a nurse or healthcare worker in any aspect. Agree or not but we are in fact a service industry and we are highly trained professionals here to help other humans get through whatever issue it is they are trying to get through. Our job is to help people and meet their needs.

I’ve also somehow landed on the side of TikTok where people are posting about their perceived bad experiences with healthcare and what they think doctors and nurses are doing wrong and it’s driving me nuts! Doctors not giving the medicine they ask for or the tests they think they need or not admitting them for the issue they think they have. Some even mad because they think they aren’t being monitored correctly, or they see the nurse dealing with something like documentation and think they are “ignoring” them, or people who want to dictate their care based on poorly researched ideas. They have no idea what’s happening or they have an expectation based on their “research” and when it isn’t what they expected they are upset.

I am all for people advocating for themselves – everyone should educate themselves about their own treatment courses and know about what medications they are taking and tests they are being submitted to. Everyone has the right to refuse (most) things, and they have the right to ask all the questions they need to before agreeing to anything. It’s difficult because while Google may give you specific answers about what certain lab or test results might mean, the doctors and nurses are trained and educated for years to interpret those things specific to the patient and the situation so things might not be what they think.

My initial thought on that is “oh but they just don’t know how things work so they complain because they don’t understand” which is all true but also there’s so much more to unpack with that.

An amazing response from another nurse to the question of “how can I learn to communicate better?” was that people just want to know what to expect. This rings true on so many levels. This is exactly the key to good communication with your patients, families and coworkers.

Nurse Noah Wiggins summed this up so perfectly I had to share:

“This is an interesting topic. While I have only been an RN for about a year, I was in customer service and management for the automotive industry for many years. In fact, it’s part of why I chose to make the shift into nursing. I have always noticed the comparison of nursing and customer service. Sadly, when I have told fellow nurses and administration that in realty nursing and healthcare is basically a combination of Customer Service and Skilled Trades (the skill being the nursing) people often get offended. As if that somehow belittles their role or education. When in reality it is a very accurate analogy. We have to wear so many hats as nurses but at the end of the day that patient is our customer and if healthcare treated patients like customers that have a choice, they would receive much better care. All that said I will share something I learned in the auto industry that is use every day in my nursing practice from a man named Jeff Cowan. “People want to know what is going to happen, or what might happen. If they do, they will be completely satisfied.” If people know what is going to happen or what might happen, they can make plans. I cannot think of an industry that this is truer than healthcare. We cannot assume that people know what we know, and we have to realize that there is a lot of mistrust in the public for healthcare, that if we are being honest is justified in many cases. So, over communicate, advocate, educate, set a standard and expectation, empathize and do not get hung up on the tasks of nursing over the people. This is a people business, and they have to come first.”

I used to get so annoyed when I would read the Press-Gainey reviews and comments when I was an ER nurse and labor nurse. There were so many complaints about things that patients just didn’t understand – having to get stuck multiple times for an IV or blood draw, having to wait to be seen, not liking the diagnosis or lack of diagnosis.

We have to remember that they don’t know what we know! We need to explain what we know in a way that they can understand and in a timely fashion. When I was an ER nurse I was trained by some amazing nurses and one of the things I was trained to do was to explain EVERYTHING. We had a speil for all the different visits and procedures and proceeded to talk through everything we were doing.

Putting in an IV? Here’s how IVs work, here’s how this specific style of IV works, here’s why I may have to try multiple times, here’s why we need to give you two IVs, here’s why I can’t put the IV in your hand or antecube, here’s why I need to take multiple vials of blood.

In the ER for abdominal pain? These are the tests we will likely perform, here are the things we are looking for and ruling out, here is the reason you can’t eat right now and here is approximately when you will be able to eat, this is approximately how long the tests will take to come back, if we are extra busy or a CT scanner or X-ray room is down then it may take longer. We always informed them that often abdominal pain is difficult to get a solid diagnosis and you may be going home tonight with no answers but at the very least we can rule out the scary things and the surgical things then work from there.

When a patient was there for something critical and wasn’t able to be receptive to the explanations (PCI, stroke, trauma, etc), they often had family members who needed to know because they were scared and didn’t understand. We always had a nurse or sometimes the chaplain stand with the family member and explain what was happening. Can you imagine how you would feel if your loved one was seriously ill and everyone was running around doing things and you have no idea what anything means or what’s happening?

