Repeat Visitors to Nurse's Office

[assistantasnurse]

First of all, let me start off by saying I am NOT a school nurse. I hope some school nurses will be able to help me anyway. I am an administrative assistant at a small private elementary school who acts as a "nurse"/first aid person. I have training in first aid, adult/child/infant CPR, and adult/child AED. In addition, our phys. ed. teacher is a great help with injuries such as twisted ankles, bumps on the head, etc. My "nurse"-type duties mainly consist of handing out Band-Aids, administering medications (usually cough syrup or Tylenol brought in by parents), and determining whether a student is well enough to remain in school. It's that last one that's driving me crazy.

How do you tell whether a student is sick enough to be sent home (besides them having a fever)? Actually, the real question is what do you do with a child who keeps coming to the nurse's office even though you're pretty sure they're fine? It seems like teachers are always sending me students who have stomachaches but no other symptoms. I've read that younger children with stomachaches usually aren't faking, but if I call the parent they always ask if the student has a fever and if not, they want their child to stay in school. I guess another question is, how do you tell a student "You're not really sick and you need to go back to class and stay there," especially if they're whining and telling you that they don't feel well?

Last year I had to physically walk a child back to class, cajoling him all the way (he had thrown up at home two days before and claimed that his babysitter told him if you throw up you have to stay home from school for 11 days!). My latest problem is two twin kindergarteners who come down several times a day, complaining of feeling "dizzy" and wanting to lie on the cot or go home. The mother is aware of the problem and even took one of the girls to the doctor, who found nothing wrong. The issue of teachers sending students to the nurse's office is supposed to be addressed at the next staff meeting, so hopefully that will help.

I think I generally have a pretty good idea of who just wants some attention or an escape from class and who is really feeling yucky, but sometimes I have trouble. I don't want to annoy parents with phone calls, but on the other hand I don't want to send a sick child back to disrupt a class because they can't concentrate (it's mainly younger students, K-2, who give me the most trouble). Is it the school nurse's sole responsibility to decide when a student should go home, or do you seek parents' input through phone calls? Does that annoy the parents? How do you insist that a parent pick up a sick child who doesn't have a fever?

This is really frustrating for me! I know you all are busy with your own positions, but if you could take a moment to post a little guidance for me, I would really appreciate it.

Thanks,

Jenny in Ohio

[tencat]

Howdy. I'm not a nurse yet, but I was a teacher. If you have repeat visitors to the office who are K-2, it might be worth asking the kids why they feel sick. You might ask if they are having problems with something they're learning ie: do they feel overwhelmed by math or reading? Are they having problems with the other kids in class? Stomach aches can be from stress, and a lot of kids have a lot to be stressed about these days. Just sitting and talking with a kid might be all he/she needs, especially if they are constantly visiting you and they're that young. Now, if it were 6th graders I'd just tell them to get their little fannies back to class and quit coming to see me!

As to parents, if you want to contact a parent, I think that's fine to do. Maybe they'll be annoyed, but they'll get over it. I really don't know what you do about the ones who won't pick up their truly sick kid, though.

[bergren]

It is hard for a person who is not trained or experienced in health assessment to make these determinations. In fact it is often hard for those of us that do have health assessment skills to be certain, but two recent research studies show that registered nurses send home 57% fewer students than non licensed assistants. In BSN programs all students now take 15 weeks of health assessment classes and lab experience , and then add on to that all the on the job experience in hospital and community settings.

I encourage talking to the parents, and it is OK to acknowledge that a child has a headache or stomach ache, but that they can go back to class. For the frequent kids, I suggest working with the teacher and the parent regarding how often to let them go to you and rewarding them for staying in class. Asking the child to wait is OK too. Automatically releasing them from the classroom for each twinge and minor discomfort reinforces the behavior. The parents should make sure they are fed breakfast and get a good nights sleep.

Just simply asking them a few questions can let you know if there is a reason they are experiencing anxiety that is manifesting in a headache or stomach ache. Sometimes a parent or grandparent is sick, a dog is lost, parents are on vacation, mom is having a baby, mom and boyfriend are fighting, domestic abuse, alcoholism, etc. A child a few weeks ago had visited a school nurse I know and the nurse commented to a colleague of mine who was visiting that the child had been visiting often complaining of a headache and that it was a new behavior. My colleague asked the child a few questions and it turned out that the child's mother was at the hospital 24 hours a day with a sibling who was dying - no one at school knew.

[DDRN4me]

does your state have any written guidelines? here in MA we have specific guidelines as to when a child needs to be sent home (temp, vomiting, diarrhea etc.) alot of times i will refer to that when i call a parent to pick up a child. and remind them that i have rules that i need to follow. Is there a nurse available for you to call in case of the "iffy" ones?

i agree that some students need just some tlc. sometimes a "magic mint" (Necco wafer, peppermint, etc) is enough to cure a tummy ache and make the student feel like they can last the day.

i agree that it is an art to figure out what is really ok and not, even i (a nurse with 20 + yrs experience) am unsure at times!

