Anaphylaxis is an extremely serious condition. It is an over-exaggerated response by the body to a substance to which a person is allergic.
All school staff should know which students have life-threatening allergies.
Symptoms of severe allergic reaction may include:
Management
Call 911 immediately if any of the following symptoms occur:
Follow the Emergency Action Plan for Severe Allergy to _____ (see page F-17).
Asthma is the leading chronic disease that affects children in Hawaii. It is one of the most common reasons for hospitalization, particularly for children. Caregivers of children often overlook asthma symptoms because common symptoms do not appear to be serious. Yet, symptoms like coughing after exercising or coughing at night can be an indication of a serious problem.
With asthma, the airways (the windpipes) are super sensitive or “twitch” (hyperactive). Asthma is a chronic condition, which means the individual will have asthma for a long time. When asthma causes disease, there are usually three problems:
This series of events can make it hard to breathe or may cause excessive coughing. Asthma is also called Reactive Airway Disease (RAD).
The terms “asthma attack” and “asthma exacerbation” mean the same thing: an acute breathing problem caused by asthma.
A trigger is something that causes or initiates an asthma episode. It can start an episode at the time of contact with the trigger or later. Once triggers are identified, some of them can be avoided so that the student doesn’t have asthmatic episodes. Sometimes the triggers cannot be avoided, but recognizing the trigger and warning signs allows treatment of the student at the earliest possible time. In young children, the most common trigger is a “cold” or viral upper respiratory infection. In other children, irritants or allergens can trigger asthma.
Some common triggers:
Other triggers:
| ALLERGENS |
|
|---|---|
| HEALTH CONDITIONS |
|
| MEDICATIONS |
|
| OTHER |
|
Recognizing the student’s symptoms early is important because they can be treated before they become severe. Common symptom’s include:
Prior to having an asthma “attack”, the child may have symptoms similar to the start of a cold. These may include:
Follow the Emergency Action Plan for Severe Allergy to___ (see page F-17), EpiPen Administration (see page F-18), and Request for Administration/Storage of Medication, Rescue Medication for Asthma (see page F-19).
Students with a history of breathing difficulties, including asthma/wheezing, should be known to all school staff. A health/emergency care plan should be developed.
Department of Health Public Health Nursing Branch and Emergency Medical Services Systems Branch, “Emergency Guidelines for Hawaii Public Schools”
(Refer to “Hawaii Students with Diabetes” –
Department of Health Public Health Nursing Branch.)
Diabetes is a chronic condition that prevents the body’s ability to use food (i.e., glucose) properly. Food is converted into energy for the body with the help of the hormone insulin. The student with diabetes usually has a pancreas that makes little or no insulin or the body (i.e., cells) develops resistance to the insulin. As a result, the body cannot properly use the food for energy, and blood sugar levels rise.
The main goal of diabetes management is to MAINTAIN THE TARGET BLOOD GLUCOSE. The key to optimal diabetes control is careful balance or juggling of food, exercise, and insulin and/or oral medication. As a general rule, insulin and exercise make the blood glucose levels go down. Food makes blood glucose levels go up. Several other factors, such as stress, illness, or injury, can also affect blood glucose levels.
ROUTINE CARE: The need for assistance with diabetes care tasks will vary from student to student. Many students will be able to handle all or almost all of their routine diabetes care by themselves. Some students will need help from school staff due to their age, developmental level, or inexperience.
The school PHN is the most appropriate person in the school setting to oversee the care for a student with diabetes. However, because the school’s PHN is not always available to provide direct care, the school staff can and should be trained to assist students in both routine and urgent care.
The school’s PHN should write an Individual School Diabetes Plan (ISDP) to identify the specific needs of the student and all the elements of routine and urgent care necessary to assist the student in school. This plan includes the EAP that addresses how to recognize and treat hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar). (See pages F-22 and F-23.)
The ISDP is implemented by the school diabetes team (School PHN, School Health Aide, student, parent, and other school personnel).
Students may not be able to help themselves and are dependent on others to recognize that they are experiencing low blood glucose levels, and also to know how to treat the condition. Left untreated, hypoglycemia can lead to unconsciousness, seizures, and may even be lifethreatening.
Hypoglycemia impairs cognitive and motor functioning. A student may be aware that he/she needs to eat but may not be able to problem-solve how to get the food, or may not have the fine motor skills to remove the juice lid or open a cracker package. Some students may become combative and/or verbally abusive. Hypoglycemia can often be mistaken for misbehavior.