In general, people want to know what you are doing now, what you are going to do, when they can expect answers, and what kind of answers might they be getting. Honestly, just keeping them in the loop makes them feel seen.

So how does this apply to us as school nurses? Most parents want to know all the things. Even if they don’t remember specifics, have things in writing for them to refer to if needed or to present in the case of questions. They don’t know what they don’t know, and they often don’t know what we know.

  • Policies should be stated plainly and available in written form from the district/school.
  • Keep parents updated on changing policies such as Covid management and immunization recommendations.
  • Create newsletters explaining things like what happens if your child needs medicine at school? What happens if your child becomes sick at school? What happens if your child becomes injured at school? Present this information periodically and include it in registration info, back to school night presentations, kindergarten orientation, etc.
  • Call them. If you’re ever questioning if this issue requires a phone call or communication err on the side of caution and call them, text them, dojo message them, email them, whatever, just give them a heads up. I have messaged parents because their child came to me complaining that they have an invisible injury but I know that that child will go home and tell their parent they fell or got hurt and no one let the parent know. I’ve had my share of irate parents that weren’t informed of an issue because to ME it wasn’t concerning but to them it was.
  • Meet people at their own level. This calls back to “they don’t know what we know” as most of the people in your school don’t have the nursing training you have and don’t understand medical jargon. Speak to people with vocabulary they will understand. This also applies to parents and students who may not understand english well – learn what kind of translation services you can access to communicate appropriately. Assess learning level of students and parents – I’ve had parents that can’t read and I was sending home note after note that they couldn’t read. It wasn’t till I was at an IEP meeting for the student that I found out that the parent couldn’t read and I needed to be speaking with her directly because the notes were going unseen. Obviously students themselves are at varying age levels and levels of understanding so you would meet them at their educational level as well.
  • Never be condescending and speak to people like they are stupid. Again, they don’t know what you know, they are all at different levels of understanding and education. Uneducated about a specific topic does not equal stupid.
  • Encourage research into issues and provide resources to help them get the best information. Patients should be advocating for themselves and their care but they need to have the appropriate information to make the best choices.
  • If applicable, ask questions. You want to know from them what they know about the topic already, what are their concerns and questions about it, you might even want to know where they get their info because you could be speaking to a parent who is a pediatrician and is well versed in pediatric healthcare already but just doesn’t know our specific policies. You might want to make sure that there aren’t any cultural or religious concerns that you weren’t aware of as a reason for certain choices. I’ve found that most of the time people would prefer if you asked them sincere questions regarding their culture or religious practices instead of assuming things.
  • Listen and be empathetic. It’s not enough to just explain things, we need to listen to the patient/parent/student’s concerns and craft our responses with care.
  • Remember that it’s ok if you don’t know the answers to their questions. It’s ok to tell the patient that you don’t know but you will look into the concern and find the answer for them or point them in the direction of someone who may be able to better answer.
  • Always be kind. You don’t know what kind of day someone is having or what they are going through. There is no reason to be unkind or act irritated with someone’s needs. I know it can be difficult to NOT match energies with someone but try not to.

At the end of the day, we are in a customer service industry and we are here to help people. As Nurse Noah said, “do not get hung up on the tasks of nursing over the people. This is a people business, and they have to come first.”

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What is Commotio Cordis and Why Should a School Nurse Be Worried?

I’m sure everyone has heard of the devastating event with Damar Hamlin at the Buffalo Bills vs Bengals game last night. Damar took what appeared to be a not super hard shoulder to the chest during a play as probably happens a million times during a million football games but this time one was way more serious because he went into cardiac arrest almost immediately, collapsing on the field.

Because there are obviously trainers and medical personnel present, they identified cardiac arrest and began CPR almost immediately, also utilizing the AED and shocking him on the field. They were able to get a heart rhythm back and get him to the hospital for further treatment but he is presently in the ICU. The world is praying for a good outcome for this young, healthy athlete.

So what happened? The speculation regarding this event is that he suffered from something called Commotio Cordis (comm-OH-shee-oh COR-diss) which is a cardiac arrest after a blow to the left chest at the exact second the heart is entering the T-wave portion of the electrical impulse. The reasoning for assuming this diagnosis is that he took the shoulder to the chest and then almost immediately dropped on the field. He is a healthy, young man with no existing conditions, cardiac or otherwise, that would give concern for a cardiac event.

