1. Minimal Recommended Screening Schedule (Table)

 

This minimal schedule for screenings is based on recommendations by experts in their respective specialty. Screenings may certainly be performed more frequently. Of greatest importance is accurate screening and rescreening procedures, identification of problems, referral and follow-up, and ongoing surveillance to assure the student's problem has been received the necessary intervention and treatment.

SCREENING

PreSch (3-4 yrs)

K

1

2

3

4

5

6

7

8

9

10

11

12

VISION (1)

X

X &/

or X

X

X or

X

X

COLOR VISION (2) (once only)

X or

X or

X

(or new student not previously screened)

AUDIOMETRY (3)

X

X

X

X

X

X or

X

X

ACOUSTIC IMMITTANCE (4)

X

X

X

X

X

HEIGHT & WEIGHT (5)

X

X

X

X

X

X

X

X

X

X

X

X

X

X

SCOLIOSIS (6)

Girls: grades 6 and 8; Boys: grade 8 or 9

X

X

X

BLOOD PRESSURE (7)

Assessment is recommended from age three through adolescence. When instituted in the school setting, the School Nurse must include resources for counseling, referral, and appropriate follow-up care if elevated pressures are detected.

ORAL HEALTH (8)

X

X

X

X

X

X

X

X

X

X

X

X

X

X

Students with problems are screened at any time. New students are screened upon entrance unless recent health screenings and their results are received from their former school. Any screening can be performed by request of student, parent/guardian, teacher and other staff. Students with special needs require annual assessment screening.

*RECOMMENDED BY EXPERTS IN THEIR RESPECTIVE SPECIALTY: (1) National Society to Prevent Blindness (2) National Association of Schoo Nurse, Inc. (3) American Speech-Language-Hearing Association (4) American Speech-Language-Hearing Association (5) American Academy of Pediatrics (6) American Academy of Orthopaedic Surgeons (7) National Hearth, Lung and Blood Institutes' Task Force on Blood Pressure Control in Children (8) American Dental Association .

2. Vision and Color-Vision Screening

Nebraska Law 79-248

Pupils; physical examination; notice of defects; contagious or infectious disease; duty of school district. Every school district shall cause every child under its jurisdiction to be separately and carefully inspected, except as otherwise provided in this section, to ascertain if such child is suffering from (1) defective sight or hearing, (2) dental defects, or (3) other conditions as prescribed by the Department of Health and Human Services Regulation and Licensure.

Nebraska Law does not include specifications on the requirements for a vision screening. The Guidelines are based on recommendations from national organizations listed in the references at the end of this sections .

Vision appraisal should include a test for visual acuity using an age appropriate assessment tool.

The following vision testing procedures are recommended (if resources permit):

-- near vision - plus lens test,

-- muscle balance,

-- accommodation and

-- convergence

-- distant

-- color

A. Age/Grade for Vision Screening

In general, all children should be screened periodically throughout their preschool and school life. As a minimum, the National Society for the Prevention of Blindness (NSPB) recommends the following schedule:

-- Preschool (3 or 4 years)

-- Kindergarten and first grade (5 or 6 years)

-- Third grade (7 years)

-- Fifth grade and/or sixth (10 or 11 years)

-- Ninth grade (13 years)

B. Special Cases

In addition to this screening schedule, the following children should also be screened even if not in grades scheduled for screening:

-- All new students

-- All teacher referrals of children who exhibit signs and symptoms of visual problems, experience scholastic failure, or have reading difficulties or other learning problems (among them dyslexia)

-- All children at high-risk of having vision disorders due to a medical or education component should have a thorough professional eye exam

-- All students experiencing head trauma

C. Re-screening and Referral

A second appraisal of vision should be conducted by the school nurse for all students who fail the initial vision screening test. Students failing the second screening test need to be referred for definitive professional evaluation. Criteria for test failure is based on National Society for the Prevention of Blindness (NSPB) recommendations.

Criteria for referral based on the Snellen test for distance vision are as follows:

3 year olds:

Vision in either eye of 20/50 or poorer (or equivalent measurement*). This means the inability to identify correctly one more than half the symbols on the 40-foot line on the chart at a distance of 20 feet. A two-line difference in visual acuity between the eyes in the passing range, i.e. 20/20 in one eye and 20/40 in the other also constitutes cause for referral.

3 year olds are eligible for a free vision exam by a participating Eye Care Council eye care professional through the SEE TO LEARN® program. The SEE TO LEARN® is a preventative health program designed to ensure that children entering school can see to learn. To locate participating Eye Care Council doctors in your area, call 1-800-960-EYES or visit the Eye Care Council Website at www.eyedr.org/see-to-learn.html.

All other ages/grades:

Vision in either eye of 20/40 or poorer (or equivalent measurement*). This means the inability to identify correctly one more than half the symbols on the 30-foot line at a distance of 20 feet. A visual acuity of 20/20 for children of all ages is considered excellent. However, visual acuity of 20/40 is a practical referral level.