Hypoglycemia is one of the most frequent complications of diabetes. If recognized and treated early, an emergency situation can be avoided. Most hypoglycemic episodes respond within 10-15 minutes after the student eats a quick acting snack (i.e., juice, crackers, fruit). School staff needs to recognize the early symptoms and always have appropriate foods accessible.
Severe hypoglycemia is rare, but life-threatening if not treated promptly. If the student is unconscious and unable to eat or swallow, nothing should be placed in the student’s mouth. A glucagon injection may need to be administered per student’s EAP.
An isolated high blood glucose reading is cause for concern, but not alarm. Blood glucose is expected to be higher following a meal or snack.
Hyperglycemia can occur more rapidly in students with insulin pumps if a pump malfunctions or delivers less insulin. If there is insufficient insulin, there may be a breakdown in fat, causing ketones to form. Ketones may build up in the blood and may result in diabetic ketoacidosis (DKA).
High blood glucose can affect a student’s general well-being. Students who do not feel well are less able to learn and participate in school activities. When glucose remains high over time or is reoccurring, serious life-limiting complications of diabetes develop. Diabetes is the leading cause of adult blindness, lower limb amputations, and kidney failure. It can also cause heart disease.
Treating high blood glucose enables students to participate fully in their education and enhances their health and future well being.
Students need to check their blood glucose levels routinely before meals and snacks and before, during, or after exercise. Blood glucose levels should be checked during periods of stress or illness, when low or high blood glucose is suspected, or when there are changes in medication, meals, or activity.
(See pages F-20 and F-21 for REQUEST FOR INDIVIDUALIZED PROCEDURES IN SCHOOL: STUDENTS WITH DIABETES and ALGORITHMS for BLOOD GLUCOSE RESULTS.)
Seizure or convulsion is a symptom seen in students with a medical condition called epilepsy. A student with a diagnosis of epilepsy may have frequent episodes of seizure activity not related to high fever or damage to the brain. Each student’s seizure pattern is different.
There are three main characteristics of seizures:
There are varying types of seizures:
Medications are used to control epilepsy. Some students are on a single anti-seizure medication, while other students may require multiple medications.
Cognitive functions may be impaired, and processing skills may be impacted with the student taking a longer time to process information or needing more time to learn.
An EAP for the student should be developed so everyone around the child is trained and prepared to respond appropriately.
| Role of school staff | Role of School PHN | Role of Parents |
|---|---|---|
| Understand the type of seizure disorder for which student has been diagnosed and what to do when seizure occurs. | Assess the health needs of the student while in school in order to address optimal participation in academic and school activities. Request primary care provider (PCP) and specialist input: [i.e., pediatric gastroenterologist, pediatric cardiologist, pediatric pulmonologist]. | Partner with school and school PHN in sharing student-specific information regarding type of seizure, frequency, duration, triggers, medications, other treatments and pertinent information that will assist the school and nurse to address student’s needs in school. |
| Participate in developing a care plan to address special considerations for the student when seizures occur, during school activities, and/or to maintain a safe environment. | Assist school staff as health care professional on the school team in developing a care plan for the student in partnership with parent. (Reference: Seizure Training for School Personnel 2005, Epilepsy Foundation) Develop an emergency action plan, if student experiences convulsive seizures. | Help the school team to develop a care plan and an emergency action plan, if needed. |
Request training from the health care professional or school PHN on seizure disorder and what to do in the event of a seizure.
|
Provide general information about seizure disorder and studentspecific information to school staff including: Guidelines:Actions for Seizures as well as Emergency response to convulsive seizures if necessary. | Participate in assisting the nurse or health care professional to train school staff, as appropriate. |
| Types of Seizures and Signs/Symptoms | Actions |
|---|---|
1. Generalized Seizures: involves whole brain
|
1. Because of altered state of awareness
|
2. Partial Seizures: involves part of brain and symptoms relate to the part of brain effected
|
2.a. There is no change in consciousness
|
2b. Complex Partial
|
2.b. Because of altered awareness
|
Hydrocephalus is an abnormal accumulation of cerebrospinal fluid (CSF) in the brain. Hydrocephalus is sometimes called “water on the brain.” (The word “Hydrocephalus” in Greek literally means “watery head.”) This condition can arise before birth or at any age.