I will preface the further information by stating that I am NOT a cardiac nurse by any means so when I heard this was the probable diagnosis I had to start researching. I remember learning about this in nursing school and during my emergency trauma training but I didn’t remember the specifics. I remembered learning about this when I was a medical assistant in pediatrics and one of the doctors experienced a similar event while working as a medical consultant for a Little League baseball game when a young player took a pitch to the chest while not wearing a chest pad.

So what is Commotio Cordis? In a nutshell, a person receives blunt force trauma to the left chest during the exact moment that the T-wave is beginning causing an interruption in the cardiac repolarization of the ventricle thus scrambling the electrical impulse causing depolarization instead and causing the heart to go into ventricular fibrillation (v-fib) which is a non sustainable cardiac rhythm.

As we’ve all learned from nursing school and BLS/ACLS training, v-fib leads to cardiac arrest and v-fib is a shockable rhythm. This is why it is so incredibly important to have a working AED available, especially during any sports, PE class, or even recess where kids are playing and running around. It is equally as important for people (including students) to have BLS training because the sooner you start perfusion the better the outcome will be after cardiac arrest.

Commotio Cordis (CC) is most commonly associated with baseball/softball players as they run the risk of being hit directly in the chest with a fast moving ball. Additionally it is associated with hockey puck, lacrosse ball, soccer balls, cricket balls, and hockey sticks as they all have the likelihood of a fast moving direct hit to the chest. Also, any blow to the chest from a tackle, a punch (boxing, MMA fighting, martial arts), or even car accident can also cause CC.

Commotio Cordis treatment includes:

  • Rapid recognition of cardiac arrest
  • Immediately beginning CPR/chest compressions
  • Call EMS
  • Retrieve AED and defibrillate as soon as possible.

Can it be prevented? Yes, if proper safety precautions are taken then it can be prevented or treated quickly. Following these steps will help:

  • Have an athletic trainer present at practices and games
  • Educate coaches, parents, and athletes how to perform CPR and use an AED
  • Educate coaches, parents, and athletes of signs of commotio cordis
  • Have an AED accessible near playing fields at all times
  • Ensure coaches know where to locate the AED
  • Ensure there is an Emergency Action Plan in place
  • Ensure protective equipment is properly fitted
  • Teach athletes how to avoid being hit with a ball/puck
  • Avoid strength disparities among participants and coaches
  • Use safety baseballs

So why should a school nurse be worried about this? While it is fairly rare (less than 30 cases reported per year) it is always a possibility during any kind of physical activity that could cause trauma to the chest. Along with sports trainers and coaches, PE teachers, and anyone supervising physical activities and sports, we should be ensuring that people have CPR training and there are working AEDs accessible in the building. It is important that students are also educated in sudden cardiac arrest, CPR, and AED usage as there have been cases where it was the young student that saved another student or staff member’s life because of their fast thinking and knowledge of CPR.

As the school nurse be sure to consider what is the person wearing? Football pads? Baseball pads? How will you get through those to begin CPR? My suggestion for the fastest way is either trauma shears (keep them with the AED) or begin CPR with the pads on (make sure you’re giving GOOD compressions) and then cut off the clothes when the AED arrives.

Make sure there is a plan in place in the case of sudden cardiac arrest and that those present know their role and how to access the needed equipment and help. Ensure that AEDs are marked clearly and that everyone knows where they are, make sure there is someone who knows how to do CPR present. Every second counts, the longer everyone is debating what to do the longer the patient is without perfusion. Immediate CPR gives the better outcomes.

Here are some visual explanations of Commotio Cordis:

Case of Commotio Cordis

https://ksi.uconn.edu/emergency-conditions/cardiac-conditions/commotio-cordis/

https://www.ncbi.nlm.nih.gov/books/NBK526014/#:~:text=Commotio%20cordis%20plays%20a%20distressing,although%20it%20is%20increasingly%20recognized.

https://www.ahajournals.org/doi/full/10.1161/circep.111.962712

https://www.ncbi.nlm.nih.gov/books/NBK526014/

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