Common clinic visits (elementary)

BeckyESRN · Nov 6, 2019

I use "Let's see how you feel after lunch/recess/whatever" a lot for minor complaints that appear fine. I'm also a fan of "make sure you tell a grown up at home about that". Vague tummy aches in big kids sometimes get "Okay, come back if you throw up"

Ice pack (frozen paper towel, not even a good ice pack) on the back of the neck and increase water intake for most headaches.

Chest pain always felt tricky to me (I worked Cardio step-down before this). The best advice I've been given about that was to ask "what does that mean to you? what does that feel like to you?" and "what were you doing right before it started" 90% of the time that answer is running the mile in PE or some other "duh" activity.

Ice pack seeking injuries: I love "magic boo boo cream" for the littles-it's blue aloe vera, they think it fixes everything. This works especially well on "timmy touched my with his lunchbox" type injuries. It has extra healing power if you can keep it cold.

Nurse passes helped cut down on the amount of ridiculous visits. Mine have check boxes for common complaints and a space to write in the complaint if needed. Something about have to write the words "licked dog this am, now feels like he's growing fur" makes them think twice?. If you have the budget, provide at least bandaids for each classroom. After you've done that repeat "Oh, is your teacher out of bandaids?!" and send a little note asking if they need restocked.

A month in is very early, but you'll start to get a better sense of what needs intervention vs boundaries vs a little love and attention. If you are seeing certain kids several times a day or at certain times, touch base with the teacher. I have littles that will ask every adult they see through out the day and the teacher actually only sent them once, but then library, gym, lunch, and computer also sent them. And you'll absolutely send back a kid that looks fine and he'll throw up 5 minutes later and the teachers will blame you. And that's okay too!

k1p1ssk, BSN, RN · Nov 6, 2019

I have found that you just need to do your assessment and if you find nothing significant, let the child know they are going to be fine but they are more than welcome to come back should their symptoms worsen (this is key, otherwise, they'll just come back 2minutes or 2hrs later), and send them back to class AND DOCUMENT IT ALL!!

There's a lot of opinions on here for various remedies or distractors if you do a search. I find that warm packs and water for tummies, ice packs and water for headaches, and deep breathing exercises for chest pain work best; For the injuries, if I don't see any swelling or redness/new bruising, and if their ROM/strength is intact, I don't offer anything. I tell them, "You walked in here just fine, you will be fine, just take it easy at recess".

I'm still trying to figure out the "smelly student" piece. I think the teachers suspect neglect, but they don't want to be the bad guy that files, so they dump it on you. I have begun telling them that I will document that it was reported to me and if there is a pattern or worry beyond just hygiene, we can discuss it more. IMO BO does not equate neglect; If a student is well fed and appropriately clothed and there isn't any visible dirtiness/no health issues as a result, then what can we do? I don't even think DCF deeply investigates reports of neglect that are filed based on cleanliness anymore.

ruby_jane, BSN, RN · Nov 6, 2019

12 hours ago, RNashley86 said:
Just wanted to get a feel for how some of you handle/treat common complaints among kids..
-“stomachache” with no fever, vomiting, diarrhea. - rest, back to class, come back if it's worse.
- “headache” with no fever or other symptoms - water, sometimes rest
- smelly kids that teachers send - one on one with that teacher about how to contact the parent, which the teacher needs to do.
- “ chest pain”- with zero other symptoms, vitals look perfect, they are not in distress. rest after I've documented the pants off of all the vitals are benign. It's usually anxiety. Or in the case of one teenager, seatbelt deployment after a low-speed accident! Be sure to ask "Is there anything else you haven't told me about this?"
- teachers that send students for literally anything and practice no common sense/judgement. ?‍♀️
Call that teacher every time to tell him/her why you're returning the acutely well student. At the beginning of the year we do a powerpoint that features Gail Trano's NASN work - when to send and when not to send. Try to get the kid to wait a few minutes. If the teacher sends a kid to me every time the kid complains I am now worried about lost content time (use those words) and parenthetically classroom management.

those are the most common ones I encounter. I have found that ice packs work wonders on almost everything, also water and crackers, just sitting with me for a few minutes lol, and a little attention.
a month in, still trying to figure this school nursing thing out ! I think you have a really good handle on it!
Notice I never said call the parents??? At some point when this student has established a pattern of math-itis or sub-itis, it becomes a multidisciplinary collaboration with parent, counselor, and admin.

tining, BSN, RN · Nov 6, 2019

ditto

SaltineQueen · Nov 6, 2019

3 hours ago, k1p1ssk said:
I'm still trying to figure out the "smelly student" piece.