Hydrocephalus can be due to many causes including a birth defect, hemorrhage into the brain, infection, meningitis, tumor, or head injury. Most forms of hydrocephalus are the result of an obstructed flow of CSF into the ventricles or normal cavities in the center of the brain. Increased CSF in the brain can compress and damage the brain.
The key sign of hydrocephalus in infants is an abnormally large head. This occurs because of the constant outward pressure on the brain and skull from the CSF during the development and growth of the head. In older children, symptoms of hydrocephalus include headaches, nausea, vomiting, and blurred vision.
Contact the PHN assigned to your school for:
Some children may come to school with assistive medical devices/appliances that may require attention during the school hours. Many receive the skilled nursing services provided by a licensed nurse. Contact the PHN assigned to your school if you have questions or concerns.
Anyone can have a stoma (Greek word for opening). Stomas are created surgically by a procedure known as an ostomy. A stoma is not a disease, but is required because of a congenital or chronic health condition/disability, infection, or trauma. Individuals with a stoma are no different from anyone else, but have an alternative way of breathing, eating, or eliminating waste.
An incision is made through the neck into the windpipe (trachea) to allow breathing when the normal pathways are impaired. A tracheostomy tube is then inserted into the stoma (opening), which keeps the hole open. The tracheostomy bypasses a person’s nose and mouth and becomes his or her airway. People with a tracheostomy may not be able to communicate effectively with staff or family and may rely on the ability of others to read their lips or use other communication strategies such as writing or a letter board.
A tracheostomy becomes a person’s airway.
Periodic suctioning may be necessary to remove secretions that accumulate and to maintain the airway. Suctioning requires inserting a small catheter into the tracheostomy tube. To properly care for a child with a tracheostomy tube, a portable suction machine may be needed. The frequency and extent of care needed varies with each student. The physician, in collaboration with the school nurse and parents, should develop a procedural care plan and standing orders.
A nebulizer is a device used to humidify air or deliver medication in a mist form. When breathing through a tracheostomy, the air no longer passes through the nose where it normally would be warmed, filtered, and humidified. Because of this, most patients require a nebulizer that humidifies the air delivered to the trachea and lungs. A large volume nebulizer provides this humidification and is commonly used.
In some situations, a child with a tracheostomy is ventilator dependent.
When a child is physiologically stable and able to attend school, the IEP team needs to consider placement where nursing care is available on a regular basis.
(See page F-11 for Request for Individualized Procedures in School - Tracheostomy.)
When a child cannot be fed by mouth, an opening is made in the abdominal wall and a tube inserted directly into the stomach (gastrostomy). A qualified individual can give liquid or semiliquid foods directly through the gastrostomy. The amount of food, as prescribed by the physician, varies greatly and is based on age, weight, and physical condition. The doctor may also prescribe blenderized table food for the child. The child’s feeding, as at any mealtime, should be a social event where the child can join others during their regular meals.
Tube Feedings:
Some students are fed with a tube inserted through the nose, which goes down the back of the throat, and into the stomach (a nasogastric tube). A tube that starts in the mouth is an orogastric tube. Nose and mouth tubes are changed by parents and healthcare professionals as prescribed by the physician to prevent irritating the lining of the nose and throat.
Some students may use a combination of oral and tube/gastrostomy feedings. Certain health professionals (i.e., occupational therapists, nutritionists, nurses, and speech pathologists) are trained to work with feeding problems and can be consulted (see dysphagia, pages 25-27).
Follow any specific directions you receive for positioning the student prior to and after feeding — usually the student’s head is at least at a 45-degree angle.
(See page F-9 for Request for Individualized Procedures in School - Gastrostomy and F-10 for Emergency Action Plan.)
For some children with inflammatory bowel diseases (i.e., ulcerative colitis, Crohn’s), cancer, congenital abnormalities, or trauma, an opening in the abdomen is required for the removal of waste products from the body. The three main types of abdominal ostomies are colostomy, ileostomy, and urostomy.
The bladder, which is the storage vessel for urine, is removed or bypassed. There are two kinds of urostomies:
Because an ostomy may be a permanent condition, the basic goal is to promote personal habits and techniques that keep the skin and stoma healthy.
As defined by the Maternal and Child Health Bureau (MCHB) of the U.S. Health Resources and Services Administration (HRSA): “Children with special health care needs are those who have or are at increased risk for chronic physical, developmental, behavioral, or emotional conditions and who also require health and related services of a type or amount beyond that required by children generally.”
One end of the spectrum of children with special health care needs: those with the most severe medical problems and most complex medical service needs.