*The ideal distance for vision screening is 20 feet; at this distance light rays are nearly parallel as they enter the eye, so the eye requires minimum accommodation to focus the rays on the retina. If screening is done at a distance other than 20 feet with the appropriate chart, e.g. a 10-foot chart is used due to space limitations or age of child, an equivalent measurement should be used. Since 20/x is better understood as a common referral point, it is best to convert other visual acuity results to a 20/x format. Divide the numerator into 20 and multiply the denominator by the result. For example, to find the 20/x equivalent for 10/30, first divide 10 into 20, which equals 2. Then multiply the denominator (in this case, 30) by 2, for a product of 60 or 20/60.

A Vision Report Card© is available at the end of this section to assist teachers, parents and the eye care professional in the referral process.

D. Near Vision Test

It is sometimes urged that a visual acuity near point test be included in school vision screening procedures because so much reading at this distance is necessary in school. However, the NSPB states that authorities agree that a plus lens test of central distance vision is a more reliable indicator of a child's ability to accommodate for near vision tasks than a near vision test.

This plus lens test should only be administered to children who pass distance visual acuity screening. Although visual acuity near point test cards are useful for quick screens in special situations (e.g. following trauma to the head), the near vision test with cards held at a distance of 14 or 16 inches is not recommended by NSPB as a routine procedure.

Because vision screening equipment may vary from school to school, use the directions for hyperopia screening as described in the manual accompanying your equipment.

E. Signs of Possible Eye Problems

All children observed during the screening who have any of the complaints or behavior listed below, regardless of screening results, are referred for a professional exam.

• One eye turns in or out (at any time)
• Reddened or encrusted eyes or lids
• Blinks excessively during reading
• Squints to see chalkboard
• Covers one eye to see
• Tilts or turns head to see
• Holds work excessively close to see.
• Complaints of:
  • Headaches
  • Nausea
  • Dizziness
  • Blurred vision (far or near)
  • Broken or missing glasses

F. Children Wearing Glasses or Contacts

The need for referral of children who fail the visual acuity test with their present correction should be based on

-- date of last examination; with knowledge of best possible correction if known

-- observation by parent, teacher and screener, and

-- schedule of re-examinations recommended by the eye care specialist.

COLOR-VISION SCREENING

About eight percent of males and less than one percent of females have faulty color perception from birth. The degree to which a person may possess abnormal color-vision ranges from slight difficulty in recognizing shades of color to complete loss of color-vision.

A. Age/Grade for Color-Vision Screening

A test of color-vision using pseudoisochromatic plates will be done once only -- preferably at kindergarten or first grade, if it has not been done at preschool level, and also if the student has no record of a color-vision screening.

B. Referral

There is no cure for color-vision defects so referral to a vision care specialist is not usually indicated. However, education and counseling of the student and parent is important. The school nurse's verbal contact with the parent/guardian should be followed by sending home informational material on color-vision deficiency, particularly if the parent/guardian is unfamiliar with this condition. Teachers should be counseled regarding the educational implications of color-vision deficiency and how this condition can affect all areas of a person's life.

At this point in the Screening Process, refer to the "Structure, Process and Outcome Criteria" as outlined in the Introduction to this section

3. Hearing Screening

The screening protocol for a hearing screening program in schools as recommended by the American Speech-Language-Hearing Association (ASHA) should consist of

-- visual inspection,

-- pure-tone audiometry, and

-- acoustic immitance ( tympanometry)

This combination would avoid excessive over referral rates.

It is beyond the scope of a screening program to obtain a complete case history on every student screened. However, it is important to know the case history of students with special ear problems.

Overall external visual inspection of the student's ears is a natural occurrence prior to screening.

Otoscopic inspection is a helpful adjunct to the overall assessment of the student's ears. The school nurse who becomes adept at the use of the otoscope will be able to view structural defects, ear-canal abnormalities, and eardrum abnormalities requiring immediate medical referral.

Screening tests are not diagnostic. They merely identify students who may need further attention by a primary caregiver or hearing specialist.

Audiologists are available in some schools for consultation and assistance with hearing programs.

AUDIOMETRIC SCREENING

ASHA defines the primary goal of identification audiometry as the use of pure-tone air conduction testing to identify students who have hearing loss that potentially interferes with communication.

Equipment should be calibrated according to manufacturer and ANSI S3.6-1996 specifications. Perform a listening check daily to determine that no defects exist in major components.

A. Age/Grade for Audiometric Screening

Individual limited-frequency screening should be administered annually to children functioning at a developmental level of 3 years through Grade 3 and to any high-risk children including those above Grade 3.

It is recommended that preschoolers (3 to 4 years of age), kindergarten, first, second, third, fifth and/or sixth and ninth or tenth grade students be screened annually.

B. Special Cases Audiometric Screening

In addition to the above screening schedule, the following children should also be screened:

--All new students and transfer students

--Students with known hearing loss and/or failed previous screenings

--Academic and/or behavior problems in the classroom

-- Speech patterns suggesting hearing problems

--Students referred for special education

-- Students who repeat a grade

-- Health histories of high risk factors for hearing problems including students with a history of exposure to noise

-- Students referred by school personnel, parent, or student self-referral

School-age children who receive regular audiologic management need not participate in a screening program

C. Screening

The ASHA Guidelines for Audiologic Screening ( 1996) recommend conducting screening in a manner congruent with appropriate infection control and universal precautions.

