School Nurse Sub doing Assessments?

Posted
by uthscsa2011 uthscsa2011 Member Nurse

Has 5 years experience.

Hello fellow school nurses,

I had a question that struck me recently when I had to take a day off from work. Firstly, let me give you some background info. I am a RN with a BSN and have been a school nurse fro 3 years (my first job as a nurse ). I noticed at my district, things were way different that you would expect at a hospital (obviously). Here, we do not have a "policies and procedures manual". Also, when the RN's are out, they do not fill our spot with another RN, or even LVN. They choose from a pool of subs, that also sub for teachers. These are unlicensed personnel. I assume they can do first aid without much trouble, but my one concern was assessments. These subs have students coming in with asthma attack sx, and have to make the discernment whether or not to administer the inhaler. (Our kiddos sometimes fake sx and come to the nurse because they like getting out of class, and after I assess, they are perfectly fine, normal vitals, so they get sent back). But how do these subs know what to look for? How can they tell when these students needs their meds or not? I find that bad practice for district. What if something ever went wrong, and a sub ends up giving the inhaler, or even worse, DOESN'T give it and the student dies from an untreated asthma attack??? These thoughts run through my head all the time, and really keep me from taking days off that I need sometimes. I'm just wondering, who subs fro yall? Do you have RN's or LVNS?

JustBeachyNurse, RN

Specializes in Complex pediatrics turned LTC/subacute geriatrics. Has 12 years experience. 1 Article; 13,952 Posts

Wow my one PDN agency provides RNs (via contract with the board of Ed) to substitute as school nurses and RN or LPNs to attend to needs on field trips if a parent cannot attend (such as asthmatics, diabetics, allergies, epilepsy and also handles first aid). LPN's work under the direction of the school nurse who supplies the plan of care or IHP for the field trip. Only parents or nurses can administer medications except staff trained on assisting with inhalers or epipens.

Only an RN can be a substitute school nurse. Only an RN/BSN with post bacc school nurse certification can be a regular school nurse. Per the State Dept of Education & BoN in my state. LPNs can work along side the RN if more than one nurse is needed or on field trips.

Your situation is scary. In my sons current MS/HS district there is one HS nurse and one MS nurse. When one is on lunch students go to the office. Office staff can take temps then consult with the other nurse. who is in the building next door. Students can self-carry epipens & MDIs with physician/parent approval.

Edited by JustBeachyNurse

kidzcare

kidzcare

Has 5 years experience. 3,393 Posts

I either have a sub nurse (I think we have RNs only on the list) and in the (very often) case that I can't get a sub, office staff or principal fill in and end up calling tons of parents and sending tons of kids home because they want to err on the side of caution.

RatherBHiking, BSN, RN

Specializes in Med-Surg, Oncology, OB, School Nurse. Has 30 years experience. 1 Article; 551 Posts

I understand your concern. We have only RN's that sub but it's a state mandate that only an RN can give insulin and all other meds must be given by trained personnel (trained by an RN). I know the secretary (not trained) will sometimes fill in and has to figure out if a kid is ill or not but she doesn't give meds. We have trained personnel for that.

The thing with schools though is it's not usually life and death and if it is they call 911. Where my kids go to school (different state-we live on the border) there is a nurse once a week in the building so the secretary plays nurse. Different state mandates. So it would be sort of similar to your state but if they aren't trained in administering medication and something happens the board could be sued. However, common sense is if you give an inhaler and kid still having issues hopefully they'd call someone. If kid didn't really need it but got it anyway, probably not going to hurt them. Sometimes kids can feel tightness in chest with no obvious symptoms and need it so even if they could properly assess it might not change the outcome (no obvious symptoms but getting it anyway). If students who are faking it go home more often because the sub didn't know exactly how to determine that well no big deal. The parents can deal with the lying kid. See what I mean?

Although i completely agree it's best for the students, staff, parents, etc to have a nurse in the building at all times for the most protection, some states just don't see it that way. Thankfully, most of the time everything turns out ok. Someday if something bad happens that could have been prevented by having a nurse maybe they'll change their mind and fund it. So call off sick if you truly are. No sense making others ill. Things may not run perfect but chances are it will be ok.

On on a side note, be careful refusing a kid an inhaler if they ask for it. Like I said, some kids truly feel their bronchial tubes tightening up before they get to the point you see symptoms. If they are asking for the inhaler regularly (and you truly think they just want out of class) you need to teach the student it's a prescription med that shouldn't be abused and secondly require parent to follow up with the dr. Unless the inhaler is being given for preventative activity induced asthma then the inhaler shouldn't be used more than once or twice a week. If it is then there asthma is not being controlled well enough and the dr needs to know (this coming from a dr-not me). I've had the same thing happen and sometimes explaining to the student it's not healthy to take it when they don't need it works. Other times a phone call home stops that. If that doesn't then resort to dr.

Edited by Blue_Moon
I wasn't done.