Me too! I hate this complaint. Hey...let's give the kid a complex by having someone he hardly knows (me) talk to him about how smelly he is when someone he has a good relationship with (teacher) could easily pull him aside and ask a few questions. I'm happy to talk hygiene, but I don't think the kid needs to hear it from me first.

k1p1ssk, BSN, RN · Nov 6, 2019

19 minutes ago, SaltineQueen said:
Me too! I hate this complaint. Hey...let's give the kid a complex by having someone he hardly knows (me) talk to him about how smelly he is when someone he has a good relationship with (teacher) could easily pull him aside and ask a few questions. I'm happy to talk hygiene, but I don't think the kid needs to hear it from me first.

Right now I'm dealing with a student who had the occasional tantrum last year in Kindergarten, but is in a whole other realm this year. Started with refusal to do work and spending 20-30min in the bathroom "pooping" 2-3x per day. The teacher started sending him to my BR where I had to implement a visual reminder of the order of operations. When that didn't work, I would have to stand outside the door and listen for certain sounds and give verbal reminders/cues. When he was still taking 5minutes to pee, I started a timer, giving him 4 minutes total in the BR, along with the visual and verbal cues. After that, he began complaining that his pants were too hot. Ok, great, bring a pair of shorts to change into. Then the shorts were too hot, he needs another pair. When we started letting him have only the one change, he began purposefully DUNKING THE PANTS/SHORTS IN THE TOILET. So now, if he wants to change, I have to lug out my crappy privacy shade and set that up so he can change in private without having access to the toilet at the same time. Today, he showed up to school REEKING of stool. He is insistent that his bottom and underpants are clean, but there is no other explanation for the smell. I now have the lovely task of calling home to see if he has been having stool incontinence. We have him using wet wipes when he has a BM here, but I am not certain he is capable (or honestly, if he is choosing not to) of cleaning himself thoroughly.

We're in the process of having him tested and I am hoping beyond everything that he qualifies for an IEP & 504 with a 1:1. I have been spending at least an hour solid supervising him every day this year between all the bathroom trips, conversations around hygiene, and tantruming in my office.

MrNurse(x2), ADN · Nov 6, 2019

17 minutes ago, k1p1ssk said:
Right now I'm dealing with a student who had the occasional tantrum last year in Kindergarten, but is in a whole other realm this year. Started with refusal to do work and spending 20-30min in the bathroom "pooping" 2-3x per day. The teacher started sending him to my BR where I had to implement a visual reminder of the order of operations. When that didn't work, I would have to stand outside the door and listen for certain sounds and give verbal reminders/cues. When he was still taking 5minutes to pee, I started a timer, giving him 4 minutes total in the BR, along with the visual and verbal cues. After that, he began complaining that his pants were too hot. Ok, great, bring a pair of shorts to change into. Then the shorts were too hot, he needs another pair. When we started letting him have only the one change, he began purposefully DUNKING THE PANTS/SHORTS IN THE TOILET. So now, if he wants to change, I have to lug out my crappy privacy shade and set that up so he can change in private without having access to the toilet at the same time. Today, he showed up to school REEKING of stool. He is insistent that his bottom and underpants are clean, but there is no other explanation for the smell. I now have the lovely task of calling home to see if he has been having stool incontinence. We have him using wet wipes when he has a BM here, but I am not certain he is capable (or honestly, if he is choosing not to) of cleaning himself thoroughly.
We're in the process of having him tested and I am hoping beyond everything that he qualifies for an IEP & 504 with a 1:1. I have been spending at least an hour solid supervising him every day this year between all the bathroom trips, conversations around hygiene, and tantruming in my office.

Sounds like a child who doesn't like having to conform to the authority in school after a childhood without structure. Honestly, I am surprised we don't see this more often.

k1p1ssk, BSN, RN · Nov 7, 2019

21 hours ago, MrNurse(x2) said:
Sounds like a child who doesn't like having to conform to the authority in school after a childhood without structure. Honestly, I am surprised we don't see this more often.