Conditioned play audiometry (CPA) or conventional audiometry are the procedures of choice.

Conduct screening in a quiet environment with minimal visual and auditory distractions.

Conduct screening using earphones at 1000, 2000, and 4000 Hz tones at 20 dB HL.

ASHA currently does not recommend 3000 Hz, 6000 Hz, or 8000 Hz as screening frequencies.

Pass if responses are judged to be clinically reliable at criterion dB level at each frequency in each ear.

If a student does not respond at criterion dB level at any frequency in either ear, the student should be reinstructed, earphones repositioned, and screened again in the same session .

All hearing screening programs should include an educational component designed to provide parents with information, in lay language, on the process of hearing screening, the likelihood of their child having a hearing impairment, and follow-up procedures.

D. Re-screening

All students failing the initial individual pure tone screening should be rescreened and assessed utilizing otoscopic and/or additional acoustic immittance within a 3 - 4 week period of the initial screen and a medical referral if indicated.

Refer students who fail the screening or fail to condition to the screening task for an audiologic assessment.

Refer for medical examination of the ears if:

• ear drainage is observed,
• visual identification of previously undetected structural defect(s) of ear occurs,
• ear canal abnormalities such as obstruction, impacted cerumen or foreign objects, blood or other secretions, stenosis or atresia, otitis externa, and perforations or other abnormalities of the tympanic membrane are apparent.

Hearing status of referred students should be confirmed within one month, and no later than 3 months, after initial screening.

F. Annual Audiometric Rescreening

All students with previously identified hearing losses will need annual threshold pure-tone audiometric tests. These usually include students with:

-- A family history of hearing impairment

-- A history of temporary hearing loss, tinnitus, or prolonged exposure to firecrackers, firearms, loud farm machinery, or loud music

-- Speech, language, and communication problems

-- Identified losses with no known cause

ACOUSTIC IMMITTANCE SCREENING

The tympanometer provides acoustic immittance screening by objective measurement of middle ear mobility (compliance) and pressure within the middle ear system. This test helps in identifying students with potential medically significant middle ear disorders that have been undetected or untreated.

Immittance screening is not intended to be a diagnostic procedure; nor is isolated immittance screening advocated by ASHA. Otoscopic exam is a prerequisite to acoustic immitance screening.

The acoustic immittance instrument should be properly maintained and checked annually to make sure it complies with the current ANSI standards for aural acoustic immittance instruments (ANSI S3.39-1987).

A. Age/Grade for Acoustic Immittance Screening

The Importance of Acoustic Immittance Screening for All Students

If time permits and equipment is available, all students at any grade level selected to receive audiometric screening can also receive acoustic immittance screening. Ultimately this screening can yield invaluable information, thereby enhancing the overall hearing screening findings on any child.

M iddle ear problems are most apt to occur in the younger child. Therefore , it is recommended that preschoolers (3 to 4 years of age), kindergarten, first, second, and third grade students receive an annual screening,

Note: ASHA guidelines state that when otoscopic evidence of middle ear infection is present or when a pressure-equalization tube is in place, tympanometry should not be performed unless requested by a physician

B. Screening

Assistance in understanding and learning how to perform acoustic immittance screening is available from school audiologists, experienced school nurses, and private providers. In addition, the School Nurse should be sure to:

• Utilize the operating instructions provided with the tympanometer equipment.
• T est both ears each time the student is screened.
• Read the manual which accompanies the tympanometers, especially the information regarding normal and abnormal test results.

C. Re-screening and Referral

ASHA guidelines for re-screening and referral are as follows:

Refer for rescreening if:

-initial tympanometric screening test results are outside of test cutoffs

(Peak Admittance (Y tm) <0.3 mmho or Tympanometric Width (TW).>200daPa)

The ASHA guideline recommends that a child with unilateral or bilateral tympanogram meeting referral criteria other than those that are consistent with a TM perforation should be rescreened 6 - 8 weeks after the initial test. Because middle ear disease is often self-limiting, referral based on a single screening is generally not recommended.

Refer for medical examination of the ears if:

• ear drainage is observed,
• visual identification of previously undetected structural defect(s) of ear occurs,
• ear canal abnormalities such as obstructions, impacted cerumen or foreign objects, blood or other secretions, stenosis or atresia, otitis externa, and perforations or other abnormalities of the tympanic membrane are apparent,
• tympanometric equivalent ear canal volume (V ec ) is greater than 1.0cm 3 accompanied by a flat tympanogram (i.e., there is no admittance peak) to select those at risk for TM perforation,
• follow-up tympanometric screening (i.e., rescreen) test results are outside the test criteria (Peak Admittance? >200daPa)

Do not refer if tympanostomy tube is in place or a perforation of the TM is under management of a physician .

For more accurate interpretation of screening results which warrant a referral, become familiar with normal and abnormal test results as described in your instrument manual, review and compare your screening print-outs, consult with an audiologist, and study the literature.

At this point in the Screening Process, refer to the "Structure, Process and Outcome Criteria" as outlined in the Introduction to this section.

4. Height & Weight Measurement

The measurement of Height and Weight is an important part of assessing whether the student's growth and development is progressing normally.