[Chaya, ASN, RN]

As strange as it seems I learned the first thing to ask kids was if they had eaten breakfast. Some of the really little ones were hungry and they interpreted this as stomache discomfort. Then you need to ask if they just didn't have time to eat or chose not to eat because they were truly feeling yucky. With the older kids they come in with a headache midmorning. With many of my frequent flyers (older and younger), their symptoms would resolve with a couple of crackers. With others, the short time away from the classroom was what it took.

[farishtaRN]

I am actually in the process of dealing with a frequent flyer right now! I would certainly encourage you and echo the statements of some of the others, that even as nurse's who are trained to assess this sort of thing, it can be hard to know what to do.

I would recommend (particularily in younger ones) looking for patterns with the frequent flyers. Do they came at or around the same time day to day? Is there a particular class or is it break time that they are missing? A lot of times kids are reacting to stress in their lives and not just faking, which can be why a little TLC seems to do the trick fairly quickly. However, if you can pin it down to a specific time, or class and the child won't express that something (other than physical symptoms) is bothering them after you ask, it is time to involve the teacher and probably the parents. Although I feel like I am here to meet emotional needs as well as physical ones, I am not doing a child any favors by helping them to hide from problems and not face them. If this is what they are doing in the second grade and I reinforce the behaviour, think what they will be like when they encounter problems as a highschooler!

Also, with little ones who are complaining of stomach pain, ask them to take one finger and point to the spot where it hurts. If they cannot specifically point to a particular place, chances are that they are not experiencing any acute pain. I don't give any meds for stomach aches, but have discovered that a little sprite and crackers can work wonders. They do a good job of settling the stomach, and the sprite helps to neutralize stomach acid which will help if what they are experiencing is indigestion.

I don't know what your setup is, but if you can do it, this works really well for kids who really aren't sick and are just trying to go home: have them lay down in as much darkness as you can get (my office has no windows, so it gets pretty dark) and make sure there is no stimulation - no books, no talking, nothing! Being sick isn't a reward, and if they are really fine, it will take about 5 minutes before they are ready to go back to class. The sick ones will fall asleep, but generally the well ones will not. This technique doesn't work real well with older kids because if they are in their teens, chances are they will fall asleep regardless!

If all else fails, call a parent and have them speak to the child, and let them make the decision. Sometimes the child needs to hear there parent tell them to go back to class --- of course, I am talking about children who aren't sick here, not a child that you think might be sick. I think that it would be a good idea for you to talk to your boss (principal or whoever you ultimatly answer to) about putting some policies in place for sending kids home. Especially since you aren't trained as a nurse, it isn't fair to leave all responsibility on your shoulders without some backup. If you could talk to some medical professionals and have them help you to develop some policies for when a child needs to go home and when they can stay in school, I think that would be a good idea. That way, even if they don't have a fever, if the parent is upset about picking up the child you would have policy that you can hold up and insist that they do it anyway.

I hope that some of this is helpful! Rest assured that nursing is not an exact science, and we all have patients that we just aren't sure about...... don't be afraid to ask for help.

[jen42]

I second the breakfast thing. It's amazing how many kids just don't eat breakfast, and then have stomach complaints! Or don't have enough lunch, like the 3rd-grader who packs her own every day and just doesn't get the concept of it, and so she always has one granola bar, or half a sandwich.

Whether I send kids home often depends on the kid. If it's a frequent flyer- and I have many- they don't go home until they have a fever, are vomiting, or have some other objective symptom. A kid I've never seen before, I may send home if he's curled up on the cot, even without a fever. It also depends on what's going around the school- if there's strep going around a classroom, and someone's complaining of a sore throat and has swollen glands... home they go. I go on my gut a lot. If they're very pale, glassy eyes, or just "don't seem right", it's usually at least worth a phone call to mom or dad.

As far as how I deal with my frequent flyers, I try to get to the bottom of it. A lot of them have parents who are getting divorced, have social issues, or are not doing well in school. I can't solve these things, but it gives me a better framework. A lot of them just need an "Oh, poor baby" and five minutes of rest. I usually don't let them stay longer than 10 minutes. I occasionally have 5th and 6th grade girls come in sobbing hysterically- they usually just had a fight with a friend, but if they have a stay-at-home mom nearby, I call her right in.

I have only had one parent ever get mad at me for calling... and she is a parent the school has lots of problems with. "Your daughter is having bladder pain and said she hasn't urinated today." "So?" Yesterday a little girl taking a math test suddenly and mysteriously developed all-over body itching. No rash, no nothing. Called her mom, who said "You send that drama queen right back to class!" Back she went, and the itching miraculously disappeared. If a parent gets mad at you for calling- unless they're a brain surgeon in the middle of an operation- you're either calling them too much, or they've got other issues.