The funny thing is, he is actually very agreeable most of the time; In general, a happy kid who makes really weird choices and rationalizations in his mind. For example, when he dunked his pants in the toilet it was because the pants were hot, and he needed to cool them down and the only way he could think of was to get them wet. He had personified the pants and truly believed they were hot/had a fever. It didn't matter that he had already changed into shorts. A truly bizarre series of events.

BrisketRN, BSN, RN · Nov 7, 2019

-“stomachache” with no fever, vomiting, diarrhea--> crackers, water, 5 min & back to class

- “headache” with no fever or other symptoms --> drink 8 oz water, rest 15 minutes, try to get through 1 more hour of school and come back if it doesn't improve

- smelly kids that teachers send --> I've actually never gotten this

- “ chest pain”- with zero other symptoms, vitals look perfect, they are not in distress. --> these kids usually need reassurance and then back to class

- extremity “injuries” that kids are totally playing up lol. Aka walk to the nurses office and as soon as they get in here they are suddenly limping --> poke around at the injury and look for wincing/actual signs of pain, tell them to shake it off, sometimes show them a stretch to do (the littles want SOMETHING to fix it)

- teachers that send students for literally anything and practice no common sense/judgement. --> "you're fine" back to class

BooBooCrew, BSN, RN · Nov 8, 2019

For the HAs with no fever I usually ask them how much water they've had today and encourage more no mater what they say. I have a big timer in my clinic and set it for 10 min and tell them they have that long to rest here. Typically before I do that though, I ask what they were working on in class in an attempt to detect avoidance behavior. Almost always, esp. for 3rd grade and up, they end up deciding to leave before the timer goes off.

SAs with no other signs - I go full-on nurse here ? I ask "have you pooped today?" If they say yes I ask if it was diarrhea or if it was difficult to get it out. If they say no I ask when the last time was and encourage them to drink water and be active in PE and recess to get things moving. The look on their faces with all this BM talk is priceless! It has definitely cut down and those that don't really have anything going on. I also ask if they've eaten. If they say yes I ask if it made them feel better or worse. If they say no I ask why and also tell them to try to make it to lunch and see if that makes them feel better. If it doesn't, come back and see me. If they are obviously in distress I do the same as the HAs and let them rest 10 min.

Teachers and coaches at my school send a kid to me for any. little. bump. It's crazy to me. Did none of them get hurt as a kid?! Kids are rough and get hurt. Not everyone has a broken bone ? This is much more prevalent among teachers who are new and think thie is what they should be doing. Again, if they are not at all in distress and are moving whatever just fine, I tell them they'll be okay and send them on. If I ask what happened and they do a full demonstration by re-rolling their ankle, I tell them their best bet would be to go ahead and stop doing that and their ankle will probably feel better. Most other cases, and especially for the PK, K and 1st graders, I give them ice and tell them to leave it on for 15min.

Kooky Korky, BSN, RN · Nov 9, 2019

On 11/6/2019 at 12:50 PM, k1p1ssk said:
Right now I'm dealing with a student who had the occasional tantrum last year in Kindergarten, but is in a whole other realm this year. Started with refusal to do work and spending 20-30min in the bathroom "pooping" 2-3x per day. The teacher started sending him to my BR where I had to implement a visual reminder of the order of operations. When that didn't work, I would have to stand outside the door and listen for certain sounds and give verbal reminders/cues. When he was still taking 5minutes to pee, I started a timer, giving him 4 minutes total in the BR, along with the visual and verbal cues. After that, he began complaining that his pants were too hot. Ok, great, bring a pair of shorts to change into. Then the shorts were too hot, he needs another pair. When we started letting him have only the one change, he began purposefully DUNKING THE PANTS/SHORTS IN THE TOILET. So now, if he wants to change, I have to lug out my crappy privacy shade and set that up so he can change in private without having access to the toilet at the same time. Today, he showed up to school REEKING of stool. He is insistent that his bottom and underpants are clean, but there is no other explanation for the smell. I now have the lovely task of calling home to see if he has been having stool incontinence. We have him using wet wipes when he has a BM here, but I am not certain he is capable (or honestly, if he is choosing not to) of cleaning himself thoroughly.
We're in the process of having him tested and I am hoping beyond everything that he qualifies for an IEP & 504 with a 1:1. I have been spending at least an hour solid supervising him every day this year between all the bathroom trips, conversations around hygiene, and tantruming in my office.

What's going on at his home? Is he sexually abused? Any kids bullying him?

Etc.