The measurements are not diagnostic, but such measurements are useful for identifying children that are short or tall for their age and under or over weight for their height.

Height and Weight measurement can also provide a partial portrait of a student's state of health and wellness. The evaluation of growth is an important part of assessment at all ages but even more so at adolescence when the normal variation in the timing of pubescence and the accompanying growth spurt require more sensitive assessment than in childhood. The student's height and weight record allows the student, as well as the parent and teacher, to see the changes in growth and development.

A. Age/Grade for Height and Weight Measurement

The American Academy of Pediatrics (AAP) recommends students be weighed and measured annually. Weighing and measuring more than once each school year should be determined on the basis of need of individual children, the use that is to be made of the additional information, and the time available.

B. Measurement of Height and Weight

The School Nurse may delegate the weighing and measuring of students to an assistant or volunteer making sure that the appropriate procedure guidelines are used.

The AAP recommends that weight should be taken on a standard beam balance, calibrated at least annually for accuracy.

Standing height, without shoes, should be measured against a steel measuring tape, or similar device such as an accustat stadiometer. A measuring rod on a platform scale is inaccurate for measuring height. Accurate measurement is of no use unless it can be compared with previous measurements of the same child and measurements of normal children of the same age. This is accomplished by appropriate use of growth charts prepared by the National Center for Health Statistics (NCHS) from cross sectional data. If charts are not available on the student health record, they may be obtained from various pharmaceutical companies

C. Re-measurement

If there is any concern about a child's height and weight, measurements should be obtained every three to four months until the child's pattern of growth or weight becomes clear.

D. Referral

The AAP recommends close attention to students who have weight problems.

Children who lose excessive weight, show no gain, gain excessively, or have a great variance between their height and their weight need close assessment and require follow-up. Investigate carefully by questioning the student and parent/guardian to determine if a referral to their health care provider is indicated.

The basic guideline for referral to the health care provider relating to weight for height status (under weight or over weight in relation to their height) is:

Any child whose weight for height ratio differs by greater than two centile lines on the NCHS growth grid. Stress referral when weight is less than the 5th percentile or greater than the 95th percentile.

Growth spurts during pubescence and early puberty are normal; therefore, the AAP states that a growth cessation during these years should not be ignored. The AAP further states that growth of less than two inches a year at any age should be investigated by the child's primary care physician.

Two basic guidelines for referral to the health care provider relating to delayed growth are:

-- Any child whose height is below the fifth percentile or above the 95th percentile on the NCHS growth grid.

-- Any child whose height is deviating from an established growth curve (crossing centile lines), regardless of height on the NCHS growth grid.

--Tall stature is rarely of as much concern as delayed growth; however, a child who is growing at an abnormally fast rate needs medical attention.

At this point in the screening process, refer to "Structure, Process, Outcome Criteria" as outlined in the Introduction to this Section.

Immunization

IMMUNIZATION ASSESSMENT

The School Nurse or designated school personnel will ensure that all students enrolled are in compliance with the Nebraska Administrative Code, Title 173, Chapter 3, Rules and Regulations (79-444.01, 79­444.03, 79-444.06 to 70.444.08).

RATIONALE

To minimize the number of preventable communicable diseases, the legislature has enacted these laws regarding the immunizations required for school attendance. All students enrolled in any public or private school throughout the state must meet these requirements. The nurse is the appropriate person to review, evaluate, and oversee compliance of the immunization statutes.

STRUCTURE CRITERIA

The state immunization requirements are as follows:

-- at least 3 doses DtaP,DT orTd vaccine, one given no earlier than 4 days before or after the 4 th birthday

-- at least 3 doses of polio vaccine

-- 2 doses measles, mumps, and rubella (MMR) given no earlier than 4 days before twelve months of age and separated by at least one month

1. Three doses of Hepatitis B vaccine

Varicella immunization is being phased in beginning with the 2004-2005 school year. Varicella will be included as a required vaccine in each subsequent grade as the child progresses from kindergarten (1 st grade) or 7 th grade through the remaining grades.

The number of doses for varicella is dependent on the age of the child - 1 dose of varicella vaccine before the 13 th birthday; or 2 doses of varicella vaccine administered at least 28 days apart if the first dose was given on or after the 13 th birthday.

2. The law provides for provisional admission when immunizations have been given appropriately, and the student is in a waiting period for the next required dose.

3. Exemption from the immunization requirements are limited by law to the specific circumstances listed below:

CONTRARY TO RELIGIOUS BELIEFS - Requires a signed affidavit from the student or, if a minor, from their legal representative that states the immunization conflicts with their religious beliefs.

MEDICAL CONTRAINDICATION - Requires a signed statement from a

licensed physician which states the required immunizations would be injurious to the health and well being of the student, or a member of the student's family or household.

4. The School Immunization Record will be maintained as part of the permanent mandatory record.

PROCESS CRITERIA

The School Nurse provides inservice education to designated personnel.