Working definition used by Kapiolani Medical Center: “The child with (a) severe (potentially life-threatening) disability(ies) who has reached his or her state of well-being which is maintained only with continuing complex interventions that are medical/nursing and/or technologic in nature.”
Definition used by the Department of Human Services under Medicaid, for Early Periodic Screening, Diagnosis, Treatment (EPSDT) Medically Fragile Case Management Services:
Child, with complex medical problems AND WITHOUT technological devices, for whom care coordination service is essential to prevent re-hospitalization. Examples: child with
**A Task Force was formed in 2001 to establish a common definition of medically fragile. SCR No. 15, H.D. 1: Requesting the Creation of A Coordinating Committee to Oversee The Care of Medically Fragile Children. A Specialized or Individualized Physical Health Care Plan includes those physician prescribed services that must be provided by a nurse or qualified, trained person during the school day to assist the student to benefit from education or to attend school, i.e., gavage feeding, suctioning, catheterization.
A “qualified person” can be school personnel trained and delegated to provide the nursing services by the nurse or physician in the administration of the specialized physical health care procedure(s).
A plan of action which is developed by the nurse in collaboration with the parent, physician, and school staff for children who have a known life threatening condition. Training on intervention(s) by the responsible parties is provided, as appropriate, by the nurse or physician.
A disorder of language learning; the loss of the ability to express or understand language symbols (the spoken or written word) as a result of some central nervous system dysfunction. It can be expressive (or motor) in which the person can understand but cannot give back appropriate responses, receptive (or sensory) in which the person cannot understand language he/she hears or sees, or both.
A brain disorder characterized by loss of ability to manipulate and use common objects and execute planned movements.
The inability to coordinate the muscles in voluntary movement. Ataxic is often used to describe a staggering gait.
A condition in which slow, irregular, twisting, involuntary movements occur.
An “umbrella” term for a group of disorders resulting from central nervous system damage before, during, and after birth. Although non-progressive, these disorders may become more obvious as the infant grows older. Symptoms include paralysis, weakness, uncoordinated movement, and/or ataxia.
An interference with sound transmission in the outer part of the middle ear. Causes include wax accumulation and chronic ear infection.
Any mental or physical trait or condition that exists at birth because of something that happened to the fetus during the time it was in the womb; it may nor may not be hereditary.
An abnormality of the hip joint present from birth. It is the most common disorder that affects hip joints of children under the age of three. Congenital hip dislocation can cause abnormal joint development and permanent disability.
An inherited disease of infants, children, and young adults. It causes abnormal gland secretions that are carried throughout the body in the blood. The hallmark of this condition is severe, chronic lung disease in children which is characterized by increased mucus production and thickness. It is also associated with malnutrition and diseases of the liver.
A progressive disorder with muscle deterioration, usually beginning in childhood. The disease, mostly in males, is transmitted as a sex-linked recessive trait.
Paralysis of one side of the body. It is caused by a brain lesion involving the upper motor neurons which results in paralysis of the opposite side of the body.
Excessive muscle tone.
Less than normal muscle tone.
Unknown cause.
A protrusion of the membranes around the brain or spinal cord.
Any problem in the body that interferes with how food is built up or broken down in the body. Disorders are usually caused by an abnormality in enzyme production.
A chronic, progressive disease of the central nervous system characterized by a patchy loss of myelin (fatty sheath) in the brain and spinal cord. The cause is unknown but an immunologic abnormality is suspected.
Paralysis of the lower portion of the body and both legs due to a lesion or injury involving the spinal cord.
Indicates an ongoing disease process during which the symptoms get worse. Examples of such diseases include multiple sclerosis, myasthenia gravis, brain tumor, and other rare degenerative diseases affecting the central nervous system. In certain conditions, the earliest symptoms observed are subtle changes in the higher cognitive functions. If the motor area of the brain is involved, a change in writing or physical ability may be noticed.
Paralysis of all four extremities and, usually, the trunk. The cause is an injury to the spinal cord in the cervical spine. The higher the injury, the less intact function and sensation is in the arms. An injury above the third cervical vertebra requires a mechanical respiratory device to maintain life as innervation to the diaphragm is lost.
A loss of function in the inner ear or on the path from the ear to the brain. Causes include birth defects, certain medications, and prolonged exposure to noise.
Increased tension/contractions of muscles causing stiff and awkward movements.
A group or set of symptoms that together make up a certain disease or condition.