OldDude

Specializes in Pediatrics Retired. 1 Article; 4,787 Posts

Well, since you're in Texas, like me, you might as well get used to it because it isn't going to change unless the legislature changes the law. In Texas, public school districts are not required by law to have a school nurse. Most of them do, as one would imagine, because of the complexity of student health. If they do not employ a RN (which only a RN in Texas can be referred to as a school nurse according to Texas Education Association rules) the campus principal is responsible for health care supervision of their students; regardless of who, other than a RN or someone supervised by a RN (LVN), is providing the care. If a RN is employed the health care responsibility shifts from the principal to the RN - Another reason school districts hire school nurses. So, since there is no requirement for school nurses (RNs) - there is no requirement for subs to be RNs. Add to that, the sub pay is terrible ($70.00 a day in my district), so no licensed person wants to work as a sub - unless they're just looking for a hobby, to hang out at school with their kids, or trying to get their foot in the door for a future school nurse job. I know you are a patient advocate and want the best care for your kids every day but, if it's any consolation for you, professionally, you are not responsible for health care on your campus when you are not present (in Texas).

bell1962

bell1962

Specializes in family practice and school nursing. Has 30 plus years experience. 345 Posts

In NYS all our subs have to be an RN's. Only nurses can admininister meds. The exceptions are epipens and glucagon. Trained staff can administer these in emergency situations. If students can be deemed to be self sufficient in taking their own meds under the supervision of a staff member, that is allowed. It must be approved by their physician, their parent, and the school nurse. In my building this rarely occurs as most of the kids have special needs and are not able to do this. If no subs are available then the school needs to find a nurse through an agency which is very expensive in this area. Therefore I am rarely absent and I think that's why they like me :)

Farawyn

Has 25 years experience. 12,646 Posts

In NYS all our subs have to be an RN's. Only nurses can admininister meds. The exceptions are epipens and glucagon. Trained staff can administer these in emergency situations. If students can be deemed to be self sufficient in taking their own meds under the supervision of a staff member, that is allowed. It must be approved by their physician, their parent, and the school nurse. In my building this rarely occurs as most of the kids have special needs and are not able to do this. If no subs are available then the school needs to find a nurse through an agency which is very expensive in this area. Therefore I am rarely absent and I think that's why they like me :)

I have a student on Diastat. An RN must always be on the premises when this student is, and she is never absent. If they go on a field trip, a sub RN must go with them. I am off work the next 3 days for a college trip with the 10th graders and one of our district RNs is subbing Wednesday and Thursday with an agency sub on Friday. The kids have mid terms, so it shouldn't be too bad for them, barring any emergencies.

NYS only hires RNs, but to my knowledge that is not NYS law. Meaning, I think that they could get away with an LPN at each school with an RN traveling between schools to pass meds, legally. The Diastat is what makes it a MUST in my district. All 3 of our schools have a child with Diastat.

Edited by Farawyn
clarification.

Farawyn

Has 25 years experience. 12,646 Posts

Well, since you're in Texas, like me, you might as well get used to it because it isn't going to change unless the legislature changes the law. In Texas, public school districts are not required by law to have a school nurse. Most of them do, as one would imagine, because of the complexity of student health. If they do not employ a RN (which only a RN in Texas can be referred to as a school nurse according to Texas Education Association rules) the campus principal is responsible for health care supervision of their students; regardless of who, other than a RN or someone supervised by a RN (LVN), is providing the care. If a RN is employed the health care responsibility shifts from the principal to the RN - Another reason school districts hire school nurses. So, since there is no requirement for school nurses (RNs) - there is no requirement for subs to be RNs. Add to that, the sub pay is terrible ($70.00 a day in my district), so no licensed person wants to work as a sub - unless they're just looking for a hobby, to hang out at school with their kids, or trying to get their foot in the door for a future school nurse job. I know you are a patient advocate and want the best care for your kids every day but, if it's any consolation for you, professionally, you are not responsible for health care on your campus when you are not present (in Texas).

Sub pay in our district not more than $125, not less than $100. Not quite sure of the exact number, but it's low too. My go to sub works Cardiac ICU all weekend but has school age kids in my district. She is amazing.

sarenymRN

sarenymRN

5 Posts

I have a question... Can an LPN give Diastat? I just recently found out that special services has an LPN riding a school bus here in NY for a child that has Diastat. I was under the impression an LPN can only give if an RN oversees. I am not sure who the RN that oversees it and non of the other RN's in my district were even aware of her existence. Thoughts?

JustBeachyNurse, RN

Specializes in Complex pediatrics turned LTC/subacute geriatrics. Has 12 years experience. 1 Article; 13,952 Posts

I have a question... Can an LPN give Diastat? I just recently found out that special services has an LPN riding a school bus here in NY for a child that has Diastat. I was under the impression an LPN can only give if an RN oversees. I am not sure who the RN that oversees it and non of the other RN's in my district were even aware of her existence. Thoughts?

It doesn't need to be direct supervision. The care plan specifies when to give Diastat. She's likely working through a pediatric home health agency and has a clinical supervisor RN created plan of care with standing orders signed off by the primary physician. The RN created plan of care is sufficient oversight, a qualified LPN can assess/evaluate a seizing child, time the seizure and safely administer Diastat. The protocol is usually have the driver pull over, maintain safety, if the seizure hits the limit (I have orders varying from administer Diastat upon onset to after 5-10 minutes of seizure, or clusters of 3-5 seizures) safely position the child and administer Diastat. Continue to monitor patient. Usually 911 is called after 3 minutes and then the rest of the notification list (parent, RN clinical supervisor, physician, school nurse) and the PDN accompanies the child to the ED.

Generally speaking the nurse is an employee of a pediatric home health/private duty nursing agency. The RN clinical supervisor provides the oversight and guidance for the field nurse (LPN or RN). When I do bus runs (child medically stable enough to not require 1:1 nursing in school and can be cared for by the school nurse) my contact with the school nurse is limited to handing over the travel chart and Diastat then accepting the Diastat to accompany the child at dismissal. In NJ the board of education contracts the nursing agency for transport and/or 1:1 nursing care in school for students and this is covered in the student's IEP/IHP.