The School Nurse and/or designated personnel:

1. Review records to assess the immunization status of all entering and currently enrolled students.
2. Notify parent/guardian of the immunization status of the student, providing the optimal recommended immunization schedule.
3. Provide necessary information to the parent and or guardian of those students who are not in compliance.
4. Subsequent to parent notification of requirements, assure the student complies with the next required dose.
5. Exclude -- upon the school administration's authority -- those students who have not received the required immunizations.
6. Readmit excluded students as they meet requirements.
7. Record all immunization data, updating records as necessary.
8. Exclude exempted students in the event of an outbreak, as directed by the public health officer.
9. Complete NEBRASKA HEALTH AND HUMAN SERVICES immunization survey and submit by November 15 annually.

OUTCOME CRITERIA

1. Student immunization records will be complete and accurate and will reflect compliance with state laws.
2. Students attending school will be optimally protected from the preventable communicable diseases.

IMPORTANT RESOURCE The Red Book, Report of the Committee on Infectious Diseases. (2003). Elks Village, IL. American Academy of Pediatrics.

5. Scoliosis Screening

Screening for scoliosis (lateral curvature of the spine) in schools is recommended by the American Academy of Orthopaedic Surgeons (AAOS), the National Scoliosis Foundation, and The Scoliosis Association, Inc.

The screening procedure includes observing for

-- kyphosis (round back deformity of the spine) and

-- lordosis (sway back deformity of the spine).

A. Age/Grade for Scoliosis Screening

Minimal screening, as recommended by the AAOS, should include

-- girls twice, at 11 and 13 years of age (grades 6 and 8), and

-- boys once, at age 13 or 14 (grades 8 or 9).

The National Scoliosis Foundation, Inc. recommends screening annually in grades 5 through 10. As of February, 1990, twenty-one states require postural screening for spinal curvatures at various grade levels within the 5 through 10 grade span.

The Nebraska Health and Human Services School Health Advisory Committee recommends that at least the minimal screening as advised by the AAOS be carried out in each school and would further recommend screening 5th grade girls due to earlier onset of menses in today's young women.

B. Special Cases

In addition to the screening schedule adopted by a school, any child may be screened for spinal curvatures at any grade level at the request of the parent/guardian, school personnel or student.

Children with special needs who are prone to orthopedic problems, e.g. a child with Down's Syndrome, should be screened annually, regardless of age.

C. Screening

The screening procedure for scoliosis, as well as kyphosis and lordosis, includes viewing the student for trunk asymmetry from the front, side and back as well as in a forward bend position.

Since the student's back is exposed, as much privacy as can be afforded should be provided.

During the viewing process, the nurse should inquire as to the existence of a family history of back problems. The possibility of leg length discrepancy must also be a consideration. Use of a scoliometer is advised to measure the degree of rotation of an observed deformity and to measure possible curve progressions. Orientation to the correct procedure for screening and experience are vital to assure that a valid postural screening program is carried out.

D. Re-screening

Students with questionable findings should be re-screened in three to six months. It is advisable to place these students on a "watch" list for a given period of time dependent on the reassessment findings (that is, progression or non-progression of the earlier assessment).

E. Referral

Referrals for further evaluation by the family physician, pediatrician or orthopedic surgeon should be made on all students who are found to have:

1. Obvious spinal curvature.
2. Prominence on one side of the upper or lower back during forward bend test.
3. Scoliometer measurement of 7 degrees or more at any level of the spine.
4. Roundback which cannot be flattened with hyperextension of the head and neck.
5. Swayback which does not reverse or flatten on forward bending.
6. Other observed signs such as shoulder elevation, uneven or prominent scapula, unequal arm to body space, uneven waist creases, and hip elevation.

Referral Rate

The guidelines for a school screening program for spinal deformity available from the AAOS states that with experience the referral rate can be maintained at less than 3 percent overall which is no more than 4 percent of girls and 2 percent of boys.

The Referral Form

When referring a student, notify the parent/guardian by phone and send a written referral form detailing your findings and recommending that the student be examined in the near future. Briefly explain to the student and the parent the significance of the screening without causing undue anxiety and apprehension. Send explanatory written information with the referral.

Both scoliosis organizations publish pamphlets describing scoliosis, kyphosis, and lordosis which can be helpful to parents. At this point in the Screening Process, refer to the "Structure, Process and Outcome Criteria" as outlined in the Introduction to this section.

6. Blood Pressure Screening

Blood pressure (BP) variance in the child and adolescent is dependent upon a multitude of factors, both genetic and environmental, many of which are unknown. Several observations can be made as stated in the

Report of the Second Task Force on Blood Pressure Control in Children - 1987.

The Report's observations include:

-- BP increases with age during the pre-adult years. This occurs in all populations that have been studied, although the level and trend vary from population to population.

-- Larger children (heavier and/or taller) have higher BP than smaller children of the same age.

-- Obese children have higher BP than lean children.

Therefore, the level of a given child's or adolescent's BP must take into account the individual's body size as well as age. Height and weight should be used in assessing medical significance of BP judged to be high on age/sex-specific distributions.

A. Age/Grade for Blood Pressure Measurement

The Report of the Second Task Force on Blood Pressure Control in Children--1987 stresses the importance of BP surveillance of children by their primary health care providers and reinforces the recommendation of the American Academy of Pediatrics for annual routine BP measurements between the ages of 3 and 20 years.

Ideally, all students should have a BP measurement by the School Nurse each year.

When BP measurement of all students is not possible, as a minimum standard students at one or more grade levels should be selected for an annual BP measurement. A written policy should be established to assure this minimum standard is maintained. Of merit would be a consistent selection of one grade at elementary, middle, and upper levels.

B. Special Cases for BP Measurement

If only students at selected grade levels have annual BP measurements, other students with a known potential for hypertension should be screened.

These include:

-- Known past high blood pressure readings
-- Family history of hypertension
-- Headaches, dizziness, epistaxis, visual problems
-- Chronic fatigue or weakness
-- Urinary tract problems, e.g. frequency or nocturnal enuresis
-- Joint pain and swelling or edema
-- Current or ongoing stress problems
-- Use of tobacco and drugs
-- Nutritional problems
-- History of heart anomaly or disease
-- Other children with special needs, e.g. diabetes

C. BP Screening

Accurate and standardized BP measurement is essential to insure comparability of BP taken at various times by different health care providers in the school.

The School Nurse or designee, properly trained and supervised, obtains the BP of students and school personnel.

Appropriate equipment is crucial in order to obtain reliable BP readings of students and school personnel.

Cuff Size

Various arm sizes require the availability of appropriate-sized cuffs. An appropriate-sized cuff is essential for measuring BP accurately.

A Child-sized, adult-sized, large arm-sized and a thigh-sized BP cuff - each of which can be attached/detached to the manometer with ease -- should be available for use in the school.

References to cuff size apply only to the inner inflatable bladder rather than to the cloth covering. The inner bladder is usually significantly narrower and shorter than the cloth covering.

The width of the inner bladder of the cuff should encircle at least 40 percent of the arm, and the length of the cuffs inner bladder should encircle at least 80 percent of the arm.

When the BP cuff is in place, approximately 75 % of the upper arm between the top of the shoulder and the elbow is covered, leaving sufficient room both at the antecubital fossa to comfortably place the bell of the stethoscope and at the upper edge of the cuff to prevent obstruction of the axilla.

Note: The cuff name, e.g. adult, is no guarantee that the cuff will fit all adults. In general, selection of the proper-sized cuff will result whether circumference or width is used as a selection criterion.

If there is a question between two cuffs regarding appropriate cuff width ...

...use of the smaller width cuff may result in an artificially elevated blood pressure;

... whereas use of a slightly wider cuff than needed is unlikely to mask hypertensive levels of blood pressure.

Therefore it is best to select the largest cuff that will fit the arm.

MERCURY MANOMETER and ANEROID MANOMETER

The mercury manometer is considered the standard of accuracy.

However, the aneroid manometer is more commonly used.

It is recommended that an aneroid manometer be calibrated at least annually against a mercury manometer -- or more often, depending upon frequency of use.

Right/Left Arm

The right arm is recommended for routine measurement and for consistency between screeners unless there is an impeding physical condition.

When either the systolic or diastolic reading is greater than the 90th percentile for age in the right arm, the BP is also measured in the left arm.

In the Report of the Second Task Force on Blood Pressure Control in Children--1987, Korotkoff sounds, phases IV and V:

... K4 was used in the standards for infants and children 3 to 12 years of age, and

. K5 diastolic BP was used in the standards for adolescents 13 to 18 years of age.

If both phases are heard, record both, e.g., BP = 110/78/70.

D. Re -screening

Elevated BP measurements should be repeated at least two times at weekly intervals following the initial screening.

The level of a child's or adolescent's BP must take into account their height and weight, as well as age.

The Report of the Second Task Force on Blood Pressure Control in Children--1987 developed charts similar to growth and development grids to assist

An age and gender BP chart should be maintained as a part of a student's health record when BP readings are above the 90th percentile. This chart is used to track progression.

If the student is within the norm for his height and weight, the table below outlines the upper limits of normal BP (90th percentile) and high normal BP (95th percentile) in children by gender and age. This table can be used as a guideline to determine whether the student's BP is considered elevated.

Students at or above the 90th percentile for gender and age should have BP measurements repeated at three different times within one month to confirm baselines. Height and weight must also be a consideration.

Thereafter BP should be monitored every 6 to 12 months

 

	Age Blood Pressure (Girls) 90th - Percentile - 95th		Blood Pressure (Boys) 90th - Percentile - 95th
1	105/67/--	109/71/--	105/69/--	109/73/-­
2	105/69/--	109/73/--	106/68/--	110/72/-­
3	106/69/--	110/73/--	107/68/--	111/72/-­
4	107/69/--	111/73/--	108/69/--	112/73/-­
5	109/69/--	113/73/--	109/69/--	114/74/-­
6	111/70/--	115/74/--	111/70/--	115/75/-­
7	112/71/--	116/75/--	112/71/--	117/76/-­
8	114/72/--	118/76/--	114/73/--	118/77/-­
9	115/74/--	119/78/--	115/74/--	120/78/-­
10	117/75/--	121/79/--	117/75/--	122/80/-­
11	119/77/--	124/81/--	119/76/--	124/81/- ­
12	122/78/--	126/82/--	121/77/--	126/82/-­
13	124/78	128/82	124/77	128/81
14	125/81	129/85	126/78	130/82
15	126/82	130/86	129/79	134/84
16	127/81	131/85	131/81	136/86
17	127/80	131/85	134/83	138/87
18	127/80	131/85	136/84	140/88

E. Referral

Students with BP readings (systolic and/or diastolic) the average of which is greater than or equal to the 95th percentile for age and sex, taken on at least three separate occasions, should be referred to their medical care provider.

Referral to their medical care provider should be within 24 hours when a student's BP is very elevated, e.g., a systolic of 150 and a diastolic over 100.

A telephone conference with the parent/guardian is advisable prior to sending the written referral which includes all BP readings, dates obtained, and any pertinent health observations.

Over 18 Years of Age

For students or personnel over 18 years of age, The 1992 Fifth Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure recommends the use of the diastolic measurement of 90 mm Hg or higher and the systolic measurement of 140 mm Hg or higher as reason for recheck within one month and possible referral for medical evaluation. This measurement should be the result of at least two or more measurements and their average on two or more separate occasions. If the initial BP reading is markedly elevated, refer the results to the student's source of care immediately.

School Nurses should be familiar with the recommendations for measurement, follow-up and classification of blood pressures as described in the most recent Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure.

At this point in the screening process, refer to "Structure, Process, Outcome Criteria" as outlined in the Introduction to this Section.

7. Oral Health Screening

An Oral Health Screening is an appraisal activity and identifies individuals with pain or imminent pain. It also creates awareness about the importance of good oral health. Please note, an oral screening does not replace a regular dental examination by a dentist. Routine oral screenings will assist in securing every child dental services and education to prevent pain, infection, premature loss of teeth and/or malocclusion.

The Oral Health Screening Program is designed to preserve the health of children and provides a procedure whereby

1. a program in preventive dental hygiene is presented;
2. dental defects are discovered early so they can be corrected with the least amount of discomfort to the child;
3. early symptoms of oral disease may be detected and corrected;
4. irregularity of tooth position may be observed and preventive measures instituted;
5. referral for early treatment before problems become magnified will keep the cost of dental care to a minimum.

A. Age/Grade for Oral Health Screening

The American Dental Association recommends annual oral health screenings for every student. The Nebraska Health and Human Services, Dental Health Division, has screening tools available at www.hhs.state.ne.us/dental , If you need further assistance, please call (402) 471-1077.

B. Screening

Oral health screening is performed using a

-- tongue depressor -- disposable gloves -- flash light

-- Gauze pads may be helpful if the tongue needs to be manipulated.

An overall visual inspection is performed in order to view the outer and inner aspects of the oral cavity, including the

-- lips -- outer cheeks -- all inner tissues

-- floor of the mouth --tongue -- palate

-- oropharynx -- uvula -- teeth

When viewing the student's face and neck prior to the oral health screening, swollen and tender lymph nodes may be noted in the neck and/or jaw. If breath is highly odiferous, seek the cause. Also, observe the quality of the voice.

C. Symptoms for Referral (with or without screening)

1. Visibly decayed and/or fractured teeth, broken filling(s) and/or missing permanent teeth.
2. Toothache, swelling and/or bleeding gums.
3. Ulceration, lesions, inflammation or draining of oral mucosa, palate, tongue, gums.
4. Malocclusion, mal-position or supernumerary teeth.
5. Protrusion of upper/lower jaw; deviate swallowing (tongue thrust).
6. Leukoplakia (on tongue or cheek) in known tobacco user.
7. Broken or ill fitting orthodontic appliance.
8. Difficulty in eating -- e.g. chewing or swallowing of food.
9. Swollen or tender lymph nodes in neck and jaw.
10. Dental-related injuries obviously requiring treatment.
11. Unusual lip conditions such as fissures, drooping, or color (e.g. pale or bluish).
12. Nasal voice quality can suggest a health problem such as enlarged adenoids.

Statement on Use of Epinephrine (Epi-Pen)

Anaphylaxis is a life-threatening, rapid onset allergic reaction occurring in some students with severe allergies. Children who have known episodes of anaphylaxsis often are prescribed inject-able epinephrine in the event of an anaphylactic reaction. Since this medication must be used immediately in order to be effective, and the allergic reaction can be rapidly life-threatening, this policy delineates the regulations regarding these medications.

1. Epinephrine shall be in the form of pre-measured, auto-inject-able syringes prescribed for each student individually by his/her physician.

2. The parent/guardian must supply the medication and is responsible for making certain that the medication is in-date and the prescription current.

3. Written permission to administer the medication from the parent/guardian and written orders from the physician should be congruent with the aforementioned medication policy.

4. The School Nurse, if available, will administer the injection.

However, since this reaction may not occur when the School Nurse is in attendance (for example, bee stings on outdoor field trips, during physical education classes, or recess, etc. ), it is essential that the School Nurse review the use of auto-injectors with designated personnel. Auto-injectors are designed for use by non-medical personnel.

5. Immediately after administering the medication,

-- activate as a medical emergency (911)

-- notify the parent/guardian

Statement on Anaphylaxis at School

The AAP Committee on School Health recommends schools be equipped to treat anaphylaxis in children whether or not the student has a history of allergies since life-threatening anaphylaxis to a variety of agents (e.g., foods, stinging insects, and medications) can occur while at school.

Therefore, the AAP/Section on Allergy and Immunology made the following recommendations (February, 1993):

1. Prevention of exposure is of primary importance and requires close communication between school, family and medical authorities.

2. Treatment of choice is epinephrine subcutaneously.

3. Students with a history of anaphylaxis should have ready access to epinephrine. Preferably the student carries it.

4. In the absence of the school nurse, other school personnel should be taught to recognize anaphylaxis and to administer epinephrine in an emergency.

5. Legislation is needed in many states to provide a mechanism for certifying non-medical persons to administer epinephrine.

School Nurses in Nebraska may want to work with the district's school health advisory committee and/or a local physician to develop a protocol which addresses the treatment of the student without a prior history of anaphylaxis.

Competency Guideline for Delegation of Medications

 

Regulations Governing the Provision of Medications by Medication Aides and Other Unlicensed Persons (Title 172, Chapter 95) became effective July 1999. The Medication Aide Act allows, under certain conditions, unlicensed individuals to legally provide routine medications in designated settings, school being one.

Medications may be provided by unlicensed staff only when direction and monitoring is provided and documented by a licensed health professional or parent/caretaker. The Medication Aide Act requires that school staff members who provide medications must demonstrate certain competency standards. Competency must be documented in order for the unlicensed person to provide the specific activity for the individual student, and ongoing direction and monitoring must be documented . Primarily, school staff is responsible to provide the right medication to the right student at the right time in the right dose by the right route. The overall accountability for monitoring side effects, contraindications etc. related to the medication remain the responsibility of the parent.

This competency documentation and student specific record of medications provided must be maintained by the district for a minimum of two years or longer if directed by school policy. Non-prescription medications do not require licensed professionals statements. An Individual Healthcare Plan is recommended for these additional activities whenever a student has a complex health condition.

There is no specific training that is required either by statute or regulation. There is only an outcome requirement for competency demonstration. A suggested set of instructions may be found in APPENDIX B which includes competency standards, recommended curriculum, sample forms and sample overheads for use in the Medication Aide training.

Initial training of staff may require approximately 4 hours of classroom time while a refresher course may only require 2 hours of classroom time.

Frequency of training will depend on the route of administration and based on the judgement of the school health professional or parent/caretaker.

School Records: Access and Disclosure

THE FAMILY EDUCATIONAL RIGHTS AND PRIVACY ACT OF 1974

The Statute :

"No [federal] funds shall be made available under any applicable program to any educational agency or institution which has a policy of denying, or which effectively prevents, the parents of students who are or have been in attendance at a school of such agency or at such institution, as the case may be, the right to inspect and review the education records of their children." -- 20 U.S.C. S 1232g(a)(1).

Procedure after a Parent's (or Eligible Student's) Request for Access:

1 . District's policies must allow access within a reasonable time -- no longer than 45 days after request.

2. District is required to respond to any reasonable requests for interpretation or explanation of the records.

3. Policies must also allow procedures for a challenge of inaccurate, misleading or intrusive entries in the educational record.

What is an "education record"?

1. Any records that are directly related to a student, and are maintained by the educational agency or institution or by a person acting for the agency or institution.

2. The statute also defines records that are NOT "education records" subject to FERPA:

a. Notes (personal) "which are in the sole possession of the maker ... and which are not accessible or revealed to any other person except a substitute";

b. Certain documents used by law enforcement officials;

c. Medical records of a student who is 18 years of age or older which are made and used only in connection with treatment to the student, and which are available only to those providing treatment.

What must the authorization for release of information include?

1. written consent

2. from student's parents (or from "eligible student" 18 years old or older)

3. identifying records to be released

4. stating reason for the release

5. identifying the individual receiving the records.

NOTE: If a student is a 18 years old or older, Q if the student is attending a post-secondary institution, only the student (and NOT the parent) may authorize (permit) disclosure. However, the parents of a dependent over the age of 18 may review the educational records of their child without the child's authorization.

What must be done to document release of educational records?

1. Records must be kept showing when and to whom educational records are disclosed.

2. All educational records disclosed to third parties must be disclosed on the condition that the third party will not re-disclose the records without another consent form.

What are the exceptions to the rule requiring prior authorization for the release of educational records?

1. May disclose records to "other school officials" if the institution or district has identified the individuals entitled to review the records for legitimate educational interests."

2. May disclose to schools to which the student will transfer--parents must be notified of the transfer of records. Nebraska Revised Statutes, Section 79-­4,157.01, also provides for the transfer of a student's file to a school to which the student is transferring.

3. May disclose to certain governmental authorities for audit purposes.

4. May disclose in connection with the student's application for or receipt of financial aid.

5. May disclose to organizations conducting academic studies, or to accrediting organizations.

6. May disclose in the event of an emergency which is threatening the safety and health of the student or others.

7. May (and probably must) disclose in response to a subpoena or court order.

Again, all disclosures and the grounds therefore must be carefully documented.

Material developed by James L. Quinlan, Amy S. Bones and John M. Ryan for Confidentiality of Medical Records and Consent to Treatment, June, 1993.